Adult Health EAQ #1 Cardiovascular

which herbal product is contraindicated when a client is receiving anticoagulant therapy? 1. garlic 2. flaxseed oil 3. red yeast rice 4. horse chestnut seed extract

1. garlic

client is in the ICU. the nurse observing the telemetry monitor identifies flattening T waves and peaked P waves. what problem should the nurse consider based on these ECG changes? 1. hypokalemia 2. hypocalcemia 3. hyponatremia 4. hypomagnesemia

1. hypokalemia

ausculating the chest of a client with dyspnea orthopnea and fatigue the nurse hears a high pitched diastolic murmur and austin flint murmur which condition might the nurse suspect 1. mitral valve regurgitation 2. aortic valve regurgitation

2. aortic valve regurgitation

which process involves replacing dead and decomposed tissue with frest collagen tissue? 1. incision 2. irrigation 3. granulation 4. evisceration

3. granulation

client with a distal femoral shaft fracture is at risk for developing a fat embolus. nurse considers that a distinguishing sign thats unique to fat embolus is what? 1. oliguria (small amount of pee) 2. dyspnea (breathing) 3. petechia (vessel breaks) 4. confusion

3. petechia

A child with beta-thalassemia is receiving therapy that includes multiple blood transfusions this child is at risk for which common complication? 1. serum hepatitis 2. allergic response 3. pulmonary edema 4. hemolytic rxn

3. pulmonary edema

A client has untreated stage 1 hypertension. What is the minimum systolic pressure the nurse expects when obtaining this client's blood pressure? 1. 110-119 2. 120-129 3. 130-139 4. 140-159

4. 140-159

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 schilling test? 1. storage 2. digestion 3. production 4. absorption

4. absorption

nurse is counseling the parents of a 12 yr old child with duchenne muscular dystrophy about problems that may develop during adolescence what body system does the nurse expect will be affected? 1. neurological 2. integumentary 3. gastrointestinal 4. cardiopulmonary

4. cardiopulmonary

is increase in urinary output a symptom of heart failure ?

no

client who was in an automobile collision is now in hypovolemic shock. why is it important for the nurse to take the clients VS freq during the compensatory stage of shock? 1. arteriolar constriction occurs 2. cardiac workload decreases 3. contractility of the heart decreases 4. parasympathetic nervous system is triggered

1. arteriolar constriction occurs

what functions of leukocytes are involved in inflammation? select all that apply 1. destruction of bacteria and cellular debris 2. selective attack and destruction of nonself cells 3. release of vasoactive amines during allergic rxn 4. secretion of immunoglobulins in response to a specific antigen 5. enhancement of immune activity through secretion of various factors, cytokines, and lymphokines

1. destruction of bacteria and cellular debris 3. release of vasoactive amines during allergic rxn

which instructions should the nurse include in the teaching plan for a client with hyperlipidemia whos being discharged with a prescription for cholestryamine (Questran) 1. increase your intake of fiber and fluid 2. take the medication before you go to bed 3. check your pulse before taking the medication 4. contact HCP if your skin or sclera turn yellow

1. increase your intake of fiber and fluid

client is scheduled to have a coronary artery bypass graft the clients spouse asks what the benefit of the surgery is how should the nurse respond? 1. this surgery significantly decreases symptoms in most clients 2. procedure will enable your spouse to return to work after healing occurs 3. evidence substantiates that surgery can prevent progression of coronary artery disease

1. this surgery significantly decreases symptoms in most clients

nurse is reviewing a teaching plan for a client that has been prescribed a 2 gram sodium diet. the plan should include which foods that are low in sodium? 1. meat and fish 2. fruits and juices 3. milk and cheese 4. dry cereals and grains

2. fruits and juices

what should the nurse identify as primary cause of pain experienced by a client w coronary occlusion? 1. arterial spasm 2. heart muscle ischemia 3. blocking of coronary veins 4. irritation of nerve endings in cardiac plexus

2. heart muscle ischemia

client receiving hemodialysis has external shunt for circulatory access which life threatening complication associated with external cannulas should the nurse be most concerned? 1. infection 2. hemorrhage 3. skin breakdown 4. impaired circulation

2. hemorrhage

which phase of wound healing involves adherence of blood platelets to the walls of an injured vessel? 1. maturation 2. hemostasis 3. reconstruction 4. inflammatory phase

2. hemostasis termination of bleeding

when a client is experiencing hypovolemic shock with decreased tissue perfusion the nurse expects that the body initially attempts to compensate by doing what? 1. producing less ADH 2. producing more RBC 3. maintaining peripheral vasoconstriction 4. decreasing mineralocorticoid production

3. maintaining peripheral vasoconstriction

client w HF is digitalized (given a loading dose of digoxin) and placed on maintenance dose of digoxin 0.25 by mouth daily what responses does the nurse expect the client to exhibit when a therapeutic effect of digoxin is achieved? 1. diuresis and decreased pulse rate 2. increased BP and weight loss 3. reg pulse rhythm and stable fluid balance 4. corrected heart murmur and dec pulse pressure

1. diuresis (excessive urine) and decreased pulse rate

when supporting vasodilation by the use of warmth for a client with peripheral arterial insufficiency what does the nurse caution the client to avoid? 1. applying a hot water bottle to the abdomen 2. using a heating pad to warm the extremities 3. drinking a warm cup of tea when feeling chilly 4. turning the room thermostat above 72 degree

2. using a heating pad to warm the extremities

which of following symptoms indicates to nurse that client has an inadequate fluid vL select all that apply 1. dec urine 2. hypotension 3. dyspnea 4. dry mucous membranes 5. pulmonary edema 6. poor skin turgor

1. dec urine 2. hypotension 4. dry mucous membranes 6. poor skin turgor

nurse is caring for client with sepsis who is hemodynamically stable. the client is complaining of abdominal pain which of these primary HCP orders should the nurse carry out first? 1. draw peripheral blood cultures 2. administer levofloxacin 500 mg IV over 30 min 3. administer 1 L IV bolus ringers lactate over 30 min 4. take client to xray for abdominal computed tomography CT scan

1. draw peripheral blood cultures

nurse is caring for a client who just had coronary artery bypass graft surgery for which complication should the nurse monitor the client in the immediate postoperative period? 1. dysrhyrhmias especially atrial fibrillation 2. postpericarditomy syndrome w fever and friction rub 3. mediastinits with boggy sternum and increased WBC count 4. increased hemoglobin and hematocrit levels w a risk for embolization

1. dysrhyrhmias especially atrial fibrillation

client w low hemoglobin level which is attributed to nutritional deficiency the nurse provides dietary teaching which food choices by client indicate that nurses instructions are effective select all that apply 1. raisins 2. sqaush 3. carrots 4. spinach 5. apricots

1. raisins 4. spinach

person brought to ER after prolonged exposure to cold weather. what clinical manifestations of hypothermia does the nurse expect? select all that apply 1. stupor 2. erythema 3. increased anxiety 4. rapid respirations 5. paresthesia in affected body parts

1. stupor 5. paresthesia in affected body parts

nusse caring for client who was diagnosed with a MI while caring for client 2 days after event nurse identifies clients temp is elevated nurse concluded thats increase temp most likely result of what 1. tissue necrosis 2. venous thrombosis 3. pulmonary infarction 4. respiratory infection

1. tissue necrosis

a client with dehydration suddenly becomes diaphoretic, clammy, and pale the clients BP falls to 50/30 the nurse should place the pt in what position? 1. trendelenburg 2. high fowler 3. prone 4. whatever position is most comfy

1. trendelenburg

lab results of clients blood after chemotherapy indicate bone marrow depression what should nurse encourage client to do select all that apply 1. use soft toothbrush 2. sleep w head of bed elevated 3. inc activity levels and freq walks 4. read ingredients in otc drugs b4 taking them

1. use soft toothbrush 4. read ingredients in otc drugs b4 taking them

nurse is providing dietary instruction to a client with cardiovascular disease. which dietary selection by the client indicated the need for further instruction? 1. whole milk with oatmeal 2. garden salad with olive oil 3. tuna fish with a small apple 4. soluble fiber cereal with skim milk

1. whole milk with oatmeal

nurse is caring for 2 clients one has polycythemia (too many RBC cancer) and the other prolonged anemia what do these clients have in common? 1. increased urinary ouptut 2. increased cardiac workload 3. decreased oxygen saturation 4. decreased arterial BP

2. increased cardiac workload

client with thrombocytopenia what specific nursing actions are appr to include in the plan of care for this client? select all that apply 1. avoid IM injections 2. institue neutropenic precautions 3. monitor the WBC count 4. administer prescribed anticoagulants 5. examine skin for eccymotic areas

1. avoid IM injections 5. examine skin for eccymotic areas

nurse prepares a list of recommended foods for a client w hypertension whos to begin 2 gram sodium diet which foods should the nurse include in the list? select all that apply 1. beef steaks 2. mushrooms 3. aged cheeses 4. luncheon meats 5. cooked broccoli

1. beef steaks 2. mushrooms 5. cooked broccoli

client with hypertension is to begin 2 gram sodium diet nurse should teach the client to avoid which foods ? select all that apply 1. celery sticks 2. ground beef 3. fresh salmon 4. luncheon meat 5. cooked broccoli

1. celery sticks 4. luncheon meat

a client is diagnosed with Hodgkins disease (cancer in blood) which lymph nodes does the nurse expect to be affected first? 1. cervical 2. axillary 3. inguinal 4. mediastinal

1. cervical

client had an open reduction and internal fixation of the head of the femur in the postanesthesia care unit the clients vital signs remained stable 1 hour with blood pressure 130/78 pulse 68 and respiration 16 one hour after returning to the postsurgical unit the clients VS are BP 100/60 p 74 and R 22 and the client is restless. what should the nurse do first? 1. check the dressing on the incision 2. increase the IV flow rate 3. elevate the head of the clients bed 4. continue monitoring the clients VS

1. check the dressing on the incision

nurse monitoring client whos having a 3rd transfusion of packed RBC which of these may evident if client is experiencing a febrile transfusion rxn? select all that apply 1. chills 2. urticaria (hives) 3. hypotension 4. tachycardia 5. bronchospasm 6. sense of impending doom

1. chills 3. hypotension 4. tachycardia

client w history of HF is admitted to the hospital w diagnosis of pulmonary edema for which S/S specfic to pulmonary edema should the nurse assess the client? select all that apply 1. coughing 2. orthopnea 3. diaphoresis 4. yellow sputum 5. dep edema

1. coughing 2. orthopnea 3. diaphoresis

client w rheumatoid arthritis has been taking a steroid medication for the past yr for which complication of prolonged use of this medication should the nurse assess the client? 1. dec WBC 2. Inc C-reactive protein 3. inc sedimentation rate 4. dec serum glucose levels

1. dec WBC

clinical indicators nurse is going to identify when taking admission history of a client w right ventricular failure? select all that apply 1. edema 2. vertigo 3. polyuria 4. dyspnea 5. palpitations

1. edema 4. dyspnea

client with inflammation of membranous sac surrounding the heart has muscle aches, fatigue, and dyspnea the client reports chest pain that radiates to the shoulder and neck which condition does the client have? 1. pericarditis 2. endocarditis 3. hypertension 4. arteriosclerosis

1. pericarditis

a nurse teaches a client about warfarin which information is essential for the nurse to include in the education plan? 1. periodic blood testing is necessary 2. foods dont affect the medication 3. physical activities should be limited 4. daily doses should not be interrupted

1. periodic blood testing is necessary

client is brought to ER w moderate substernal chest pain radiating to inner aspect of left arm unrelieved by rest and nitroglycerin the pain is associated with slight nausea and anxiety whats the priority nurse intervention for this client? 1. provide pain med 2. obtain ECG 3. transfer to coronary care unit 4. have blood specimen drawn for enzyme studies

1. provide pain med

client with a history of HF is experiencing dyspnea with a RR of 32 crackles are noted bilaterally the client is in sims position receiving o2 at 2L/min via nasal cannula which action should the nurse take first? 1. raise the client to high fowler poisiton 2. obtain the apical pulse and BP 3. call the HCP asap 4. monitor the pulse oximeter to ascertain the oxygen level

1. raise the client to high fowler poisiton

nurse is caring for a client w an abdominal aortic aneurysm before surgery which nursing care is essential preoperatively? 1. administering supplemental O2 2. maintaining a reduced BP 3. keeping the client in supine position 4. monitoring the peripheral vascular status

2. maintaining a reduced BP preventing rupture

client diagnosed w acute lymphoid leukemia and is receiving chemotherapy the nurse should monitor what thrombocytopenic side effects of chemotherapy select all that apply 1. nausea 2. melena 3. purpura 4. diarrhea 5. hematuria

2. melena 3. purpura 5. hematuria

client reports fatigue and dyspnea and appears pale the nurse question the client about medications currently being taken in light of symptoms which medication causes the nurse to be most concerned 1. famotidine 2. methyldopa 3. levothryoxine 4. ferrous sulfate

2. methyldopa

while collecting data a client complaining of palpitations and fatigue the nurse finds a loud accentuated s1 and low pitched rumbling diastolic murmur which condition does the nurse suspect? 1. tricuspid stenosis 2. mitral valve stenosis 3. aortic valve stenosis 4. acute aortic valve regurgitation

2. mitral valve stenosis

most essential nursing care for a client who just had a cardiac catheterization? 1. maintain the semi fowler position 2. monitor the apical pulse and BP 3. take temp hourly till it stabilizes 4. encourage frequent coughing and deep breathing

2. monitor the apical pulse and BP

client w history of type 1 diabetes is diagnosed with HF digoxin is prescribed what should the nurse do when administering the medication? 1. administer the medication w 8 oz of OJ 2. monitor the client for atrial fibrillation and first degree heart block 3. administer the digoxin an hr after the clients morning insulin

2. monitor the client for atrial fibrillation and first degree heart block

client who recently had a MI is admitted to the cardiac care unit how can the nurse best determine the effectiveness of the clients ventricular contractions? 1. observing anxiety levels 2. monitoring urinary output hourly 3. evaluating cardiac enzyme results 4. assessing breath sounds freq

2. monitoring urinary output hourly

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 clients body should the nurse assess? select all that apply 1. sclera 2. nail beds 3. lining of eyelids 4. palms of hands 5. bony prominences

2. nail beds 3. lining of eyelids 4. palms of hands

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 what? 1. nausea 2. tachypnea 3. constipation 4. hypotension

4. hypotension

which leukocyte is responsible for the allergic response? 1. basophils 2. monocytes 3. eosinophils 4. macrophages

1. basophils

nurse is assessing a client w the diagnosis of chronic HF which clinical finding should the nurse expect the client to experience? 1. dep edema in evening 2. chest pain that dec w rest 3. palpitations in chest when resting 4. freq coughing w yellow sputum

1. dep edema in evening evening after long day of standing

assessing client w peripheral arterial disease nurse anticipates presence of which clinical manifestations? select all that apply 1. dep rubor (red) 2. warm extremities 3. ulcers on toes 4. thick hardened skin 5. delayed in cap refill

1. dep rubor (red) 3. ulcers on toes 5. delayed in cap refill

nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program which physiologic effect of nicotine should the nurse explain to the group? 1. constriction of the superficial vessels dilates the deep vessels 2. constriction of the peripheral vessels increases the force of flow 3. dilation of the superficial vessels causes constriciton of collateral circulation 4. dilation of the peripheral vessels causes reflex constriction of visceral vessels

2. constriction of the peripheral vessels increases the force of flow

nurse is collecting a health history from a client with thromboangiitis obilteran (buerger disease) what symptoms are most likely to be associated with this disorder? 1. general blanching skin 2. easy fatigue of extremities 3. burning pain after exposure to cold 4. presence of Homans sign when ambulating

3. burning pain after exposure to cold

dietary choices for client taking spironolactone to avoid increasing? select all that apply 1. potatoes 2. red meat 3. cantaloupe 4. wheat bread 5. flavored yogurt

1. potatoes 3. cantaloupe

after ordinary physical activity a client w cardiac insuffciency reports fatigue and dyspnea thats relieved by rest. according to NY heart association heart failure classification into which category of HF does this client fit? 1. Class I 2. Class II 3. Class III 4. Class IV

2. Class II

A client has untreated stage 1 hypertension. What is the minimum systolic pressure the nurse expects when obtaining this client's blood pressure?

140 mm hg

doc prescribes a reg diet gait training elastic stocking and benztropine mesylate for client. client experiences orthostatic hypotension a side effect of benztropine mesylate what should nurse set as priority nursing action? 1. postpone gait training 2. apply elastic stockings 3. w/hold next dose 4. inc fluid intake

2. apply elastic stockings

dietary instructions to client w iron deficiency anemia which food choices by client does nurse consider most desirable? select all that apply 1. raw carrots 2. boiled spinach 3. sweet potatoes 4. brussels sprouts 5. asparagus spears

2. boiled spinach 3. sweet potatoes

client has surgery to replace a prolapsed mitral valve what should the nurse teach the client? 1. S/S of pericarditis 2. possible need for prophylactic antibiotic therapy before dental work 3. cardiac surgery will have to be done eventually for the other valves 4. pregnancy and childbirth are too stressful when one has this prop

2. possible need for prophylactic antibiotic therapy before dental work

client has been admitted with severe edema and hypertension IV furosemide has been prescribed which subjective clinical manifestations lead the nurse to suspect that the furosemide is infusing too rapidly? select all that apply 1. hunger 2. tinnitus 3. weakness 4. leg cramps 5. excess salivation

2. tinnitus 3. weakness 4. leg cramps

client lab reports hyperkalemia which response should nurse expect client to exhibit? select all that apply 1. anorexia 2. vomiting 3. constipation 4. muscle weakness 5. irreg heart rate

2. vomiting 4. muscle weakness 5. irreg heart rate

a client is on a cardiac monitor. the monitor begins to alarm showing ventricular tachycardia what should the nurse do first? 1. check for a pulse 2. start cardiac compressions 3. prepare to defibrillate the client 4. administer oxygen via an ambu bag

1. check for pulse

client is being treated for hypertension reports having a persistent hacking cough what class of antihypertensive should the nurse identify as a possible cause of this response when reviewing a list of this clients medications? 1. ACE inhibitors 2. thiazide diuretics 3. calcium channel blockers 4. angiotensin receptor blockers

1. ACE inhibitors

A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I'm ready for this move?" From this statement the nurse determines that the client most likely is experiencing: 1 Fear 2 Depression 3 Dependency 4 Ambivalence

1. Fear

a nurse identifies that client who had a myocardial infarction is struggling with an alteration in self-concept. the nurse intervenes to promote client autonomy. the behavior that demonstrates an increase in client autonomy is when the client does what? 1. actively participates in providing self care 2. verbalizes realistic expectations of caregivers 3. discuss necessary lifestyle changes with family members 4. lists the indicators of recovery after a myocardial infarction

1. actively participates in providing self care

nurse is providing instructions to a client on how to reduce the dietary intake of sodium. what should the nurse include in the instructions? 1. avoid carbonated beverages 2. use steak sauce for flavoring foods 3. increase the intake of dairy products 4. restrict the use of artificial sweeteners

1. avoid carbonated beverages

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? 1. hepatitis A 2. rheumatic fever 3. spinal meningitis 4. rheumatoid arthritis

2. rheumatic fever

client with cardiac dysrhythmia reports fatigue, dizziness, and headache the primary HCP finds peripheral edema what may be causing the clients symptoms? 1. diltiazem 2. dopamine 3. dobutamine 4. disopyramide

1. diltiazem

a nurse is auscultating a clients heart sounds which valves close when the first heart sounds are produced? 1. mitral and tricuspid 2. aortic and tricuspid 3. mitral and pulmonic 4. aortic and pulmonic

1. mitral and tricuspid

for the first several hours after a cardiac catheterization its most essential for the nurse to do what? 1. monitor the clients apical pulse and BP 2. keep the head of the clients bed elevated 45 degrees 3. encourage the client to cough and deep breathe every 2 hrs 4. check the clients temp every hr until it returns to normal

1. monitor the clients apical pulse and BP

which leukocyte values should be assessed to determine the adequacy of a clients response of inflammation? select all that apply 1. monocytes 2. neutrophils 3. plasma cells 4. t helper cells 5. macrophages

1. monocytes 2. neutrophils 5. macrophages

A client with varicose veins is scheduled for sclerotherapy. What clinical finding does the nurse expect to identify when assessing the lower extremities of this client? 1 Pallor 2 Ankle edema 3 Yellowed toenails 4 Diminished pedal pulses

2 Ankle edema

which client is considered at the highest risk for a dissecting aneurysm? 1. 50 yr old white male with moderate hypertension 2. 55 yr old black male with uncontrolled hypertension 3. 40 yr old white female with uncontrolled hypertension 4. 42 yr old black female with peripheral vascular disease

2. 55 yr old black male with uncontrolled hypertension

client who had uncomplicated MI asks the nurse about resumption of sex which parameters should the nurse consider to determine safe sex select all that apply 1. client adn partner are not fearful of sex 2. at least bw 4-6 wks 3. client feels emotionally ready 4. point at which 2 flights of stairs can be climbed wo dyspnea

2. at least bw 4-6 wks 4. point at which 2 flights of stairs can be climbed wo dyspnea

nurse collecting data from client w atherosclerosis finds syncope, fatigue, pulse deficit, palpitations and pulmonary edema which disease condition might the nurse suspect? 1. angina pectoris 2. atrial fibrillation 3. myocardial infarction 4. ventricular tachycardia

2. atrial fibrillation

high in potassium 1. corn 2. bananas 3. strawberries 4. cucumber salad 5. mashed sweet potatoes 6. baked potatoes w skins

2. bananas 6. baked potatoes w skins

A client's cardiac monitor shows a PQRST wave for each beat and indicates a rate of 120 beats per minute. The rhythm is regular. The nurse concludes that the client is experiencing? 1. atrial fibrillation 2. sinus tachycardia 3. ventricular fibrillation 4. first degree atrioventricular block

2. sinus tachycardia

client w stage III-B Hodgkin disease (blood cancer starts in lympatic system) is started on chemotherapy the nurse teaches the client to notify the HCP to seek treatment for which response to chemotherapy? 1. fever of 100 F 2. sores in mouth 3. moderate diarrhea after treatment 4. nausea for 6 hrs after treatment

2. sores in mouth

A client comes to the medical clinic complaining of headaches. The nurse measures the blood pressure at 172/114. What should the nurse do first? 1 Page the on-call health care provider and continue to monitor the blood pressure. 2 Administer ibuprofen and have the client rest quietly for 20 minutes. 3 Elevate the head of the bed, provide reassurance, and reassess the blood pressure. 4 Place the client in the supine position, administer oxygen, and notify the health care provider.

3 Elevate the head of the bed, provide reassurance, and reassess the blood pressure.

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? 1 Increasing activity tolerance 2 Preventing cardiac dysrhythmias 3 Promoting physical and emotional rest 4 Maintaining potassium and sodium intake

3 Promoting physical and emotional rest

HCP isosorbide dinitrate 10 mg as needed three times a day and a nitroglycerin transdermal disk once a day for a client with chronic angina pectoris the client asks the nurse why the isosorbide dinitrate is prescribed what is the nurses best response? 1. the isosorbide dinitrate prevents the blood from clotting 2. the isosorbide dinitrate suppresses irritability in the ventricles 3. the isosrybide dinitrate allows more O2 to get to the heart tissue 4. the isosorbide dinitreate increases force of contraction of the heart

3. the isosrybide dinitrate allows more O2 to get to the heart tissue

nurse providing care to client who had major abdominal surgery monitors the client for postoperative complications which clinical findings are indicators of impending hypovolemic shock? 1. diuresis, irritability, and fever 2. lethargy, cold skin, and hypertension 3. thirst, cool skin, and orthostatic hypotension 4. bounding pulse, restlessness, and slurred speech

3. thirst, cool skin, and orthostatic hypotension

a 75 yr old client has a baseline bp of 140/90 the nurse obtains a sitting blood pressure in the clients left arm and the reading is 160/100 what action should the nurse take next? 1. advise the client to restrict fluid and sodium intake then begin to develop a teaching plan for the client 2. contact the primary HCP immediately to report to bp reading 3. record the findings recognizing that the result is expected for an older adult 4. take the BP in the right arm and then take the BP in both arms while the client is standing

4. take the BP in the right arm and then take the BP in both arms while the client is standing

client who has major abdominal surgery what client responses indicate the possibility of developing a superficial venous thrombosis? 1. pitting edema of ankle 2. reddened area at ankle 3. pruritus (extreme itching) on the side of the calf 4. tender area in posterior lower leg 5. warmth along the course of the involved vessel

4. tender area in posterior lower leg 5. warmth along the course of the involved vessel

client admitted for uncontrolled hypertension and chest pain was prescribed a low sodium diet and started on furosemide. the nurse should instruct the client to include which foods in the diet? 1. liver 2. apples 3. cabbage 4. bananas

nurse is assessing the needs of a client who just learned that a tumor is malignant. has metastasized to several organs the nurse expect the client to exhibit during the initial stage of grieving? 1. crying uncontrollably 2. criticizing medical care 3. refusing to receive visitor 4. asking for a second opinion

client w peripheral arterial disease what assessments are consistent w this diagnosis? select all that apply 1. absence of hair on toes 2. superficial ulcer w irreg edges 3. pitting edema of lower extremities 4. reports of pain associated w exercising 5. increased pigmentation of medial malleolus area

1. absence of hair on toes 4. reports of pain associated w exercising

nurse in ICU is monitoring a client who has an aortic valve replacement what can a slow pulse rate during the early postoperative period after open heart surgery indicate? 1. shock 2. hypoxia 3. heart block 4. cardiac failure

3. heart block

client who is in automobile collision is now in hypovolemic shock why is it imp for the nurse to take clients VS freq during compensatory stage of shock 1. arteriolar constriction occurs 2. cardiac workload dec 3. contracility of heart dec 4. parasympathetic nervous system is triggered

1. arteriolar constriction occurs

client with a history of severe intermittent claudication has a femoral popliteal bypass graft what is an appropriate postoperative nursing intervention on the day after surgery 1. assist the client with walking 2. help the client to sit in a chair 3. maintain the client on bed rest 4. encourage the client to keep the legs elevated

1. assist the client with walking

factos should nurse identify that can precipitate hyponatremia? select all that apply 1. GI suction 2. diuretic therapy 3. ADH secretion 4. continous bladder irrigation 5. parenteral infusion of 0.9% sodium chloride

1. GI suction 2. diuretic therapy 4. continous bladder irrigation

student nurse demonstrates correct understanding of anemia related to chronic disease with which statement? 1. RBC appear normal in size and color however theres a decreased amount produced 2. the RBC have an increased life span with a decrease in normal functioning 3. administration of vitamins B12 and folate will help to treat this type of long term anemia 4. this is the mildest form of anemia and is easily corrected through administration of blood products

1. RBC appear normal in size and color however theres a decreased amount produced

client is taking administering warfarin (Coumadin) the nurse recalls that the antidote for this medication is what? 1. Vitamin K 2. Fibrinogen 3. Prothrombin 4. Protamine sulfate

1. Vitamin K

wha is the most important information the nurse and the rapid response team must keep in mid when caring for a client who had a cardiac arrest? 1. age of the client 2. how long the client was anoxic 3. heart rate of the client before the arrest 4. emergency medications available for the client

2. how long the client was anoxic

furosemide has been prescribed as part of the medical regimen for a client with hypertension an the nurse has provided related teaching the nurse concludes that the client needs additional teaching when the client makes which statement? 1. i will take the medication first thing in the morning 2. i plan to eat a food high in vitamin K everyday 3. i will contact my HCP if i notice muscle weakness 4. i plan to take the medication as prescribed regardless of how i feel that day

2. i plan to eat a food high in vitamin K everyday

priority nursing action when caring for a client w disseminated intravascular coagulation? 1. monitor for homan sign 2. avoid giving IM injections 3. take temp via rectal route 4. apply sequential compression stockings

2. avoid giving IM injections

client is receiving doxorubicin as a part of a chemotherapy protocol. nurse should assess the client for which major life-threatening side effect of doxrubicin? 1. anemia 2. cardiotoxicity 3. pulmonary fibrosis 4. ulcerative stomatitis

2. cardiotoxicity

what should the nurse include in teaching plan for a client taking calicum channel blockers such as nifedipine select all that apply 1. reduce calcium intake 2. change positions slowly 3. report peripheral edema 4. expect temporary hair loss 5. avoid drinking grapefruit juice

2. change positions slowly 3. report peripheral edema 5. avoid drinking grapefruit juice

nurse conducting a nutrition class for a group of clients with congestive heart failure it would be most imp for the nurse to explain the imp of what? 1. restricting fluid intake 2. choosing fresh or frozen veggies instead of canned ones 3. eating a low calorie diet to reduce weight 4. recognizing which products are high in cholesterol

2. choosing fresh or frozen veggies instead of canned ones

monitoring client for hyponatremia which clinical findings should nurse consider significant? select all that apply 1. thirst 2. confusion 3. tachycardia 4. pale coloring 5. poor tissue turgor

2. confusion 5. poor tissue turgor

nurse assess client IV site which clinical finding leads nurse to conclude that IV site has been infiltrated? select all that apply 1. redness along the vein 2. coolness of skin near the insertion site 3. swelling around insertion site 4. cessation in flow of solution 5. vein feels hard and cordlike

2. coolness of skin near the insertion site 3. swelling around insertion site 4. cessation in flow of solution

client w cardiac dysrhythmia is undergoing drug therapy the HCP instructs the nurse to monitor the client for fatigue, dizziness, and tachycardia which medication may be responsible for the clients condition? 1. warfarin 2. diltiazem 3. dopamine 4. propranolol

2. diltiazem

nurse is preparing to teach a client to apply a nitroglycerin path (Nitro-Dur) as prophylaxis for angina. which instruction should the nurse include in the teaching plan? 1. apply the patch on a distal extremity 2. remove a previous patch before applying the next one 3. massage the area gently after applying the patch to the skin 4. apply a warm compress to the sit before attaching the patch

2. remove a previous patch before applying the next one

nurse caring for client w diagnosis of varicose veins which clinical findings can nurse expect to identify when assessing the client select all that apply 1. discolored toenails 2. reports of leg fatigue 3. localized heat in calf 4. reddened areas on leg 5. tortuous veins in legs 6. pain in lower extremities when standing

2. reports of leg fatigue 5. tortuous veins in legs 6. pain in lower extremities when standing

nurse is caring for a client who is a victim of trauma and is to receive a blood transfusion. how should the nurse respond when the client expresses fear that acquired immunodeficiency disease (AIDS) may be acquired as a result of the blood transfusion? 1. the blood is treated with radiation to kill the virus 2. screening for HIV antibodies has minimized this risk 3. ability to directly identify HIV has eliminated this concern 4. consideration should be given to donating your own blood for the transfusion

2. screening for HIV antibodies has minimized this risk

client with midsternal pain presents to the emergency department. VS are stable which form of nitroglycerin does the nurse anticipate giving initially? 1. oral 2. spray 3. intravenous 4. transdermal

2. spray

during a blood transfusion a client develops chills and a headache. whats the priority nursing action? 1. cover the client 2. stop the transfusion at once 3. decrease the rate of the blood infusion 4. notify the HCP immediately

2. stop the transfusion at once chills, headaches, nausea, and vomiting are signs of transfusion rxn

which client should a nurse consider the greatest risk for developing hypernatremia? 1. 52 yr old receiving 0.45% NaCl IV 2. 76 yr old who developed syndrome of inappropriate antidiurectic hormone secretion as a result of head trauma 3. 63 yr old who has watery diarrhea since traveling abroad 4. 48 yr old who is admitted with a diagnosis of addison disease

3. 63 yr old who has watery diarrhea since traveling abroad

classifying a client with HF in accordance w NY heart association guidelines nurse finds the performing less than ordinary acitivty causes fatigue palpitations dyspnea and angina in client what classification of HF does the nurse document in clients medical record? 1. Class I 2. Class II 3. Class III 4. Class IV

3. Class III

which relationship does the nurse consider reflective of the relationship of naloxone (Narcan) to morphine sulfate? 1. aspirin to warfarin (Coumadin) 2. amoxicillin (Amoxil) to systemic infection 3. Protamine sulfate to parenteral heparin 4. enoxaparin (lovenox) to dalteparin (fragmin)

3. Protamine sulfate to parenteral heparin

while receiving a blood transfusion the client suddenly shouts " i feel like someone is lowering a heavy weight on my chest I feel like I'm going to die" which actions are priority? 1. administer nitroglycerin and aspirin 2. slow the rate and monitor the VS 3. stop the transfusion and administer normal saline 4. ask the client to further describe the feeling and rate the pain

3. stop the transfusion and administer normal saline because client symptoms shows an acute hemolytic rxn (rxn during a blood transfusion wrong blood)

HCP in ER identifies that a client is in mild hypovolemic shock which type of drug should the nurse anticipate will be prescribed? 1. loop diuretic 2. cardiac glycoside 3. sympathomimetic 4. alpha adrenergic blocker

3. sympathomimetic

A client with bilateral varicose veins of the lower extremities questions the nurse about the brownish discoloration of the lower legs. The best response by the nurse is, "This is probably the result of: 1 Inadequate arterial blood supply." 2 Delayed healing of tissues after an injury." 3 Increased production of melanin in the area." 4 Leakage of red blood cells through the vascular wall."

4 Leakage of red blood cells through the vascular wall."

client is admitted to the emergency department with crushing chest pain. a diagnosis of acute coronary syndrome is suspected. the nurse expects that the clients initial treatment will include which medication? 1. gabapentin (neurontin) 2. midazolam HCL (Versed) 3. Alprazolam (Xanax) 4. Aspirin (ASA)

4. Aspirin (ASA)

client with cancer of the tonsils and enlarged lymph glands in the neck is receiving chemotherapy after surgery. which laboratory is most imp for the nurse to monitor when considering the effects of chemotherapy? 1. platelets 2. hemoglobin level 3. RBC count 4. WBC count

4. WBC count

client is admitted to the hospital with a large leg ulcer and a femoral angiogram is performed. what should the nurse do after this procedure? 1. provide range of motion to all extremities 2. elevate the foot of the bed for 36 hrs 3. assist the client to stand if unable to void 4. apply pressure to the catheter insertion site

4. apply pressure to the catheter insertion site

a nurse is assessing the needs of a client who just learned that a tumor is malignant has metastasized to several organ and that the illness is terminal. what behavior does the nurse expect the client to exhibit during the initial stage of grieving? 1. crying uncontrollably 2. criticizing medical care 3. refusing to receive visitors 4. asking for a second opinion

4. asking for a second opinion

client who is receiving a cardiac glycoside a diuretic and a vasodilator has been placed on best rest the clients apical pulse is 44 BPM the nurse concludes that the decreased heart rate most likely is a result of which drug? 1. diuretic 2. vasodilator 3. bed rest regimen 4. cardiac glycoside

4. cardiac glycoside

child with leukemia who is undergoing chemotherapy is susceptible to rectal ulcerations. what should the nurse recommend to the parents that will lessen the severity of this problem? 1. encourage lying on the abdomen when in bed 2. have the child wear cotton underpants at night 3. apply rectal ointment liberally 4 times a day 4. clean the childs perianal area after each bowel movement

4. clean the childs perianal area after each bowel movement

clinical manifestations of chronic mitral valve regurgitation select all that apply 1. fatigue 2. syncope 3. exertional dyspnea 4. holosystolic murmur 5. rumbling diastolic murmur

1. fatigue 3. exertional dyspnea 4. holosystolic murmur

nurse is collecting data from client with varicose veins who is to have sclerotherapy what should the nurse expect the client to report? 1. feeling of heaviness in both legs 2. intermittent claudication of the legs 3. calf pain on dorsiflexion of the foot 4. hematomas (blood outside of vessel) of lower extremities

1. feeling of heaviness in both legs

client develops iron deficiency anemia which of the clients lab test results should the nurse expect to be decreased? 1. ferritin level 2. platelet count 3. WBC count 4. total iron binding capacity

1. ferritin level

nurse provides discharge medication education to a client whos been switched from a prescription for heparin to a prescription for Coumadin the nurse concludes that the teaching was effective when the client states what? 1. i will take tylenol for my occasional headaches 2. i will spend most of the day working at my desk 3. i will ask HCP for antibiotics before going to dentist

1. i will take tylenol for my occasional headaches

client receiving warfarin (Coumadin) which test result should the nurse use to determine if the daily dose of this anticoagulant is therapeutic? 1. international normalized ration (INR) 2. accelerated partial thromboplastin time (APTT) 3. bleeding time 4. sedimentation rate

1. international normalized ration (INR)

client has painful leg ulcer and the nurse performs a physical assessment which clinical findings in lower extremity support a diagnosis of an arterial ulcer? select all that apply 1. lack of hair 2. thickened toenails 3. pain at ulcer site 4. diminished pedal pulse 5. brown skin discoloration

1. lack of hair 2. thickened toenails 3. pain at ulcer site 4. diminished pedal pulse

HIV clinical responses are associated most commonly with this sydrome? select all that apply 1. malaise 2. confusion 3. constipation 4. swollen lymph glands 5.oropharyngeal candidiasis

1. malaise 4. swollen lymph glands

nurse in postanesthesia care unit identifies a progressive dec in BP in a client who had major abdominal surgery what clinical findings supports the conclusion that client is having internal bleeding 1. oliguria 2. bradypnea 3. pulse deficit 4. high pot levels

1. oliguria

while recovering from abdominal surgery a client develops thrombophelbitis which clinical indicators of this complication should the nurse expect to identify when assessing the client? select all that apply 1. pain in calf 2. intermittent claudication 3. redness in affected area 4. pitting edema of lower leg 5. ecchymotic areas around the ankle 6. localized warmth in lower extremity

1. pain in calf 3. redness in affected area 6. localized warmth in lower extremity

which response during the immune response leads to chronic inflammation and damage to the host tissue? 1. regulation of action 2. remembering the invader 3. responding to nonself invaders 4. recognition of the self from nonself

1. regulation of action

how should nurse make bed of a client whos in acute phase after MI? 1. replace top linen and only necessary bottom linen 2. lift the client from side to side while changing the bed linen 3. change the linen from top to bottom without lowering the head of the bed 4. slide the client onto a stretcher to remake the bed and then slide the client back to the bed

1. replace top linen and only necessary bottom linen

woman comes to ER reporting S/S determined by health care provider to be caused by MI. nurse obtains health history which reported symptoms does nurse determine are specifically related to a MI in women? select all that apply 1. severe fatigue 2. sense of unease 3. choking sensation 4. chest pain relieved by rest 5. pain radiating down left arm

1. severe fatigue 2. sense of unease

client is discharged w a prescription for sustained - release nitroglycerin what should the nurse teach the client about sustained - release nitroglycerin? 1. swallow the capsule whole 2. take milk w medication 3. hold tablet under tongue 4. note a stinging feeling when the drug is under the tongue

1. swallow the capsule whole

clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block? 1. syncope 2. headache 3. tachycardia 4. hemiparesis

1. syncope

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.) 1. abdominal cramps 2. dec heart rate 3. peripheral parsthesia 4. dec BM 5. hyperactive deep tendon reflexes

2. dec heart rate 4. dec BM

client who has prescription for diuretic 2 gram sodium diet and an oral fluid restriction of 1200 ml daily the most recent lab results are blood urea nitrogen BUN level 42 mg/dL and creatnine 1.1 mg/dL considering the assessment findings whats the most app. intervention by the nurse? 1. sending the clients urine for analysis 2. expecting an inc in oral fluid intake 3. placing the client on strict intake/output measurements 4. notifying nutrionist/dietitian so that sodium can be restricted furter

2. expecting an inc in oral fluid intake

client with a history of hypertension develops dyspnea on exertion what does the nurse conclude is the most likely cause of clients dyspnea? 1. cor pulmonale 2. left HF 3. bronchial spasms 4. right ventricular failure

2. left HF

nurse is reviewing health history and lab results of a school aged child admitted to pediatric unit with acute nonlymphoid leukemia what clinical findings does the nurse expect? select all that apply 1. oliguria 2. listlessness 3. few stem cells 4. difficulty swallowing 5. bone marrow depression

2. listlessness 5. bone marrow depression

responses should a nurse expect a client experiencing hypoglycemia to exhibit? select all that apply 1. nausea 2. palpitations 3. tachycardia 4. nervousness 5. warm dry skin 6. increased respirations

2. palpitations 3. tachycardia 4. nervousness

nurse tells 71 yr old client with dyspnea orthopnea pulmonary crackles wheezing and frothy pink sputum upon coughing to avoid isometric exercise what is the rationale behind this suggestion? 1. reduce pain 2. prevent fatigue 3. improve coping 4. strengthen the body

2. prevent fatigue

client whose lab values indicate hyponatremia which risk fators should nurse assess the client most likely may have caused it? select all that apply 1. diabetes insipidus 2. profuse diaphoresis 3. excess sodium intake 4. removal of parathyroid glands 5. removal of parathyroid glands 6. rapid IV infusion of 5% dextrose in water

2. profuse diaphoresis 6. rapid IV infusion of 5% dextrose in water

client with valvular heart disease says hes extremely tired and the nurse heard a loud midsystolic murmur what does the nurse suspect from this finding? 1. tricuspid stenosis 2. pulmonic stenosis 3. aortic valve stenosis 4. mitral valve prolapse

2. pulmonic stenosis

client is admitted to the emergency department after vomiting bright red blood. after the vomiting ceases and VS are stabilized the client is transferred to a medical surgical unit to assess for bleeding what should the nurse on the medical surgical unit should monitor the client for? 1. lethargy 2. tachycardia 3. deep breathing 4. abdominal pain

2. tachycardia

client who takes high dose aspirin for arthritis has an acute episode of right ventricular HF HCP prescribes furosemide and lowers the clients usual dosage of aspirin the client asks the nurse the reason for the lower dose what principle does the nurse base a response? 1. aspirin accelerates metabolism of furosemide and decreases the diuretic effect 2. aspirin in lg doses after an acute stress episode increases the bleeding potential 3. competition for renal excretion sites by the drugs causes inc serum levels of aspirin 4. use of furosemide and aspirin concomitantly increases formation of uric acid crystals in the nephron

3. competition for renal excretion sites by the drugs causes inc serum levels of aspirin

caring for a client who has hyponatremia (high serum sodium) the nurse monitor for which symptom? 1. inc urine output 2. deep rapid respirations 3. dec specific gravity 4. distended neck veins

3. dec specific gravity

HCP asks a nurse to encourage bed rest to plan care to prevent fatigue in a client what condition might the client have? 1. pain related to ischemia ( not enough o2 to brain) 2. respiratory distress related to cardiac dysrhythmia 3. decreased cardiac output related to cardiac insufficiency 4. GI complaints related to cardiac dysrhythmia

3. decreased cardiac output related to cardiac insufficiency

nurse is assessing a middle aged female for client for the presence of risk factors associated with coronary heart disease which risk factor carries a greater risk for women than for men 1. obesity 2. hypertension 3. diabetes 4. cigarette smoking

3. diabetes

what med does a nurse expect to administer to control bleeding in a child w hemophilia A? 1. albumin 2. fresh frozen plasma 3. factor VIII concentrate 4. factor II, VII, IX, X complex

3. factor VIII concentrate is the missing plasma component needed to control bleeding a kid and it does contain frozen plasma thers not enough in a plasma infusion

nurse providing teaching to a client who is scheduled for a cardiac catheterization via the femoral approach the teaching includes that the client will be what 1. ambulated shortly after being transferred to the inpatient room after the procedure 2. given a general anesthesia and therefore will be asleep during the procedure 3. in the supine position with the affected leg extended for several hr postprocedure 4. given only liquids for the remainder of the procedure day

3. in the supine position with the affected leg extended for several hr postprocedure

valsartan 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 1. constipation 2. hypokalemia 3. irreg pulse rate 4. change in visual acuity 5. orthostatic hypotension

3. irreg pulse rate 5. orthostatic hypotension

the parents of a school age child with leukemia asks the nurse why irradiation of the spine and skull is necessary what is the most accurate response by the nurse? 1. radiation retards the growth of cells in the bone marrow of the cranium 2. this therapy decreases cerebral edema and prevents increased intracranial pressure 3. leukemic cells may invade the nervous system but the usual drugs are ineffective in the brain 4. neoplastic drug therapy without radiation is effective in most cases but this is a precautionary treatment

3. leukemic cells may invade the nervous system but the usual drugs are ineffective in the brain

while obtaining health history a nurse expects a client admitted to hospital w chronic HF to report what? 1. tingling in upper extremities 2. feeling bloated after eating 3. need to use 3 pillow at night to sleep 4. swelling of ankles thats more apparent in morning

3. need to use 3 pillow at night to sleep HF causes fluid vL excess and is pulmonary edema and dyspnea in supine position

client with pharyngitis, carditis, polyarthritis and erythematous circles and wavy lines on the trunk reports fatigue and severe chest pain which med treatment will be most beneficial to this client? 1. digoxin 2. aliskiren 3. penicillin 4. diltiazem

3. penicillin

client with a history of HF on daily weights has 2 lb weight gain and pitting edema in lower extremities bilaterally which action should the nurse take next? 1. check the record to ascertain the code status 2. encourage increased intake of fav drink 3. perform a head to toe assessment including VS 4. continue to monitor daily weights and edema and to document findings

3. perform a head to toe assessment including VS

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? 1. offer cool fluids 2. suction the airway 3. remove the clothing 4. prepare for intubation

3. remove the clothing

nurse in interpreting the clients rhythm strip and finds that P and QRS waves are consistent with a P wave preceding every QRS complex the PR interval is 0.26 sec long the rate 64 bpm how should the nurse interpret this rhythm? 1. complete heart block 2. normal sinus rhythm 3. sinus rhythm w first degree AV block 4. sinus rhythm w second degree AV block

3. sinus rhythm w first degree AV block

nurse making round w pt w developed severe bone marrow depression after receiving chemotherapy for cancer which of these actions by the nurse is app. select all that apply 1. monitor for signs of alopecia 2. encourage an inc in fluids 3. wash hands before entering the clients room 4. advise use of soft toothbrush for oral hygiene 5. report elevation in temp asap 6. encourage client to eat raw fruit and veggies

3. wash hands before entering the clients room 4. advise use of soft toothbrush for oral hygiene 5. report elevation in temp asap INFECTION

nurse is planning nutritional education for a client with lower extremity arterial disease (LEAD) what diet modifications should the nurse include? 1. decreasing both fluid and sodium intake 2. increasing both calcium and potassium intake 3. increasing both vitamin E and refined grain intake 4. decreasing both cholesterol and saturated fat intake

4. decreasing both cholesterol and saturated fat intake

amlodipine prescribed for client w hypertension which response to med should nurse instruct client to report to HCP 1. blurred vision 2. dizziness on rising 3. excessive urination 4. difficulty breathing

4. difficulty breathing

client diagnosis of acute lymphoblastic leukemia is receiving chemotherapy which assessment findings should alert the nurse to possible development of life threatening response of thrombocytopenia? select all that apply 1. fever 2. diarrhea 3. headache 4. hematuria 5. ecchymosis (bruising)

4. hematuria 5. ecchymosis (bruising)

what does a shift to left indicate in WBC differential? 1. heightened phagocytosis 2. functioning bone marrow 3. infection is being contained 4. immature neutrophils in blood

4. immature neutrophils in blood

client w history of hypertension and left ventricular failure arrives for a scheduled clinic appt and tells the nurse "my feet are killing me these shoes got so tight" what is nurses best initial action? 1. weigh the client 2. notify HCP 3. take the clients pulse rate 4. listen to the clients breath sounds

4. listen to the clients breath sounds ABC

client is admitted with stage 2 hypertension what diastolic pressure does the nurse consider to be consistent with this diagnosis? 1. 80 to 89 2. 90 to 99 3. less than 79 4. more than 100

4. more than 100

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? 1. elevate the foot of bed 2. perform urinary catheter care every 12 hrs 3. place in high fowler position 4. perform a neurovascular assessment every 2 hrs

4. perform a neurovascular assessment every 2 hrs

nurse witnesses a person fall the person becomes unresponsive and pulseless the nurse plans to use an automated external defibillator that is available on site what should the nurse do first 1. remove all jewelry 2. wash chest area 3. use a grounded electric source 4. remove any medication patches

4. remove any medication patches

which acid base imbalance causes the kidneys to increase excretion of bicarbonate in order to lower pH levels? 1. metabolic acidosis 2. metabolic alklosis 3. respiratory acidosis 4. respiratory alkaosis

4. respiratory alkaosis

which clinical indicator should the nurse expect to identify when assessing a client w varicose veins? 1. pos homans sign 2. pallor of the affected extremity 3. continuous edema of lower legs 4. sensation of heaviness of calf muscles

4. sensation of heaviness of calf muscles

client has MI one major manifestation is a dec in conductive energy provided to heart what is most imp for the nurse to assess that has direct relationship to action potential of heart 1. heart rate 2. refractory period 3. pulmonary pressure 4. strength of contractions

4. strength of contractions

what is the reason for the development of erythema, heat, edema, and pain with inflammation? 1. increase in the flow of blood elements 2. production of a thin and watery serum portion of blood 3. production of thin and red fluid exudates from the wound 4. overgrowth of collagenous scar tissue at the site of the wound

1. increase in the flow of blood elements

after sustaining multiple internal injuries when hit by a motor vehicle a client has a sudden drop in blood pressure to 80/60 mm Hg. what does the nurse determine probably causes this response? 1. reduction in circulating blood volume 2. diminished vasomotor stimulation to arterial walls 3. vasodilation resulting from diminished vasoconstrictor tone 4. cardiac decompensation resulting from electrolyte imbalance

1. reduction in circulating blood volume

a nurse has administered sublingual nitroglycerine. which parameter should the nurse use to determine the effectiveness of sublingual nitrogylcerin? 1. relief of anginal pain 2. improved cardiac output 3. decreased BP 4. dilation of superficial blood vessels

1. relief of anginal pain

a nurse is caring for a client who is receiving serum albumin. what indicates that the albumin is effective? 1. improved clotting of blood 2. formation of RBC 3. activation of WBC 4. effective cardiac output

4. effective cardiac output

the client who takes furosemide and digoxin reports that everything looks yellow. how will the nurse respond? 1. this is related to your heart problems not the medication 2. it is medication that is necessary and that side effect is only temporary 3. take this dose and when i see your HCP i will ask about it 4. i will hold the medication until i consult with your HCP

4. i will hold the medication until i consult with your HCP

28 yr old woman fractured her left tibia and fibula one week ago and has a cast in place. she is taking tylenol with codeine for pain and an oral contraceptive. she began experiencing left calf pain 3 days ago and began having shortness of breath and chest pain increase she calls the emergency department and communicates this information to the triage nurse what is the nurses best response? 1. give me your name and address i am sending and ambulance to your home you need emergency care 2. it sounds as if your cast may be constricting the blood flow in your leg you probably need a new cast 3. it sounds like youre having and allergic response to the medication can you drive yourself to the hospital? 4. youre experiencing a pulmonary embolism you need to come to the emergency department now for care

1. give me your name and address i am sending and ambulance to your home you need emergency care

A blood donor whose blood type is O-negative is known as a "universal donor." What does the nurse consider about O-negative blood that accounts for this classification? 1. it does not have any of the antigens that can cause a rxn 2. the donor can donate blood more freq than other ppl 3. the antibodies to HIV can develop more quickly than other blood types 4. it is more frequently administered when compared with other blood types

1. it does not have any of the antigens that can cause a rxn

a client is taking furosemide and digoxin for HF. why does the nurse advise the client to drink a glass of orange juice ever day? 1. maintaining potassium levels 2. preventing increased sodium levels 3. correcting the associated dehydration 4. limiting the drugs synergistic effects

1. maintaining potassium levels oj great source of potassium

a client is admitted to the ER with chest pain and shortness of breath. an electrocardiogram indicates that the client is experiencing a myocardial infarction an emergency cardiac catheterization is scheduled what information should the nurse include in the pre-procedure teaching? 1. mild sedation is maintained during the procedure 2. the procedure will take approx 15 min to complete 3. ambulation is encouraged shortly after the procedure 4. it will take approx 24 hrs to determine if blockage is present

1. mild sedation is maintained during the procedure

an 85 yr old client has serum potassium level of 6.7 mEq/l which nursing action is the priority at this time? 1. monitor for cardiovascular irregularitites 2. inquire about changes in bowel patterns 3. assess for leg muscle twitching or weakness 4. assess for signs and symptoms of dehydratino

1. monitor for cardiovascular irregularitites

client has left ventricular HR. for which clinical indicators should the nurse assess the client? select all that apply 1. ascites (fluid (swelling in abdominal)) 2. crackles 3. peripheral edema 4. dyspnea (difficult breathing) on exertion 5. jugular vein distention

2. crackles 4. dyspnea (difficult breathing) on exertion

a client is diagnosed with HF and is admitted for medical management. which statement by the client may indicate worsening HF? 1. I am unable to run a mile now 2. i wake up at night short of breath 3. my shoes seem larger lately 4. wife says i snore very loud

2. i wake up at night short of breath

a client has a tentative diagnosis of Hodgkin disease the nurse recalls that the diagnosis is confirmed by what? 1. bone scan 2. lymph node biopsy 3. computed tomography CT scan 4. radioactive iodine (I-131) uptake study

2. lymph node biopsy

during a routine physical examination an abdominal aortic aneurysm is diagnosed. the client immediately is admitted to the hospital and surgery is scheduled for the next morning which clinical finding should the nurse expect when performing an assessment for this client? 1. severe radiating abdominal pain 2. pattern of visible peristaltic waves 3. palpable pulsating abdominal mass 4. cyanosis with other symptoms of shock

3. palpable pulsating abdominal mass

client diagnosed with multiple myeloma has been given a poor prognosis after discharge the client plans to travel on airplane to attend sporting events with friends and family the nurse prepares a discharge teaching plan for this client and includes what? 1. eliminating travel plans to combat anemia related fatigue 2. reinforcing a positive mental attitude to improve prognosis 3. preventing infection the client is at risk for leukopenia 4. restricting fluid intake client is at risk for congestive heart failure

3. preventing infection the client is at risk for leukopenia

metoprolol is prescribed for a client which condition in the clients electronic medical record will cause the nurse to question the prescription? 1. hypertension 2. angina pectoris 3. sinus bradycardia 4. myocardial infarction

3. sinus bradycardia

a client with severe varicose veins has surgery that involves ligation, dissections, and removal of incompetent vessels. in which position should the nurse place the client after surgery? 1. supine with the knee support of the bed raised 2. in a semi fowler position with knees flexed 3. supine with legs elevated at 15 degree angle 4. semi fowler position w feet against a footboard

3. supine with legs elevated at 15 degree angle

nurse is caring for a client admitted with shock secondary to severe GI bleeding once the client is stabilized what intervention should the nurse do next? 1. monitor the peripheral pulses 2. check the level of consciousness 3. take a blood sample for lab tests 4. control the bleeding with a pressure dressing

3. take a blood sample for lab tests

a client is admitted with the diagnosis of possible myocardial infarction and a series of diagnostic tests are prescribed. which blood level should the nurse expect will increase first if this client has had a myocardial infarction? 1. Alanine aminotransferase (ALT) 2. serum aspartate aminotransferase (AST) 3. total lactate dehydrogensase (LDH) 4. Troponin T (cTnT)

4. Troponin T (cTnT)

when 2 nurses are getting an older adult out of bed the client reports feeling lightheaded the nurses identifies that the clients pulse is stable and the clients color has not changed what should the nurse assist the client to do? 1. slide slowly to the floor to prevent a fall and injury 2. sit on the edge of the bed while they hold the client upright 3. bend forward bc this will increase blood flow to the brain 4. lie down quickly so the legs can be raised above heart level

2. sit on the edge of the bed while they hold the client upright

the nurse is providing care for a client who had an endarterectomy (cartoid artery surgery in neck) one month ago. the nurse explains the reason that clopidogrel (Plavix) is being prescribed. the nurse concludes that the teaching is understood when the client says what? 1. medication will limit inflammation around my incision 2. medication will help prevent further clogging of my arteries 3. medication will lower the slight fever I have had since surgery 4. medication will reduce the discomfort I feel at the surgical incision

2. medication will help prevent further clogging of my arteries

during an interview the nurse discovers that the spouse of a debilitated chronically constipated client digitally removes stool from the clients rectum what response to disimpaction is the nurse attempting to prevent by presenting other strategies to regulate the clients bowel movements? 1. increased pulse rate 2. slowing of the heart 3. dilation of the bronchioles 4. coronary artery vasodilation

2. slowing of the heart

which conditions may result from immunoglobulin IgE antibodies (allergic rxn) on mast cells reacting with antigens? select all that apply 1. asthma 2. hay fever 3. sarcoidosis 4. myasthenia gravis 5. rheumatoid arthritis

1. asthma 2. hay fever

nurse is preparing a care plan for a client with fatigue angina, anxiety, and pale cool skin which nursing intervention will help reduce fatigue in this client? 1. encouraging diversionary activities 2. providing a calm relaxing environment 3. maintaining the client in a semi fowler position 4. encouraging the client to walk 3 km every two hours

1. encouraging diversionary activities

what should the nurse expect the HCP to prescribe if a client exhibits clinical indicators of warfarin (Coumadin) overdose? 1. herparin 2. vitamin K 3. iron dextran (Imeferon) 4. protamine sulfate

2. vitamin K

client is admitted with a higher than expected RBC count. what physiological alteration does the nurse expect will result form this clinical finding? 1. increased serum pH 2. decreased hematocrit 3. increased blood viscosity 4. decreased immune response

3. increased blood viscosity

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 HF? 1. weight loss 2. unusual fatigue 3. dependent edema 4. nocturnal dyspnea 5. increased urinary output

2. unusual fatigue 3. dependent edema 4. nocturnal dyspnea

a nurse is responding to the needs of victims at a collapsed building. what principle guide the nurses priorities during this disaster? 1. to save the most lives hemorrhage necessitates immediate care 2. those requiring minimal care are treated first so they can help others 3. because the care is most complex victims with head injuries are treated first 4. children receive the highest priority because they have the greatest life expectancy

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

nurse attempts to give a client with chronic arterial insufficiency of the legs the prescribed dose of aspirin the client refuses it stating "my legs are not painful" what should the nurse do? 1. explain the reason for the medication and encourage the client to take it 2. withhold the medication and tell the client to ask for it if the legs become uncomfy 3. withhold the medication at this time and return to check with the client again in 30 min 4. request that the client take the medication and explain that it will prevent the client from being uncomfy in the next few hours

1. explain the reason for the medication and encourage the client to take it

a nurse is assessing a client with the diagnosis of primary hypertension what clinical finding does the nurse identify as an indicator of primary hypertension? 1. mild but persistent depression 2. transient temporary memory loss 3. occipital headache in the morning 4. cardiac palpitation during periods of stress

3. occipital headache in the morning

a client with HF is to receive digoxin and asks the nurse why the medication is necessary the nurse explains that digoxin does what? 1. increases ventricular contractions 2. reduces edema in extracellular spaces 3. slows and strengthens cardiac contractions 4. increases cardiac impulses through the conduction system of the heart

3. slows and strengthens cardiac contractions

client who is considering sclerotherapy asks the nurse to explain what causes varicose veins what is the nurses best response? 1. they are caused by abnormal configurations of the veins 2. they are caused by incompetent valves of superficial veins 3. they are caused by decreased pressure within the deep veins 4. they are caused by atherosclerotic plaque formation in the veins

2. they are caused by incompetent valves of superficial veins

what should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension? 1. wear support hose continuously 2. lie down for 30 min after taking the medication 3. avoid tasks that require high-energy expenditure 4. sit on the edge of the bed for 5 min before standing

4. sit on the edge of the bed for 5 min before standing

client who is recovering from an acute myocardial infarction reports not being happy about the lack of salt with meals. which information should the nurse share with the client about the purpose of salt restriction? 1. prevents an increase in BP from tissue edema 2. this reduces the circulating blood volume by a diuretic effect 3. this reduces the amount of edema which interferes with heart action 4. this prevents further fluid accumulation which increases the workload of the heart

4. this prevents further fluid accumulation which increases the workload of the heart

a client with chronic liver disease reports " my gums have been bleeding spontaneously " the nurse identifies small hemorrhagic lesions on the clients face. the nurse concludes that the client needs additional what? 1. bile salts 2. folic acid 3. vitamin A 4. vitamin K

4. vitamin K

how can you control a nose bleed?

pinch the nostrils together

which task can be safely delegated by rn to cna for a client with thrombocytopenia? 1. shaving the client 2. positioning the client 3. maintaining oral hygiene 4. giving iv platelet infusin

2. positioning the client

nurse is caring for a client who has an occlusion of the left femoral artery and is scheduled for an arteriogram (image of arteries). which clinical finding is most significant when assessing the left extremity before the arteriogram? 1. mottling of the leg 2. coolness of the foot 3. absence of the pedal pulse 4. thickening of the toenails on the foot

3. absence of the pedal pulse

the spouse of a client who had emergency coronary artery by[ass surgery asks why there is a dressing on the clients left leg. what does the nurse explain? 1. this is the access site for the heart lung machine 2. a filter is inserted in the leg to prevent embolization 3. vein in the leg was used to bypass the coronary artery 4. the arteries in the extremities are examined during surgery

3. vein in the leg was used to bypass the coronary artery

client is diagnosed with hypertension that is related to atherosclerosis. which info should the nurse consider when planning care for this client? 1. renin causes a gradual decrease in arterial pressure 2. lipid plaque formation occurs within the arterial vessels 3. development of atheromas within the myocardium is characteristic 4. mobilization of free fatty acid from adipose tissue contributes to plaque formation

2. lipid plaque formation occurs within the arterial vessels

a client with a cancer develops pancytopenia during the course of chemotherapy the client asks the nurse why this has occurred what does the nurse explain? 1. steroid hormones have a depressant effect on the spleen and bone marrow 2. noncancerous cells also are susceptible to the effects of chemotherapeutic drugs 3. lymph nodes activity is depressed by radiation therapy used before chemotherapy 4. dehydration caused by nausea vomiting and diarrhea results in hemoconcentration

2. noncancerous cells also are susceptible to the effects of chemotherapeutic drugs

client with angina pectoris is scheduled for a stress echocardiogram. what does the nurse explain the echocardiogram is? 1. tool used solely to determine the cause of chest pain 2. noninvasive approach to assess cardiovascular status 3. modality of minimal value in planning treatment for angina 4. test that's invasive that measures the bodys rxn to progressive increases in exertion.

2. noninvasive approach to assess cardiovascular status

client with hypertensive heart disease who had an acute episode of heart failure is to be discharges on a regimen of metoprolol and digoxin the nurse expects that metoprolol when administered with digoxin may do what? 1. produce headaches 2. precipitate bradycardia 3. increase BP 4. stimulate nodal conduction

2. precipitate bradycardia

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? 1. cerebral embolism 2. pulmonary embolism 3. dry gangrene of a limb 4. coronary vessel occulsion

2. pulmonary embolism

nurse is providing discharge instructions for a client with angina who has prescription for sublingual nitroglycerin tablets the nurse should teach the client that the nitroglycerin sublingual tablets have lost their potency when what happens? 1. sublingual tingling is experienced 2. the tablets are more than 3 months old 3. the pain is unrelieved but facial flushing is increased 4. onset of relief is delayed but the duration of relief is unchaged

2. the tablets are more than 3 months old

a nurse is working in the ICU which client will the nurse be prepared to assist with cardioversion? 1. a client exhibiting ventricular asystole 2. a client exhibiting ventricular fibrillation 3. a client with supraventricular tachycardia 4. a client with freq premature ventricular complexes

3. a client with supraventricular tachycardia

nurse suggest to an older adult with heart disease to use an air conditioner when the room temp at home gets uncomfy warm. what is the rationale for this recommendation? 1. air conditioning increases the heart rate 2. air conditioning promotes circulation to the skin 3. air conditioning reduces the workload on the heart 4. air conditioning maintains a consistent internal body temp

3. air conditioning reduces the workload on the heart

nurse observes a client collapse while walking down the hallway. the nurse rushes to the client and determines that the client is in cardiopulmonary arrest. what will the nurse do first? 1. do a blind finger sweep 2. begin chest compressions 3. check for a carotid pulse 4. perform the abdominal thrust maneuver

3. check for a carotid pulse

plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. the client asks why all activity is restricted. the nurses response is based on which principle of bed rest? 1. prevents the further aggregation of platelets 2. enhances the peripheral circulation in the deep vessels 3. decreases the potential for further dislodgment of emboli 4. maximizes the amount of blood available to damaged tissues

3. decreases the potential for further dislodgment of emboli

a nurse provides teaching regarding vitamin B12 injections to a client with pernicious anemia. the nurse concludes that the teaching was understood when the client makes which statement? 1. i must take the drug when feeling fatigued 2. i must take the drug until my symptoms subside 3. i must take the drug monthly for the rest of my life 4. i must take the drug during exacerbations of anemia

3. i must take the drug monthly for the rest of my life

a client with coronary occlusion is experiencing chest pain and distress what is the primary reason that the nurse should administer oxygen to this client? 1. prevent dyspnea 2. prevent cyanosis 3. increase oxygen concentration to heart cells 4. increase oxygen tension in the circulating blood

3. increase oxygen concentration to heart cells

nurse is assessing a group of clients. which client is considered at the highest risk for dissecting aneurysm? 1. 70 yr old male with peripheral vascular disease 2. 65 yr old male with uncontrolled hypertension 3. 40 yr old female with controlled hypertension 4. 42 yr old female with peripheral vascular disease

2. 65 yr old male with uncontrolled hypertension

nurse concludes that the gradual occlusion of the internal or common carotid arteries manifested by transient ischemic attacks may occur because of what reason? 1. acquired valvular heart disease 2. atherosclerosis of the vascular system 3. emboli associated with atrial fibrillation 4. developmental defects of the arterial wall

2. atherosclerosis of the vascular system

a nurse identifies premature ventricular complexes on a clients cardiac monitor what does the nurse conclude that these complexes are a sign of? 1. atrial fibrillation 2. cardiac irritability 3. impending heart block 4. ventricular tachycardia

2. cardiac irritability

which client statement indicates and understanding of the nurses instructions concerning a Holter monitor? 1. the only times the monitor should be taken off is for showering and sleep 2. the monitor will record my activities and symptoms if an abnormal rhythm occurs 3. the results from the monitor will be used to determine the size and shape of my heart 4. the monitor will record any abnormal heart rhythms while i go about my usual activities

4. the monitor will record any abnormal heart rhythms while i go about my usual activities

a nurse is caring for a client with a diagnosis of polycythemia vera the client asks " why i have an increased tendency to develop blood clots?" which effect of the polycythemia vera should the nurse explain increases the risk of these thromboses ? 1. elevated BP 2. increased blood viscosity 3. fragility of the blood cells 4. immaturity of red blood cells

2. increased blood viscosity

client w hypertension is scheduled for a scan and electrolyte studies. during an interview with the nurse the client exclaims "I dont know why i just cant get a prescripiton for high BP pills that probably is all it is im missing work by being here." which is the best response by the nurse? 1. it might not be high BP we have to make sure 2. its frustrating to miss work and not know for sure whats wrong 3. i know its frustrating but you need to have a diagnostic workup 4. maybe you could ask your HCP if the tests could be done on separate days

2. its frustrating to miss work and not know for sure whats wrong

each yr a client takes many trips to other countries the client reports leg swelling during the long flights the nurse should advise the client to do what during the flights? 1. relax in a reclining position 2. sit upright with legs extended 3. walk around at least every hr 4. sit in any position that relieves pressure on the legs

3. walk around at least every hr

a client who had a right total hip replacement 3 days ago reports extreme tenderness in the right calf. on examination the nurse identifies a warm area occurring on the back of the leg extending into the popliteal space. the physical therapist has just arrived to assist the client with ambulation and exercise. what should the nurse do to the best meet this clients needs? 1. assist the therapist in ambulating the client 2. administer the clients prescribed analegesic 3. reassure the client that pain can be expected after surgery 4. notify HCP regarding the clients status

4. notify HCP regarding the clients status