Concepts 2 Perfusion Practice Assessment
A nurse is reinforcing teaching for a client about snacks that are appropriate on a low-fat, low-sodium, low-cholesterol diet. Which of the following choices indicates need for further teaching?
A slice of cheese
A nurse at a provider's office receives a phone call from a client who reports unrelieved chest pain after taking Nitrostat about 5 minutes ago. Which of the following is an appropriate response by the nurse?
Instruct the client to call 911
A nurse is providing discharge teaching to a client who is prescribed transdermal nitroglycerin paste (nitro-bid). Which of the following client statements indicates a need for additional teaching?
"I should leave the patch in place until it is time for the next dose of nitro-bid"
A client asks a nurse, "why am I taking nitroglycerin?" Which of the following is the best response by the nurse?
"Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart"
A client has a new prescription for transdermal nitroglycerin to treat angina pectoris. When talking with the patient about using this drug, the nurse should include which instructions?
-Apply to hairless area and rotate sites -Apply new patch in the morning -Remove for 10-12 hours daily
A nurse is assisting with the care of an older adult client who just had a cardiac catheterization. Which nursing interventions should the nurse contribute to the client's plan of care for the next 8 hrs
-Check peripheral pulses -Keep hip and leg extended -Have client remain in bed up to 6 hrs
A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as risks?
-Hypercholesterolemia -Hypertension -Obesity -Smoking
A nurse is preparing to obtain an ECG. Which of the following actions should the nurse implement? (Select all that apply)
-Inspect the electrode pads -Instruct the client to breath normally
A nurse is collecting data from a client who has an acute myocardial infarction (MI). Which of the following clinical manifestations should the nurse expect to find?
-Nausea -Tachycardia -Diaphoresis
A nurse is reinforcing teaching with a young adult female client who has been prescribed lisinopril. Which of the following instructions should the nurse plan to include?
-Report dry cough -Monitor blood pressure -Pregnancy
A nurse is collecting data from a client who has anemia and a hemoglobin of 7.2. Which of the following findings should the nurse expect?
Brittle fingernails
A nurse at an urgent care clinic is caring for a client who is experiencing chest pain. While waiting for emergency services to arrive, the nurse administers a total of 3 nitrostat tabs 0.4 mg. how many total mg has the patient received?
1.2 mg
A nurse is assisting with the care of a client who was admitted to the ER with reports of chest pain and severe epigastric distress. The nurse should anticipate that in the presence of an acute MI the client's creatinine kinase-MB is expected to peak how many hours after the onset of chest pain?
24 hours
A nurse is preparing to administer 400 mL of NaCl over 8 hours with a drop factor of 60gtt/min. What is the drop rate?
50 gtt/min
A nurse in a provider's office is reviewing the laboratory results of four clients who take digoxin. Which of the following clients is at risk for developing digoxin toxicity?
A client who takes Furosemide for hypertension
While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following?
A cardiac murmur
A nurse is reviewing the morning laboratory results of electrolytes for four clients who are receiving digoxin. Which of the following clients should the nurse identify as being at risk for developing digoxin toxicity?
A client taking furosemide for chronic hypertension
A nurse on a medical unit is caring for a client who has angina pectoris and reports chest pain with a severity of a 6 on a 0 to 10 scale. The nurse administers sublingual nitroglycerin (Nitrostat). After 5 min, the client states that his chest pain is now a 2. Which of the following actions should the nurse take?
Administer another nitroglycerin tablet.
A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse?
Apical
A nurse is talking with a client who is about to start using sublingual nitroglycerin (Nitrostat) to treat angina pectoris. The client asks the nurse how long he has to take the medication before his condition is cured. The nurse should first:
Ask the client what he knows about his diagnosis.
A nurse caring for a client who has a new prescription for atenolol. For which of the following adverse effects should the nurse monitor the client?
Bradycardia
The nurse is reinforcing teaching regarding diet to a client who has had a MI. Which of the following diet choices by the client indicates an understanding of the teaching?
Baked turkey and salad
The nurse is reinforcing teaching regarding diet to a client after a myocardial infarction. The nurse evaluates the reinforcement as effective if the client selects which of the following options?
Baked turkey, mashed potatoes, squash, and salad
A nurse is reinforcing teaching with a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following food choices reflects the client's understanding of these dietary instructions?
Beans
A client who has had a significant MI receives a referral to the cardiac rehab unit. During his first visit to the unit, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do as the damage is done. Which one of the following is an appropriate response?
Cardiac rehab cannot undo the damage to your heart but can help you get back to your previous level of activity safely.
A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?
Check clients vital signs
A nurse is caring for a client immediately following a cardiac catherization with a femoral artery approach. Which of the following actions should the nurse take?
Check pedal pulses every 15min
A client receives clopidogrel (Plavix) after placement of a cardiac stent. Which of the following should the nurse recognize as a therapeutic response?
Client denies difficulty swallowing
A nurse is reinforcing dietary teaching with a client who has iron deficiency anemia. Which of the following foods should the nurse recommend?
Cooked oatmeal
A nurse is caring for a client who has just had a cardiac catheterization. The post procedure nursing care plan for this client should include which of the following nursing interventions?
Have the client rest in bed for 2 to 6 hr
A nurse is collecting data from a client who has anemia due to excess blood loss during surgery. The nurse should expect which of the following findings?
Dyspnea on exertion
A nurse is reviewing the prescriptions for a newly admitted client who is to undergo cardiac testing. For which of the following procedures should the nurse verify that the client has given written informed consent?
Exercise ECG stress test
A nurse is reinforcing teaching for a client who has angina pectoris and a new prescription to apply nitroglycerin transdermal patch daily at home. Which of the following instructions should the nurse give the client?
Fold used patch with medication area to the inside and discard in a closed receptacle.
A nurse is caring for a client who has a DVT, who received IV heparin for the past 5 days, and now has a new prescription for oral warfarin in addition to the heparin. The client asks the nurse if both medications are necessary. Which of the following is an appropriate response by the nurse?
Heparin will be continued until Warfarin reaches a therapeutic level.
A nurse is reinforcing teaching with a client who has angina pectoris about starting therapy with nitrostat sublingual tablets. The nurse verifies the client's understanding when the client states states which of the following?
If one tablet does not relieve the client's pain, he should access emergency services and then take two more at 5-min intervals if he still has pain.
A nurse is reinforcing teaching for a client who has a new prescription for sublingual nitroglycerin. Which instructions should the nurse include?
If your mouth is dry, take a sip of water before putting the tab under your tongue.
A client comes to the emergency department via ambulance to report severe radiating chest pain and shortness of breath. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 l/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse assisting with this client's care take first?
Initiate oxygen therapy
A client is telling the nurse in the clinic that he gets a headache after he takes sublingual nitrostat. which of the following should the nurse remind the client to do?
Lie down in a cool environment and rest
A nurse is caring for a client following a cardiac catheterization. Which of the following is an appropriate nursing action?
Monitor pedal pulses every 15 min
While admitting a client for a cardiac catheterization, the nurse asks the client about allergies. The client states, "I always get a rash when I eat shellfish" Which one of the following is a priority action?
Notify the provider of the client's allergy.
A nurse is planning care for a client who has a suspected MI. Which of the following should the nurse administer first?
Oxygen
A nurse is assisting as adolescent client in the selection of complementary protein sources on the lunch menu. The client is a vegetarian who eats milk products but does not like beans. Which of the following food items should the nurse recommend?
Peanut butter and jelly with enriched bread
A nurse is caring for a client who enters the emergency room complaining of severe chest pain. Which of the following interventions should the nurse implement if the client is experiencing an MI?
Perform an ECG
a nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?
Peripheral edema
A nurse is collecting data from a client prior to administering nifedipine. For which of the following should the nurse contact the provider?
Peripheral edema of the ankles
A nurse is caring for a client who has a new prescription for warfarin. The nurse should use the results of which of the following diagnostic tests to monitor the effect of this therapy?
Prothrombin time (PT)
A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate (Kayexalate). If this medication is effective, the nurse should expect which of the following corrections on the clients ECG?
Reduction of T-wave Amplitude
A nurse is caring for a client whose history reveals the clinical manifestations of a pernicious anemia. The nurse should anticipate a prescription for which of the following diagnostic tests?
Schilling test
A client is requesting information regarding a serum troponin test. Which of the following is the nurse's best response?
Slightest elevation require treatment to prevent complications of heart disease
A nurse is caring for a client who asks why she is being prescribed aspirin 325mg daily following a MI. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects?
To prevent blood clotting
A nurse is reviewing the lab findings of a client who experienced an acute MI 6 days ago. Which of the following lab values should the nurse expect to remain elevated?
Troponin T
A nurse is reinforcing teaching for a client who has a new prescription for warfarin. Which should the nurse include?
Use an electric razor while on this medication
The nurse is completing a medication review of a client who has elevated cholesterol levels and takes an anticoagulant. Which of the following findings should the nurse report to the provider?
Uses garlic as a cholesterol lowering agent
A nurse is collecting data on a client's cardiac functioning and auscultates an S3 sound. The nurse is aware that this sound represents which of the following?
Ventricular gallop
A nurse is caring for a client who is prescribed aspirin (Ecotrin) 325mg and has a history of a previous MI. The nurse instructs the client that the aspiration is prescribed once daily due to its action as an:
antiplatelet aggregate
A nurse is reinforcing teaching with a client who has a new diagnosis of aplastic anemia. Which teaching should the nurse perform with pathophysiology?
aplastic anemia results from decreased bone marrow production of RBCs
A nurse is caring for a client who has a hemoglobin 10.8 and a hematocrit of 30%. The nurse should expect the client is at risk for which of the following conditions?
cellular hypoxia
