Exam 1 Evolve and Book Questions

D Defibrillating is the priority next action before any other resuscitative measures, according to advanced cardiac life support protocols.After immediate defibrillation, establish IV access, place an oral airway, and ventilate. CPR will be started after unsuccessful defibrillation.

A client admitted after using cocaine develops ventricular fibrillation. After determining unresponsiveness, which action will the nurse take next? A. Place an oral airway and ventilate. B. Start cardiopulmonary resuscitation (CPR). C. Establish IV access. D. Prepare for defibrillation.

A The best indicator that treatment is effective on a client with heart failure and problems of hypervolemia is the client's weight decreased by 5.5 lb (2.5 kg) in 1 day. The best indicator of fluid volume gain or loss is daily weight. Because each kilogram represents approximately 1 L, this client has lost approximately 2500 mL of fluid.Diuresis of 400 mL in 24 hours represents oliguria. Although a blood pressure of 122/84 mm Hg is a normal finding alone, it is not significant for relief of hypervolemia. Although an apical pulse of 82 beats/min is a normal finding alone, it is not significant to determine whether hypervolemia is relieved.

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which nursing assessment data, obtained the day after admission, is the best indicator that the treatment has been effective? A. The client's weight decreases by 2.5 kg. B. The client has diuresis of 400 mL in 24 hours. C. The client's blood pressure is 122/84 mm Hg. D. The client has an apical pulse of 82 beats/min.

D At the start of therapy with lisinopril, the nurse needs to consider the risk for hypotension. Angiotensin-converting enzyme (ACE) inhibitors like lisinopril are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years.Although desirable, ability to understand teaching is not essential. ACE inhibitors are vasodilators and do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.

A client begins therapy with lisinopril. What does the nurse consider at the start of therapy with this medication? A. The client's ability to understand medication teaching B. The potential for bradycardia C. Liver function tests D. The risk for hypotension

D ALWAYS check the client first. Cardiac monitors are a tool for assessment, but they do not replace hands on nursing assessment.

A client in the telemetry unit is on a cardiac monitor. The monitor technician alerts the nurse that there are no ECG complexes, and the alarm is sounding. What is the first action by the nurse? A. Suspend the alarm. B. Call the emergency response team. C. Press the record button to get an ECG strip. D. Assess the client and check lead placement.

B A sudden onset of low back pain with flank bruising is a classic sign of aneurysm rupture. This is a medical emergency requiring immediate nursing intervention.

A client is admitted to the hospital with an abdominal aortic aneurysm. Which assessment data would cause the nurse to suspect that the aneurysm has ruptured? A. Shortness of breath and hemoptysis B. Sudden, severe low back pain and bruising along the flank C. Gradually increasing substernal chest pain and diaphoresis D. Rapid development of patchy blue mottling on feet and toes

B, C, E, F Rationale: For a client with left sided heart failure the nurse will anticipate assessment findings of crackles in both lungs, tachypnea, tachycardia, and a third heart sound, usually an S3 gallop.

A client is diagnosed with left-sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply. A. Peripheral edema B. Crackles in both lungs C. Tachycardia D. Ascites E. Tachypnea F. S3 gallop

D Rationale: When caring for a client receiving UFH, the nurse notifies the PCP of a platelet level of 32,000/mm3 (32 × 109/L). UFH can decrease platelet counts. The PCP must be notified if the platelet count is below 100,000 to 120,000/mm3 (100 to 120 × 109/L).A 60-second PTT reflects a therapeutic value within 1.5 to 2 times the normal value. Mild leukocytosis (increased white blood cells) may be expected with deep vein thrombosis. A hemoglobin of 12.2 g/dL (122 mmol/L) reflects a normal reading.

A client is receiving unfractionated heparin (UFH) by infusion. What laboratory data will the nurse report to the primary health care provider (PCP)? a) Hemoglobin 12.2 g/dL (122 mmol/L) b) White blood cells 11,000/mm3 (11 × 109/L) c) Partial thromboplastin time (PTT) 60 seconds d) Platelets 32,000/mm3 (32 × 109/L)

C Warfarin works in the liver to inhibit synthesis of the four different Vitamin K clotting factors and it takes 3-4 days for the drug to provide therapeutic anticoagulation. As such, many clients are started on heparin therapy as well as warfarin. Both drugs work differently, and the heparin provides rapid anticoagulation that can be discontinued once the warfarin has reaching a therapeutic level as demonstrated by the client's INR.

A client who is receiving heparin therapy is started on warfarin. Which nursing explanation is appropriate? A. "You will need both drugs long term to provide long-term anticoagulation." B. "Warfarin is easier on your stomach so you can take it long term." C. "It takes several days for warfarin to begin working, so both drugs are required for a short time." D. "These drugs work the same, but one is taken by mouth, so it is easier to take at home."

C Antibiotics are only required prior to dental procedures. Good oral hygiene is the best prevention for endocarditis. The statement in option A is correct and shows the patient understands the need for oral hygiene. The patient with a mechanical valve will be on warfarin thus, foods high in Vitamin K should be avoided. This statement in option B is correct and shows the patient understands foods that are LOW in Vitamin K. This statement in option D is also correct and shows that the patient understands the importance of regular BP assessment as well as when to call the provider based on the assessment.

A client who recently had a heart valve replacement is preparing for discharge. What statement by the client indicates that the nurse will need to do additional health teaching? A. "I need to brush my teeth at least twice daily and rinse with water." B. "I will eat foods that are low in vitamin K, such as potatoes and iceberg lettuce." C. "I need to take a full course of antibiotics prior to my colonoscopy." D. "I will take my blood pressure every day and call if it is too high or low."

D The nurse is concerned with the serum potassium level of 2.8 mEq/L (2.8 mmol/L) in a heart failure client taking furosemide. Furosemide is a loop diuretic and clients taking this drug must be monitored for potassium deficiency from diuretic therapy.A serum sodium level of 135 mEq/L (135 mmol/L) is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL (88.4 mcmol/L) represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L (0.95 mmol/L) represents a normal value.

A client with heart failure is prescribed furosemide. Which assessment data concerns the nurse with this new prescription? A. Serum sodium level of 135 mEq/L (135 mmol/L) B. Serum magnesium level of 1.9 mEq/L (0.95 mmol/L) C. Serum creatinine of 1.0 mg/dL (88.4 mcmol/L) D. Serum potassium level of 2.8 mEq/L (2.8 mmol/L)

D Rationale: The nurse teaches the client who is taking verapamil to avoid grapefruit juice. Grapefruit juice must be avoided with calcium channel blockers, such as verapamil, because it can enhance the action of the drug.Foods high in potassium would be encouraged for clients taking diuretics, not calcium channel blockers such as verapamil. Bradycardia, not irregular pulse, is a typical side effect of verapamil. Muscle cramping may occur with statins, not with calcium channel blockers.

A client with hypertension is started on verapamil. What teaching will the nurse provide for this client? a) "Consume foods high in potassium." b) Monitor for muscle cramping." c) "Monitor for irregular pulse." d) "Avoid grapefruit juice."

C Rationale: After a client with PAD has had a percutaneous vascular intervention, it is essential for the nurse to assess for pedal pulses. Priority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring distal pulses to ensure adequate perfusion. Pulse checks must be assessed postprocedure to detect improvement (stronger pulses) or complications (diminished or absent pulses).Ankle-brachial index is a diagnostic study used to detect the presence of PAD. This is not necessary after percutaneous vascular intervention. It is imperative to assess for dye allergy before performing the procedure. Gag reflex is checked after procedures affecting the throat (e.g., endoscopy, bronchoscopy).

A client with peripheral arterial disease (PAD) has a percutaneous vascular intervention. What is the priority nursing assessment? a) Dye allergy b) Gag reflex c) Pedal pulses d) Ankle-brachial index

D These are the characteristics of sinus tachycardia.A normal sinus rhythm would have a heart rate of 60 to 100 beats/min. A heart rate of less than 60 beats/min would indicate sinus bradycardia. Early QRS intervals would indicate sinus rhythm with premature ventricular contractions.

A client's rhythm strip shows a heart rate of 116 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.16 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip? A. Sinus rhythm with premature ventricular contractions B. Normal sinus rhythm C. Sinus bradycardia D. Sinus tachycardia

B Rationale: The client who is most at risk for secondary hypertension is the client with kidney disease. Kidney disease is one of the most common causes of secondary hypertension.Some psychiatric conditions can exacerbate essential hypertension, but secondary hypertension is caused by a disease process or drugs. High-sodium intake is a risk factor for essential hypertension, not for secondary hypertension, which is caused by disease states or medications. Physical inactivity is a risk factor for essential hypertension.

A new nurse is caring for four clients. Which client is at risk for secondary hypertension? a) The client who is physically inactive. b) The client with kidney disease. c) The client with depression. d) The client who eats a high-sodium diet.

C The nurse would first assess the 46 year old with aortic stenosis on digoxin and now has new-onset frequent PVCs. The PVCs may be indicative of digoxin toxicity. Further assessment for clinical signs and symptoms of digoxin toxicity must be done and the primary health care provider notified about the dysrhythmia.The 55 year old is stable and can be assessed after the client with aortic stenosis. The 68 year old may be assessed after the client with aortic stenosis. This type of pain is expected in pericarditis. Tachycardia is expected in the 79 year old because rejection will cause signs of decreased cardiac output, including tachycardia. This client may be seen after the client with aortic stenosis.

After receiving change-of-shift report about these four clients, which client would the nurse assess first? A. A 79 year old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min. B. A 55 year old admitted with pulmonary edema who received furosemideand whose current O2 saturation is 94%. C. A 46 year old with aortic stenosis who takes digoxin and has new-onset frequent premature ventricular contractions. D. A 68 year old with pericarditis who is reporting sharp chest pain with inspiration.

A Rationale: The problem that must be addressed immediately in a client with an 8-cm abdominal aneurysm is a BP of 192/102 mm Hg. Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture.The nurse must consider the client's usual pulse. However, bradycardia does not pose a risk for aneurysm rupture. Straining at stool can elevate blood pressure and pose a risk for dissection. However, a potential problem would not be addressed before an actual problem. Anxiety may be benign or may be a symptom of something serious. However, the elevated blood pressure is an immediate risk.

For a client with an 8-cm abdominal aortic aneurysm, which assessment data must be addressed immediately? a) Blood pressure (BP) 192/102 mm Hg b) Report of constipation c) Anxiety d) Heart rate 52 beats/min

D The 64-year-old client has a stable, asymptomatic bradycardia, which usually requires monitoring but no treatment unless the patient develops symptoms and/or the slow heart rate causes a decrease in cardiac output. This patient can be managed by a nurse with less cardiac dysrhythmia training.The 71-year-old client is unstable and requires immediate intervention for dyspnea and tachycardia. The 88-year-old client is displaying symptoms of myocardial injury (elevated troponin) and unstable blood pressure and needs immediate attention and medications. The 92-year-old client is experiencing a dysrhythmia that could deteriorate into ventricular tachycardia and requires immediate intervention by a telemetry nurse.

The cardiac care unit charge nurse is assigning clients to the oncoming shift. Which patient is appropriate to assign to a float RN from the medical-surgical unit? A. A 92-year-old client admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min. B. An 88-year-old client admitted with elevated troponin level who is hypotensive with a heart rate of 96 beats/min. C. A 71-year-old client admitted for heart failure who is shortness of breath and has a heart rate of 120 to 130 beats/min. D. A 64-year-old client admitted for weakness with sinus bradycardia and heart rate 58 beats/min.

A The action the home care nurse takes first is to auscultate the heart failure client's posterior breath sounds. Because the client is at risk for pulmonary edema and hypoxemia, the breath sounds must be assessed.Assessment of edema may be delayed until after breath sounds are assessed. After a full assessment, the nurse must notify the health care provider. After physiologic stability is attained, then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.

The home health nurse visits a client with heart failure who has gained 5 lb (2.3 kg) in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? A. Auscultate the client's posterior breath sounds. B. Notify the health care provider about the client's weight gain. C. Remind the client about dietary sodium restrictions. D. Assess the client for peripheral edema.

C, D, E Amiodarone causes prolongation of the QT interval, which can precipitate dysrhythmia. Antidysrhythmic medications cause changes in cardiac rhythm and rate; therefore, monitoring of heart rate and rhythm is needed.Although it is always important to monitor respiratory rate and urine output, these assessments are not specific to amiodarone.

The nurse administers amiodarone to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? (Select all that apply.) Select all that apply. A. Urine output B. Respiratory rate C. Heart rate D. Heart rhythm E. QT interval

A, B, C The signs and symptoms of digoxin toxicity that the nurse notifies the provider include: blurred vision, fatigue, and anorexia. Changes in mental status, especially in older adults, may also occur.Sinus bradycardia and not tachycardia is a sign of digoxin toxicity. A serum digoxin level between 0.8 and 2.0 (1.02 and 2.56 nmol/L) is considered normal and is not a symptom.

The nurse caring for a client with heart failure who is taking digoxin. What assessment data requires that nurse notify the health care provider? (Select all that apply.) A. Anorexia B. Blurred vision C. Fatigue D. Heart rate 110/beats/min E. Serum digoxin level of 1.5 ng/mL (1.92 nmol/L)

B Further teaching about restricting sodium in the diet for a client with heart failure is needed when the client says, "I need to avoid eating hamburgers." Cutting out beef or hamburgers made at home is not necessary, but fast-food hamburgers are to be avoided owing to higher sodium content.Bacon, canned foods, lunchmeats, and processed foods are high in sodium, which promotes fluid retention, and must be avoided. The client correctly understands that adding salt to food must be avoided.

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which client statement indicates the need for further teaching? A. "I won't put the salt shaker on the table anymore." B. "I need to avoid eating hamburgers." C. "I need to avoid lunchmeats but may cook my own turkey." D. "I must cut out bacon and canned foods."

C, D, E Rationale: Teaching about hypertension has been effective when the nurse notes that the client has been on a low-sodium, diet has lost 3 lb (1.4 kg) since the last clinic visit, and has cut down on caffeine. Clients with hypertension need to consume low-sodium foods and would avoid adding salt. Weight loss can result in lower blood pressure. Caffeine promotes vasoconstriction, thereby elevating blood pressure.Although eating out may be cost-saving, fast food is often higher in saturated fat. The goal is to exercise three times and not once weekly.

The nurse in the cardiology clinic is reviewing teaching provided at the client's last appointment regarding hypertension management. Which actions by the client indicate that teaching has been effective? (Select all that apply.) a) Reports walking the neighborhood once weekly. b) Reports eating fast food frequently to cut down on food costs. c) Weight loss of 3 lb (1.4 kg) since last seen in the clinic. d) Reports eating a low-sodium diet. e) Reports drinking one less cup of coffee daily.

A, D, E Symptoms of venous insufficiency include ankle and leg swelling, ankle discoloration, and full veins with dependent positioning of the legs. Pain with ambulation would signal claudication and cold extremities would indicate poor arterial perfusion.

The nurse is admitting a client with an ulcer on the right foot. Which statement made by the client indicates venous insufficiency? Select all that apply. A. "My ankles swell up all the time." B. "My leg hurts after I walk about a block." C. "My feet are always really cold." D. "My veins really stick out in my legs." E. "My ankles have been discolored for years."

A Confusion, blurry vision, and upset stomach are symptoms of Digoxin toxicity, which is common in older adults and requires immediate treatment. The other answers are important assessment data but do not indicate immediate connection to the client's presentation.

The nurse is admitting an 84-year-old client with heart failure to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data is most concerning? A. Digoxin therapy daily. B. Daily metoprolol. C. Furosemide twice daily. D. Currently taking an antacid for upset stomach.

B, C, D, F Rationale: Risk factors that contribute to atherosclerosis include: an increase in LDL (160 mg/dL is high), obesity (as indicated by a BMI is 32), smoking, and type 2 diabetes.ASA is used as prophylaxis for atherosclerotic disease/coronary artery disease to prevent platelet adhesion. While atherosclerosis can be genetic, the fact that the client's father has lung cancer does not increase his risk for atherosclerosis.

The nurse is assessing a 54-year-old male client for risk of atherosclerosis. What assessment data is associated with an increase in risk? (Select all that apply.) a) Takes acetylsalicylic acid daily. b) BMI is 32. c) History of type 2 diabetes mellitus. d) LDL of 160 mg/dL. e) The client's father has lung cancer. f) Current smoking history.

C Splinter hemorrhages are indicative of infective endocarditis. Petechiae (pinpoint red spots) occur in many clients with endocarditis. Splinter hemorrhages appear as black longitudinal lines or small red streaks along the distal third of the nail bed.Friction rub in the left lower sternal border and pain aggravated by breathing, coughing, and swallowing are signs and symptoms indicative of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.

The nurse is assessing a client with a cardiac infection. Which nursing assessment data causes the nurse to suspect infective endocarditis instead of pericarditis or rheumatic carditis? A. Thickening of the endocardium B Pain aggravated by breathing, coughing, and swallowing C. Splinter hemorrhages D. Friction rub auscultated at the left lower sternal border

B, D, F Rationale: Signs/symptoms of acute arterial occlusion of the right lower extremity include cold right foot, numbness and tingling of the right foot, and mottling and tingling of the right foot. Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion.Hypertension presents risk for atherosclerosis, but not for acute arterial occlusion. The pulse rate does not indicate occlusion, but rather quality. Absence of pulse, rather than bounding pulse, is a symptom of acute arterial occlusion.

The nurse is assessing a client with arterial insufficiency. What assessment data would cause the nurse to suspect an acute arterial occlusion of the right lower extremity? (Select all that apply.) a) Tachycardia b) Mottling of right foot and lower leg c) Bounding right pedal pulses d) Numbness and tingling of right foot e) Hypertension f) Cold right foot

B, D Right-sided heart failure is associated with increased systemic venous pressure and congestion; producing signs such as peripheral edema, ascites, liver enlargement, and neck vein distension. Left-sided heart failure is associated with pulmonary congestion and can produce shortness of breath, weakness, fatigue, oliguria, and a third heart sound (S3 gallop).

The nurse is assessing a client with right-sided heart failure. What assessment findings will the nurse anticipate? (Select all that apply.) A. Oliguria B. Ascites C. Pulmonary congestion D. Peripheral edema E. Shortness of breath F. Third heart sound

C The nurse will document this rhythm interpretation as normal sinus rhythm. The heart rate does not reflect tachycardia or bradycardia and the rhythm is not irregular. All other assessment parameters are within normal sinus rhythm interpretation.

The nurse is assessing the client's cardiac rhythm and notes the following: HR 64, regular rhythm, PR interval 0.20; QRS 0.10. How will the nurse document this rhythm interpretation in the electronic health record? A. Sinus Tachycardia B. Sinus Bradycardia C. Normal Sinus Rhythm D. Sinus arrhythmia

A Rationale: The client who would be assessed first is the client who had a percutaneous vascular intervention of the right femoral artery 30 minutes ago. This client must have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure.The client admitted with hypertensive crisis has stabilized and is not in need of immediate assessment. The client with peripheral vascular disease is the most stable and can be seen last. The client who had a right femoral-popliteal bypass is not in need of immediate assessment and can be assessed after the client who had a percutaneous vascular intervention.

The nurse is assigned to all of these clients. Which client would the nurse assess first? a) The client who had percutaneous vascular intervention of the right femoral artery 30 minutes ago. b) The client admitted with hypertensive crisis who has a nitroprusside drip and blood pressure of 149/80 mm Hg. c) The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid. d) The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot.

D The appropriate nursing response is that this may be caused by a genetic trait. Hypertrophic cardiomyopathy is often transmitted as a single gene autosomal dominant trait.Exploring the client's feelings is important, but does not address the client's question. Hypertrophic cardiomyopathy is not caused by performance-enhancing drugs. Reminding the client that he or she is in good shape is not at all therapeutic and does not address the client's question.

The nurse is caring a college athlete who collapsed during soccer practice. The client has been diagnosed with hypertrophic cardiomyopathy and states, "This can't be. I am in great shape. I eat right and exercise." Which nursing response is appropriate? A. "How does this make you feel?" B. "This can be caused by taking performance-enhancing drugs." C. "It could be worse if you weren't in good shape." D. "This may be caused by a genetic trait."

B, C, D, G The nurse would not allow the client to eat a meal immediately following a cardioversion. The nurse will assess level of consciousness and overall client status and start with sips of liquid once the client is fully awake. The nurse will continue to carefully monitor the client, ensuring that electrodes are in place and assessing for chest burns from the electrodes used during the cardioversion. The nurse will administer oxygen until the client is fully awake. The nurse will not provide continued sedation. The nurse will document the procedure and the crash cart should remain in the room until the client is stable as lethal arrhythmias can occur during and after cardioversion.

The nurse is caring for a client immediately following a cardioversion. What nursing actions are appropriate? (Select all that apply.) A. Allow the client to eat a meal. B. Ensure electrodes are in place for continued monitoring. C. Assess the chest for burns. D. Document results of procedure. E. Remove crash cart from the room. F. Provide continued sedation. G. Administer oxygen.

B The nurse should be prepared to stop the infusion of heparin if the client is vomiting blood. The nurse would not administer Vitamin K as that is the antidote for warfarin not heparin. The nurse would not administer an antiemetic as the vomiting is from bleeding. The nurse will not insert a nasogastric tube yet as stopping the heparin may stop the bleeding and insertion of the NG tube with elevated PTT could cause additional bleeding.

The nurse is caring for a client receiving intravenous heparin for treatment of DVT that begins to begins to vomit blood. What action should the nurse be prepared to take? A. Administer Vitamin K B. Stop the infusion of heparin C. Administer an antiemetic D. Insert a nasogastric tube

A Rationale: The nurse caring for a client who had an AAA repair would be most alarmed with the client's urine output of 20 mL over 2 hours. Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria.Reduction of systolic blood pressure to 100 to 120 mm Hg is appropriate. Paralytic ileus may be a complication of AAA repair, but is not a priority over decreased urine output. +3 pedal pulses is a normal physical assessment finding.

The nurse is caring for a client who had abdominal aortic aneurysm (AAA) repair. Which assessment data is most concerning to the nurse? a) Urine output of 20 mL over 2 hours b) Blood pressure of 106/58 mm Hg c) +3 pedal pulses d) Absent bowel sounds

B Rationale: The nurse would question the prescription for dopamine. Dopamine is used for its inotropic and vasoconstrictive properties to raise blood pressure, and would not be used in hypertensive crisis.Enalapril, an angiotensin-converting enzyme inhibitor, may be used intravenously in hypertensive emergencies. Sodium nitroprusside, a direct-acting vasodilator, may be used intravenously to lower blood pressure quickly in hypertensive emergencies. Labetalol, an intravenous calcium channel blocker, is used in hypertensive crisis when oral therapy is not feasible.

The nurse is caring for a client who is being treated for hypertensive crisis. Which prescribed medication would the nurse question? a) Enalapril b) Dopamine c) Labetalol d) Sodium nitroprusside

B Rationale: The action the nurse delegates to the LPN/LVN caring for a client with dark-colored toe ulcers and a BP of 190/100 mm Hg is to administer a clonidine patch for hypertension. Administering medication is within the scope of practice for the LPN/LVN.The RN is responsible for physical assessments, making referrals for other services, and developing the plan of care for the hospitalized client.

The nurse is caring for a client with dark-colored toe ulcers and blood pressure (BP) of 190/100 mm Hg. Which nursing action does the nurse delegate to the LPN/LVN? a) Obtain a request from the primary health care provider for a dietary consult. b) Administer a clonidine patch for hypertension. c) Develop a plan for discharge, and assess home care needs. d) Assess leg ulcers for signs of infection.

A A client with heart failure has had a positive outcome to metoprolol when she states that she is able to sleep on one pillow. Improvement in activity tolerance, less orthopnea, and improved symptoms represents a positive response to beta blockers such as metoprolol.An ejection fraction of 25% is well below the normal of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest. This is not a positive outcome.

The nurse is caring for a client with heart failure in a cardiac clinic. What assessment data indicates that the client has demonstrated a positive outcome related to the addition of metoprolol to the medication regimen? A. Client states, "I can sleep on one pillow." B. Current ejection fraction is 25%. C. Client reports feeling like her heart beats very fast at times. D. Records indicate five episodes of pulmonary edema last year.

C The nurse's first action is to position the client to alleviate dyspnea. This action will help ease air hunger and anxiety. Administering oxygen therapy is also an important priority action.Determining the client's physical limitations is not a priority in this situation. Encouraging alternate rest and activity periods is not the immediate priority. Monitoring of heart rate, rhythm, and pulses is important, but is not the priority.

The nurse is caring for a client with heart failure in the coronary care unit. The client is exhibiting signs of air hunger and anxiety. Which nursing intervention will the nurse perform first for this client? A. Monitor and document heart rate, rhythm, and pulses. B. Encourage alternate rest and activity periods. C. Position the client to alleviate dyspnea. D. Determine the client's physical limitations.

C The first action of the nurse is to place the client in high Fowler's position. This position allows for maximal lung expansion. The nurse can also place pillows under each arm to maximize chest expansion. Repositioning the client with heart failure can improve overall gas exchange. If dyspnea continues the nurse may contact respiratory therapy for a breathing treatment, assess arterial blood gases (as prescribed) or increase oxygen if warranted by ABG results.

The nurse is caring for a client with heart failure who is on oxygen at 2L per nasal cannula with an oxygen saturation of 90%. The client states, "I feel short of breath." Which action will the nurse take first? A. Contact respiratory therapy. B. Increase the oxygen to 4L. C. Place the client in a high Fowler's position. D. Draw arterial blood for arterial blood gas analysis.

B Spironolactone is a potassium sparing diuretic. This drug can cause hyperkalemia and as such the client would not take potassium supplements with this drug. The statement, "I need to take potassium supplements with this medication" requires additional nursing education. It is appropriate to take the medication daily at the same time, to avoid table salt on food, and the medication does cause increased urination as it is a diuretic.

The nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement requires further nursing education? A. "I may need to take this drug every other day according to lab values." B. "I need to take potassium supplements with this medication." C. "I will try my best not to use table salt on my food." D. "This medication will cause me to urinate more often."

A, C, D When caring for a client with heart failure, the nurse needs to assess for chest discomfort or pain, tachycardia, and fatigue. Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure.Presence of a cough or dyspnea results as pulmonary venous congestion ensues. Clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Thick, yellow sputum is indicative of infection. Position for sleeping isn't a symptom. Clients usually find it difficult to lie flat because of dyspnea symptoms.

The nurse is caring for a client with heart failure. What assessment data will the nurse anticipate? (Select all that apply.) A. Fatigue B. Sleeping on back without a pillow C. Chest discomfort or pain D. Tachycardia E. Expectorating thick, yellow sputum

A, B, E Tachycardia is a heart rate greater than 100 beats/min; the patient with a tachydysrhythmia may have palpitations, chest discomfort (pressure or pain from myocardial ischemia or infarction), restlessness and anxiety, pale cool skin, and syncope ("blackout") from hypotension. Chest discomfort and palpitations may occur because decreased time for diastole results in lower perfusion through the coronary arteries to the myocardium. Hypotension results from decreased time for ventricular filling, secondary to shortened diastole, and therefore reduced cardiac output and blood pressure. Reduced cardiac output and possible development of heart failure will cause fatigue.In this situation, the patient will have pale, cool skin and not flushing of the skin. Also, reduced cardiac output and possible development of heart failure will cause fatigue and not increased energy.

The nurse is caring for a client with heart rate of 143 beats/min. Which assessment data will the nurse anticipate? (Select all that apply.) A. Chest discomfort B. Hypotension C. Flushing of the skin D. Increased energy E. Palpitations

D Gradual exercise can improve collateral circulation and decrease pain associated with intermittent claudication. Teach the client to walk until they have pain, then to stop and rest, only to resume walking again. This promotes collateral development. Complete abstinence from smoking is essential to prevent vasoconstriction. While maintaining warmth is good to promote vasodilation, use of a heating pad is not safe due to the decreased sensation that can occur. Elevation of the extremities may be beneficial to reduce swelling; however, they should not be elevated above the heart level.

The nurse is caring for a client with intermittent claudication due to peripheral arterial disease. Which client statement indicates understanding of proper self-management? A. "I need to reduce the number of cigarettes that I smoke each day." B. "I'll elevate my legs above the level of my heart." C. "I'll use a heating pad to promote circulation." D. "I'll start to exercise gradually, stopping when I have pain."

D Rationale: The symptom the nurse assesses the client with PAD is reproducible leg pain with exercise. Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances.Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin. PAD results from atherosclerotic occlusion of peripheral arteries.

The nurse is caring for a client with peripheral arterial disease (PAD). Which symptom will the nurse anticipate? a) Decreased pain when legs are elevated b) Unilateral swelling of affected leg c) Pulse oximetry reading of 90% d) Reproducible leg pain with exercise

C, D, E Hydrochlorothiazide is a common thiazide diuretic used in the treatment of HTN. This medication can cause excretion of potassium. As such clients should be instructed to increase their dietary intake of potassium. Diuretics should not be taken before bedtime as an increase in urination is expected. Taking at night will prevent the client from sleeping well due to nocturia. Clients with diabetes mellitus must use caution as this drug can alter glucose production.

The nurse is caring for a diabetic client who will be discharged on hydrochlorothiazide (HCTZ). What information will the nurse include in the discharge teaching? Select all that apply. A. "This drug may cause a dry, nagging cough." B. "Take this drug with a snack, right before bed." C. "Try to increase your intake of potassium in your diet." D. "This drug can affect your glucose control." E. "Increased urination is expected with this drug.

B The classic clinical signs of renal infarction, associated with embolization from infective endocarditis, are flank pain, hematuria, and pyuria.

The nurse is caring for a hospitalized client with infective endocarditis who has been receiving antibiotics for 2 days. The client is now experiencing flank pain with hematuria. What condition will the nursing suspect? A. Pulmonary embolus B. Renal infarction C. Transient ischemic attack D.Splenic infarction

D The nurse needs to take no action other than to continue monitoring because the patient is displaying a normal sinus rhythm and normal vital signs.Atropine is used in emergency treatment of symptomatic bradycardia. This patient has a normal sinus rhythm. Digoxin is used in the treatment of atrial fibrillation, which is, by definition, an irregular rhythm. Clonidine is used in the treatment of hypertension; a side effect is bradycardia.

The nurse is caring for a patient on a telemetry unit who has a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 second. Additional vital signs are: blood pressure 118/68 mm Hg, respiratory rate 16 breaths/min, and temperature 98.8° F (37° C). All of these medications are available on the medication record. What action will the nurse take? A. Administer clonidine. B. Administer atropine. C. Administer digoxin. D. Continue to monitor.

B The monitoring of the patient's heart rate is essential. The effects of metoprolol are to decrease heart rate, blood pressure, and myocardial oxygen demand.ST segment elevation is consistent with MI; it does not address monitoring of metoprolol. Elevation in troponin is consistent with a diagnosis of MI, but does not address needed monitoring for metoprolol. Elevation in myoglobin is consistent with myocardial injury in ACS, but does not address needed monitoring related to metoprolol.

The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol. Which data is essential for the nurse to assess prior to administration? A. Troponin B. Heart rate C. ST segment D. Myoglobin

D The nurse plans to administer heparin in addition to the antidysrhythmic. AF is the loss of coordinated atrial contractions that can lead to pooling of blood, resulting in thrombus formation. The patient is at high risk for pulmonary and systemic embolism. Heparin and other anticoagulants (e.g., enoxaparin, warfarin, and novel oral anticoagulants, when nonvalvular, such as dabigatran, rivaroxaban, apixaban, or edoxaban) are used to prevent thrombus development in the atrium, leading to the risk of embolization (i.e., stroke).Atropine is used to treat bradycardia and not rapid heart rate associated with AF. Dobutamine is an inotropic agent used to improve cardiac output; it may cause tachycardia, thereby worsening atrial fibrillation. Although electrolyte levels are monitored in clients with dysrhythmia, magnesium sulfate is not used unless depletion is noted.

The nurse is caring for a patient with atrial fibrillation (AF). In addition to an antidysrhythmic, what medication does the nurse anticipate administering? A. Magnesium sulfate B. Atropine C. Dobutamine D. Heparin

D The client's potassium, magnesium, and heart rate are within normal limits. Nicotine can be a cause of premature ventricular contractions (PVSs) and should be discussed with this provider and the client.

The nurse is caring for client who is experiencing occasional premature ventricular contractions. What is assessment data is most concerning to the nurse? A. Potassium 4.8 mEq/L B. Magnesium 2 mEq/L C. Heart rate 90 D. History of smoking

B The nurse needs to hold the digoxin and gets a prescription for a potassium supplement. Digoxin causes bradycardia and hypokalemia potentiates digoxin toxicity.Furosemide decreases circulating blood volume and depletes potassium. There is no indication suggesting that the client has fluid volume excess at this time.

The nurse is preparing to administer digoxin as prescribed to a client with heart failure and notes: Temperature: 99.8° F (37.7° C), Pulse: 48 beats/min and irregular, Respirations: 20 breaths/min, Potassium level: 3.2 mEq/L (3.2 mmol/L). What action will the nurse take? A. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. B. Hold the digoxin, and obtain a prescription for a potassium supplement. C. Give the digoxin; document assessment findings in the medical record. D. Give the digoxin; reassess the heart rate in 30 minutes.

D The client understands the discharge teaching about when to seek medical attention when the client says: "I will call the provider if I have a cough lasting 3 or more days." Cough, a symptom of heart failure, is indicative of intra-alveolar edema; it is important to notify the provider if this occurs.The client would call the provider for weight gain of 3 lb (1.4 kg) in a week or 1-2 lb (0.45 to 0.9 kg) overnight. The client would begin by walking 200 to 400 feet (61 to 123 m) per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure. The provider must be notified if this occurs.

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which client statement indicates understanding of the teaching? A. "I should expect occasional chest pain." B. "I will try walking for 1 hour each day." C. "I will report to the provider weight loss of 2 to 3 lb (0.9 to 1.4 kg) in a day." D. "I will call the provider if I have a cough lasting 3 or more days."

A The nurse will advise the client to use a stool softener. Patients at risk for bradydysrhythmias would avoid bearing down or straining during a bowel movement. The Valsalva maneuver associated with bearing down can cause bradycardia.Patients with renal failure and hyperkalemia are instructed to avoid potassium-containing foods; if risk for hypokalemia exists, such as with diuretic therapy, the patient is instructed to eat foods high in potassium. Smoking and caffeine increase heart rate; although all people would stop smoking, patients at risk for tachycardia, premature beats, and ectopic rhythms are instructed to stop smoking and avoid caffeine. Nitroglycerin is used to reduce oxygen demand in cardiac ischemia, not for bradycardia.

The nurse is teaching a client about the risk for bradydysrhythmias. What teaching will the nurse include? A. "Use a stool softener." B. "Stop smoking and avoid caffeine." C. "Avoid potassium-containing foods." D. "Take nitroglycerin for a slow heartbeat."

C Rationale: Teaching about the precautions of warfarin has been effective when the client says "that eating foods like green beans won't interfere with my Coumadin therapy." Vitamin K is not found in foods such as green beans, so these foods will not interfere with the anticoagulant effects of Coumadin.Warfarin "thins" the blood, so the risk for cutting oneself and bleeding is very high with the use of a regular razor. The client needs to use an electric razor. Clients must apply pressure to bleeding wounds and must seek medical assistance immediately. While they may need to discontinue warfarin therapy, the priority is to apply pressure to the bleeding area and seek medical care. Blood in the urine of a client taking warfarin therapy is not a side effect. The client must notify the primary health care provider immediately if this occurs.

The nurse is teaching a client the precautions to take while on warfarin therapy. Which client statement demonstrates that teaching has been effective? a) "I can use an electric razor or a regular razor." b) "When taking warfarin, I may notice some blood in my urine." c) "Eating foods like green beans won't interfere with my warfarin therapy." d) "If I notice I am bleeding a lot, I should stop taking warfarin right away."

A, D, F Clients with a new pacemaker should be taught to take their pulse daily for 1 full minute each day. It is important to be aware of the rate the pacemaker is set to know which rate changes that are important to report to your health care provider. Clients with pacemakers can use microwave ovens and may bathe normally, in either the shower or bath. Sudden, jerky movements should be avoided for 8 weeks to allow the pacemaker to settle in place. Leaning over electrical or gasoline motors should be avoided and it is important to make sure electrical devices are properly grounded.

The nurse is teaching a client with a new pacemaker. What teaching will the nurse include? (Select all that apply.) A. Do not lean over electrical or gasoline motors. B. Take your pulse for 20 seconds each day and record the rate. C. You may bathe, taking only showers. D. Be sure that you remember the rate at which your pacemaker is set. E. Avoid the use of microwave ovens. F. Avoid sudden, jerky movements for 8 weeks.

A All prescribed medications, including heart medications, are still needed after the pacemaker is implanted.Once the wound from the surgery heals, the patient will be able to shower. The patient's pulse will have to be taken and recorded for 1 full minute at the same time each day. The metal in the pacemaker will trigger the alarm in metal detector devices. A card can be shown to authorities to indicate that the patient has a pacemaker.

The nurse is teaching a client with a new permanent pacemaker. Which client statement indicates a need for further teaching? A. "I no longer need my heart pills." B. "I need to take my pulse every day." C. "I will be able to shower again soon." D. "I might trigger airport security metal detectors."

C Bruising could be indicative of excessive dosing of warfarin. Warfarin is an anticoagulant and causes decreased ability for blood to clot.Green leafy vegetables are high in vitamin K, which may antagonize the effects of warfarin; these vegetables would be eaten in moderate amounts. Aspirin and nonsteroidal anti-inflammatory agents may prolong the prothrombin time and the international normalized ratio, causing predisposition to bleeding. These agents would be avoided. It is not necessary to avoid caffeine because this does not affect clotting; however, green tea may interfere with the effects of warfarin.

The nurse is teaching a client with atrial fibrillation about a new prescription for warfarin. What teaching will the nurse include? A. "Avoid caffeinated beverages." B. "You would take aspirin or ibuprofen for headache." C. "Report bruising to your health care provider." D. "It is important to consume a diet high in green leafy vegetables."

A, B, C, D, E Rationale: Ivabradine is an HCN channel blocker that slows the heart rate. Side effects include: bradycardia, hypertension, atrial fibrillation, and luminous phenomena (visual brightness) The nurse will teach the client that visual changes are expected initially. The nurse will advise to take this medication with meals and teach the client how to check radial pulse and to report low heart rate or irregularity to the health care provider. The nurse will also teach clients that visual changes are associated with light and clients should use caution when driving or using machines in situations where light intensity may change abruptly.

The nurse is teaching a client with heart failure about a newly prescribed medication, ivabradine. What teaching will the nurse include? Select all that apply. A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your healthcare provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the healthcare provider if elevated."

A Rationale: The teaching point the nurse include for a client with PAD is walk to the point of leg pain, rest, and then resume when pain stops. Exercise may improve arterial blood flow by building collateral circulation. Instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther.Elevating the legs in PAD decreases blood flow and increases ischemia. Brown discoloration around the ankles is characteristic of venous disease. Application of heat must be avoided in clients with PAD due to a lack of sensation and possible burns to the legs.

The nurse is teaching a client with peripheral arterial disease. What teaching will the nurse include? a) "Walk to the point of leg pain, then rest, resuming when pain stops." b) "Inspect your legs daily for brownish discoloration around the ankles." c) "Apply a heating pad to the legs if they feel cold." d) "Elevate your legs above heart level to prevent swelling."

D The client's statement, "I will drink a glass of low-fat milk with my breakfast" indicated correct understanding of the DASH approach which includes low-fat dairy products. Caffeine (in coffee) should be avoided and sodium should be reduced to an optimal goal of 1500 mg daily. The DASH guidelines do not restrict the intake of lean protein.

The nurse is teaching a client with stage 1 hypertension. Which client statement indicates understanding of dietary modifications? A. "I will reduce my sodium intake to 2500 mg per day. B. "I will restrict my intake of daily dietary lean protein. C. "I am only going to drink one cup of coffee to start my day.". D. "I will drink a glass of low fat milk with my breakfast."

B, C, E, F Rationale: The American Heart Association publishes dietary recommendations to decrease LDL levels. These recommendations include: emphasizing the intake of whole grains, vegetables, and fruits; consuming poultry without the skin; consuming low-fat dairy products and nuts; cooking with nontropical oils (e.g. Canola); limiting trans-fat intake and aiming for a dietary pattern that includes 5% to 6% of calories from saturated fat

The nurse is teaching the client dietary methods to reduce LDL levels. What teaching will the nurse include? (Select all that apply.) a) Aim for 10% of calories from saturated fat b) Limit trans-fat intake. c) Emphasize the intake of whole grains. d) Avoid cooking with all oil. e) Nuts are a good snack food. f) Try to purchase skinless chicken to cook with.

C Loss of capture occurs when the pacing stimulus (spike) is not followed by the appropriate response, either P wave or QRS complex, depending on placement of the pacing electrode.Pacemaker spikes falling on the T wave indicate improper sensing. A heart rate of 42 beats/min with no pacemaker spikes seen on the rhythm strip indicates failure to pace or sense properly. Demand pacing would cause the pacemaker to intervene with electrical output when the heart rate falls below the set rate. Although the set rate is not given, this heart rate indicates profound bradycardia. Hiccups may indicate stimulation of the chest wall or diaphragm from wire perforation.

The nurse receives a report that a client with a pacemaker has experienced loss of capture. What assessment data would the nurse anticipate? A. The heart rate is 42 beats/min, and no pacemaker spikes are seen on the rhythm strip. B. The patient demonstrates hiccups. C. Pacemaker spikes are noted, but no P wave or QRS complex follows. D. The pacemaker spike falls on the T wave.

C Clients taking warfarin need to avoid foods high in Vitamin K including green leafy vegetables; INR needs to be measured frequently; black stools are a sign of bleeding and should be reported; herbal medications interfere with functioning of coumadin.

The primary health care provider prescribes warfarin for a client with atrial fibrillation. Which client statement indicates that additional education is needed? A. "I need to go to the clinic once a week to have my blood level checked." B. "If my stools turn black, I will be sure to call my primary health care provider" C. "I'm glad I don't need to change my diet. Salads are my favorite food." D. "I need to stop taking my herbal supplement."

C, D, B, A, E When the nurse enters the room to find an unresponsive person the order of care is: Call for help (Notify the Rapid Response Team) Secure the crash cart/AED Check the carotid pulse for 5- 10 seconds Begin chest compressions Provide rescue breaths

Upon entering a client's room, the nurse finds the client unresponsive. In what order will the nurse provide care? A. Begin chest compressions B. Check carotid pulse C. Notify the Rapid Response Team D. Get the crash cart/AED E. Provide rescue breaths

D Rationale: The nurse suspects dissection of an AAA when the client says that "I just started to feel a tearing pain in my belly." Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA.The sensation of feeling the heartbeat in the abdomen is a symptom of AAA but not of dissection or rupture. Headache may be benign or indicative of cerebral aneurysm or increased intracranial pressure. Hoarseness, shortness of breath, and difficulty swallowing may be symptoms of thoracic aortic aneurysm.

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? a) "I have a headache. May I have some acetaminophen?" b) "I have had hoarseness for a few weeks." c) I feel my heart beating in my abdominal area." d) "I just started to feel a pain in my belly and low back."

B Rationale: The vascular assessment by the new nurse that requires intervention by the charge nurse is simultaneously palpating bilateral carotids. Carotid arteries are palpated separately because of the risk for inadequate cerebral perfusion and the risk for causing the client to faint.Prolonged capillary filling generally indicates poor circulation, and is an appropriate assessment. Many clients with vascular disease have poor blood flow. Pulses that are not palpable may be heard with a Doppler probe. Because of the high incidence of hypertension in clients with atherosclerosis, blood pressure is often assessed in both arms.

Which assessment by a new nurse requires the charge nurse to intervene? a) Assessing pedal pulses by Doppler b) Simultaneously palpating bilateral carotids c) Measuring blood pressure in both arms d) Measuring capillary refill in the fingertips

D A P wave is generated by the SA node and represents atrial depolarization and needs to be followed by a QRS complex. When the electrical impulse is consistently generated from the SA node, the P waves have a consistent shape in a given lead.The QRS complex represents ventricular depolarization. The PR interval represents time required for atrial depolarization and for the impulse delay in the atrioventricular node and travel time to the Purkinje fibers. Normal PR level is up to 0.20 seconds. Elevation of the ST segment indicates myocardial injury.

Which assessment data indicates proper function of the sinoatrial (SA) node? A. The QRS complex is present. B. The ST segment is elevated. C. The PR interval is 0.24 second. D. A P wave precedes every QRS complex.

A A bruit is considered an abnormal finding that is associated with atherosclerotic disease. A bruit is a turbulent, swishing sound that occurs when blood is passing through a narrowed artery. All other values are related to atherosclerotic disease- however, they are normal values. Abnormal values or findings would be anticipated in a client with severe atherosclerotic disease.

Which assessment finding will the nurse anticipate in a client with severe atherosclerotic disease? A. Carotid artery bruit B. HDL 60 mg/dL C. Palpable peripheral pulses D. BP 120/58 mm/Hg

C The best client to assign to the LPN/LVN working on the telemetry unit is the client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. This client is the most stable. Administration of oxygen to a stable client is within the scope of LPN/LVN practice.The client with heart failure is receiving an intravenous inotropic agent, which requires monitoring by the RN. The client with pericarditis is displaying signs of cardiac tamponade and requires immediate lifesaving intervention. The client with a new-onset murmur requires assessment and notification of the primary health care provider, which is within the scope of practice of the RN.

Which client is best to assign to an LPN/LVN working on the telemetry unit? A. Client with pericarditis who has a paradoxical pulse and distended jugular veins. B. Client with heart failure who is receiving dobutamine. C. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. D. Client with rheumatic fever who has a new systolic murmur.

D Rationale: The client who just arrived in the ED and needs immediate medical evaluation is the 70 year old with a history of diabetes who has "tearing" back pain and is diaphoretic. This client's history and clinical signs and symptoms suggest possible aortic dissection. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery.The 64 year old is most stable and can be seen last. The 60 year old and the 69 year old would both be seen soon, but the 70-year-old client must be seen first.

Which client who has just arrived in the emergency department does the nurse assess as emergent and in need of immediate medical evaluation? a) A 64 year old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C). b) A 60 year old with venous insufficiency who has new-onset right calf pain and tenderness. c) A 69 year old with a 40-pack-year cigarette history who is reporting foot numbness. d) A 70 year old with a history of diabetes who has "tearing" back pain and is diaphoretic.

A The best intervention to help the client with acute pulmonary edema to reduce anxiety and dyspnea is to place the client in high-Fowler position with the legs down. High-Fowler position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion.Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member's presence may help alleviate anxiety, but dyspnea and anxiety resulting from hypoxemia secondary to intra-alveolar edema must be relieved.

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? A. Place the client in high-Fowler position with the legs down. B. Reassure the client that distress can be relieved with proper intervention. C. Ask a family member to remain with the client. D. Monitor pulse oximetry and cardiac rate and rhythm.

B Safety during cardioversion depends upon setting the defibrillator to the synchronized mode to avoid discharging the shock during the vulnerable period on the T wave. Unsynchronized cardioversion may cause ventricular fibrillation.Cardioversion is usually performed starting at a lower rate of 120 to 200 joules for biphasic machines. Although it is imperative to obtain informed consent, this does not improve the safety of the procedure. Oxygen would be turned off because it presents a safety issue; fire could result.

Which intervention provides safety during cardioversion? A. Setting the defibrillator at 220 joules B. Setting the defibrillator to the synchronized mode C. Applying oxygen D. Obtaining informed consent

A The nursing action that can be delegated to a UAP on the medical unit is to obtain daily weights for several clients with class IV heart failure. Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN.The role of the professional nurse is to perform assessments. Determining alcohol intake, monitoring pain level, and assessing for peripheral edema would not be delegated.

Which nursing action may be delegated to assistive personnel (AP) working on the medical unit? A. Obtain daily weights for several clients with class IV heart failure. B. Check for peripheral edema in a client with endocarditis. C. Monitor the pain level for a client with acute pericarditis. D. Determine the usual alcohol intake for a client with cardiomyopathy.

C The nursing intervention that can help the client admitted today with heart failure is to have a bedside commode available to the client before administering furosemide. Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand.Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand. The nurse must prevent this situation.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? A. The nurse monitors the client's pulse and blood pressure frequently. B. The client ambulates around the nursing unit with a walker. C. The nurse obtains a bedside commode before administering furosemide. D. The nurse returns the client to bed when the client becomes tachycardia.

A, C, D. Risk factors contributing to atrial fibrillation include excessive alcohol use, advancing age, and hypertension. Other risk factors involve previous ischemic stroke, transient ischemic attack or other thromboembolic event, coronary heart disease, diabetes mellitus, heart failure, mitral valve disease, obesity, and chronic kidney disease. The incidence of atrial fibrillation also occurs more often in those of European ancestry and African Americans.Beta-adrenergic blocking agents, which reduce heart rate, are used to treat atrial fibrillation. Palpitations are a symptom of atrial fibrillation, rather than a risk or a cause.

Which risk factors are known to contribute to atrial fibrillation? (Select all that apply.) A. Advancing age B. Palpitations C. High blood pressure D. Excessive alcohol use E. Use of beta blockers

B Removing the noxious stimuli causing the vagal response would be the first action. If this does not resolve the bradycardia, second action would be to administer atropine and call provider. Continuing to suction is not appropriate as this is the cause of the vagal episode.

While suctioning a client with a tracheostomy, the client becomes diaphoretic and nauseous, and the heart rate decreases to 37 beats/min. What is the priority nursing action? A. Continue to clear the airway. B. Stop suctioning the patient. C. Administer atropine. D. Call the health care provider immediately.