Exam 2 Practice Qs

A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure? "Do you have trouble breathing or chest pain?" "Are you able to walk upstairs without fatigue?" "Do you awake with breathlessness during the night?" "Do you have new-onset heaviness in your legs?"

"Are you able to walk upstairs without fatigue?" Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client's heart failure.

A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this client's discharge teaching? "Use a soft-bristled toothbrush and avoid flossing." "Avoid large crowds and people who are sick." "Change positions slowly to avoid hypotension." "Check your heart rate before taking the medication."

"Avoid large crowds and people who are sick." These agents cause immune suppression, leaving the client more vulnerable to infection. The medication does not place the client at risk for bleeding, orthostatic hypotension, or a change in heart rate.

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? "Make certain that your bath water is warm." "Avoid straining while having a bowel movement." "Limit your intake of caffeinated drinks to one a day." "Avoid strenuous exercise such as running."

"Avoid straining while having a bowel movement." Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.

A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this client's teaching? "Avoid using salt substitutes." "Take your medication with food." "Avoid using aspirin-containing products." "Check your pulse daily."

"Avoid using salt substitutes." Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the client's pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not contraindicated.

A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this client's teaching? "Walk until you become short of breath, and then walk back home." "Gather everything you need for a chore before you begin." "Pull rather than push or carry items heavier than 5 pounds." "Take a walk after dinner every day to build up your strength."

"Gather everything you need for a chore before you begin." A client who has heart failure should be taught to conserve energy. Gathering all supplies needed for a chore at one time decreases the amount of energy needed. The client should not walk until becoming short of breath because he or she may not make it back home. Pushing a cart takes less energy than pulling or lifting. Although walking after dinner may help the client, the nurse should teach the client to complete activities when he or she has the most energy. This is usually in the morning.

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure? "I get short of breath when I climb stairs." "I see halos floating around my head." "I have trouble remembering things." "I have lost weight over the past month."

"I get short of breath when I climb stairs." Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.

Which statement by a patient indicates additional teaching is required about the medication warfarin? "I will continue my diabetic diet and restrict sugar." "I will increase the intake of green, leafy vegetables for a more healthful diet." "I will restrict the intake of foods high in vitamin C." "I will increase the amount of protein in my diet to protect my kidneys."

"I will increase the intake of green, leafy vegetables for a more healthful diet." Foods such as green, leafy vegetables have high levels of vitamin K. Warfarin is an anticoagulant that acts by interfering with vitamin K-dependent clotting factors. If the amount of vitamin K is increased in the diet, the medication dose may need to be adjusted. A diabetic diet would be continued as indicated for a patient receiving warfarin. Vitamin C is not related to warfarin.

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema? "I wake up to go to the bathroom at night." "My shoes fit tighter by the end of the day." "I seem to be feeling more anxious lately." "I drink at least eight glasses of water a day."

"My shoes fit tighter by the end of the day." Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse should note whether the client feels that his or her shoes or rings are tight, and should observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply.) "Reposition the client every 2 hours." "Teach the client to perform deep-breathing exercises." "Accurately record intake and output." "Use the same scale to weigh the client each morning." "Place the client on oxygen if the client becomes short of breath."

"Reposition the client every 2 hours." "Accurately record intake and output." "Use the same scale to weigh the client each morning." The UAP should reposition the client every 2 hours to improve oxygenation and prevent atelectasis. The UAP can also accurately record intake and output, and use the same scale to weigh the client each morning before breakfast. UAPs are not qualified to teach clients or assess the need for and provide oxygen therapy.

A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best? "The t-PA didn't dissolve the entire coronary clot." "The heparin keeps that artery from getting blocked again." "Heparin keeps the blood as thin as possible for a longer time." "The heparin prevents a stroke from occurring as the t-PA wears off."

"The heparin keeps that artery from getting blocked again." After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a "blood thinner," although laypeople may refer to it as such.

A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this client's discharge teaching? "Avoid drinking more than 3 quarts of liquids each day." "Eat six small meals daily instead of three larger meals." "When you feel short of breath, take an additional diuretic." "Weigh yourself daily while wearing the same amount of clothing."

"Weigh yourself daily while wearing the same amount of clothing." Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of heart failure. The client should be taught to eat a heart-healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this client's teaching? "The best way to lose weight is a high-protein, low-carbohydrate diet." "You should balance weight loss with consuming necessary nutrients." "A nutritionist will provide you with information about your new diet." "If you exercise more frequently, you won't need to change your diet."

"You should balance weight loss with consuming necessary nutrients." Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse should encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse should include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk.

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? A 45-year-old who takes an aspirin daily A 50-year-old who is post coronary artery bypass graft surgery A 78-year-old who had a carotid endarterectomy An 80-year-old with chronic obstructive pulmonary disease

A 50-year-old who is post coronary artery bypass graft surgery Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.

An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first? A 42-year-old female who describes her pain as a dull ache with numbness in her fingers A 49-year-old male who reports moderate pain that is worse on inspiration A 53-year-old female who reports substernal pain that radiates to her abdomen A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

A 58-year-old male who describes his pain as intense stabbing that spreads across his chest All clients who have chest pain should be assessed more thoroughly. To determine which client should be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing, vise-like substernal pain that spreads through the client's chest, arms, jaw, back, or neck is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent cardiac cell death. A dull ache with numbness in the fingers is consistent with anxiety. Pain that gets worse with inspiration is usually related to a pleuropulmonary problem. Pain that spreads to the abdomen is often associated with an esophageal-gastric problem, especially when this pain is experienced by a male client. Female clients may experience abdominal discomfort with a myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal-gastric problems should be seen, they are not a higher priority than myocardial infarction.

When preparing to defibrillate a patient, in which order will the nurse perform the following steps? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the hands-free, multifunction defibrillator pads on the patient's chest. e. Check the location of other staff and call out "all clear."

ACDBE

A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take? Initiate oxygen therapy. Hold the next dose of Imdur. Instruct the client to drink water. Administer PRN acetaminophen.

Administer PRN acetaminophen. The vasodilating effects of isosorbide mononitrate frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. The client's headache is not related to hypoxia or dehydration; therefore, these interventions would not help. The client needs to take the medication as prescribed to prevent angina; the medication should not be held.

A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? Allow family members to remain at the bedside. Ask the family if the client would like a fan in the room. Keep the television tuned to the client's favorite channel. Speak loudly to the client in case of hearing problems.

Allow family members to remain at the bedside. Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more.

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) Altered mobility/immobility Decreased thirst response Diminished immune response Malnutrition Overhydration

Altered mobility/immobility Decreased thirst response Diminished immune response Malnutrition Immobility, decreased thirst response, diminished immune response, and malnutrition can place the older adult at higher risk of developing shock. Overhydration is not a common risk factor for shock.

A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first? Apply personal protective equipment. Notify local law enforcement officials. Obtain "universal" donor blood. Prepare the client for emergency surgery.

Apply personal protective equipment. The nurse's priority is to care for the client. Since the client has gunshot wounds and is bleeding, the nurse applies personal protective equipment (i.e., gloves) prior to care. This takes priority over calling law enforcement. Requesting blood bank products can be delegated. The nurse may or may not have to prepare the client for emergency surgery.

A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The client's blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the client's rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take first? Begin external temporary pacing. Assess peripheral pulse strength. Ask the client what medications he or she takes. Administer 1 mg of atropine.

Ask the client what medications he or she takes. This client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse should assess the client's current medications first.

A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first? Assess airway, breathing, and level of consciousness. Administer an amiodarone bolus followed by a drip. Cardiovert the client with a biphasic defibrillator. Begin cardiopulmonary resuscitation (CPR).

Assess airway, breathing, and level of consciousness. Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action.

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.) Assess for allergies to iodine. Administer intravenous fluids. Assess blood urea nitrogen (BUN) and creatinine results. Insert a Foley catheter. Administer a prophylactic antibiotic. Insert a central venous catheter.

Assess for allergies to iodine. Administer intravenous fluids. Assess blood urea nitrogen (BUN) and creatinine results. If the client has kidney disease (as indicated by BUN and creatinine results), fluids and Mucomyst may be given 12 to 24 hours before the procedure for renal protection. The client should be assessed for allergies to iodine, including shellfish; the contrast medium used during the catheterization contains iodine. A Foley catheter and central venous catheter are not required for the procedure and would only increase the client's risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.

An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? Assess for any hemodynamic effects of the rhythm. Prepare to administer antidysrhythmic medication. Notify the provider or call the Rapid Response Team. Turn the alarms off on the cardiac monitor.

Assess for any hemodynamic effects of the rhythm. Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed.

A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below: What action by the nurse is most important? Assess the client's blood pressure and level of consciousness. Call the health care provider or the Rapid Response Team. Obtain a permit for an emergency temporary pacemaker insertion. Prepare to administer antidysrhythmic medication.

Assess the client's blood pressure and level of consciousness. Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased perfusion, as seen in this ECG strip showing sinus bradycardia. The nurse should first assess the client's hemodynamic status, including vital signs and level of consciousness. The client may or may not need the Rapid Response Team, a temporary pacemaker, or medication; there is no indication of this in the question.

A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? Assess the client's respiratory status. Draw blood to assess the client's serum electrolytes. Administer intravenous furosemide (Lasix). Ask the client about current medications.

Assess the client's respiratory status. Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take priority over assessing respiratory status.

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take? Elevate the leg and apply a sandbag to the entrance site. Increase the flow rate of intravenous fluids. Assess the color and temperature of the left leg. Document the finding as "left pedal pulse of +1/4."

Assess the color and temperature of the left leg. Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The pulse may be faint because of edema. The left pulse should be compared with the right, and pulses should be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider should be notified. Simply documenting the findings is inappropriate. The leg should be positioned below the level of the heart or dangling to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the client's problem.

A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) Assist the client to the chair for meals and to the bathroom. Encourage the client to use the spirometer every 4 hours. Ensure the client wears TED hose or sequential compression devices. Have the client rate pain on a 0-to-10 scale and report to the nurse. Take and record a full set of vital signs per hospital protocol.

Assist the client to the chair for meals and to the bathroom. Ensure the client wears TED hose or sequential compression devices. Take and record a full set of vital signs per hospital protocol. The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done.

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.) Bringing the client warm blankets Giving the client hot tea to drink Massaging the client's painful legs Reorienting the client as needed Sitting with the client for reassurance

Bringing the client warm blankets Reorienting the client as needed Sitting with the client for reassurance The student can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. The client should be NPO at this point, so hot tea is prohibited. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? Make sure the defibrillator is set to the synchronous mode. Administer 1 mg of intravenous epinephrine. Test the equipment by delivering a smaller shock at 100 joules. Ensure that everyone is clear of contact with the client and the bed.

Ensure that everyone is clear of contact with the client and the bed. To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.

An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) Hypertension Fatigue despite adequate rest Indigestion Abdominal pain Shortness of breath

Fatigue despite adequate rest Indigestion Shortness of breath

A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect? Heart rate of 120 beats/min Cool, clammy skin Oxygen saturation of 90% Respiratory rate of 8 breaths/min

Heart rate of 120 beats/min When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturations and perfusion. The client may not be able to compensate for long, and decreased oxygenation and cool, clammy skin will occur later.

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first? Administer morphine sulfate 4 mg IV. Give acetaminophen (Tylenol) 650 mg. Infuse normal saline 500 mL over 30 minutes. Schedule complete blood count and coagulation studies.

Infuse normal saline 500 mL over 30 minutes. The patient's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions are also appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.

The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? Perform a pericardial thump. Initiate cardiopulmonary resuscitation (CPR). Start an 18-gauge intravenous line. Ask the client's family about code status.

Initiate cardiopulmonary resuscitation (CPR). The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client's code status should already be known by the nurse prior to this event.

A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? Pulmonary auscultation Pulse strength and amplitude Level of consciousness Mobility and gait stability

Level of consciousness A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light-headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the client's level of consciousness is the priority.

A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? Medication reconciliation Immunization history Religious beliefs Nutrition preferences

Medication reconciliation The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? Mid-sternal chest pain Increased urine output Mild orthostatic hypotension P wave touching the T wave

Mid-sternal chest pain Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.

The nurse is making a home visit to a patient who was discharged from the hospital on Lovenox and warfarin following replacement of the patient's pacemaker. Which observation indicates excessive bleeding? (Select all that apply.) New ecchymosis on the abdomen A nosebleed that does not stop with pressure Pain of the lower extremity with flexion Extreme fatigue Pallor Sudden onset of severe headache

New ecchymosis on the abdomen A nosebleed that does not stop with pressure Extreme fatigue Pallor Sudden onset of severe headache Excessive bleeding includes large bruises that may be increasing in size, nosebleeds, extreme fatigue from decreased tissue oxygenation due to decreased hemoglobin, and sudden onset of a severe headache, which may indicate a cerebral hemorrhage. Pain in the lower extremity may be a result of a deep vein thrombosis. Pain of the legs with flexion may be associated with venous thrombosis.

A client in shock is apprehensive and slightly confused. What action by the nurse is best? Offer to remain with the client for awhile. Prepare to administer antianxiety medication. Raise all four siderails on the client's bed. Tell the client everything possible is being done.

Offer to remain with the client for awhile. The nurse's presence will be best to reassure this client. Antianxiety medication is not warranted as this will lower the client's blood pressure. Using all four siderails on a hospital bed is considered a restraint in most facilities, although the nurse should ensure the client's safety. Telling a confused client that everything is being done is not the most helpful response.

The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important? Assess vital signs. Don a mask and gown. Gather needed supplies. Perform hand hygiene.

Perform hand hygiene. To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority.

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? Blood pressure that is 20 mm Hg below baseline Oxygen saturation of 94% on room air Poor peripheral pulses and cool skin Urine output of 1.2 mL/kg/hr for 4 hours

Poor peripheral pulses and cool skin Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.

A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.) Assist the provider to place a central venous access device. Prepare for continuous blood pressure and pulse monitoring. Administer the client's prescribed beta blocker. Give the client nothing by mouth 3 to 6 hours before the procedure. Explain to the client that dobutamine will simulate exercise for this examination.

Prepare for continuous blood pressure and pulse monitoring. Explain to the client that dobutamine will simulate exercise for this examination. Give the client nothing by mouth 3 to 6 hours before the procedure. Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, should be performed. Beta blockers are often held prior to the procedure.

A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find? Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg Respiratory rate decreased from 25 breaths/min to 14 breaths/min Oxygen saturation increased from 88% to 96% Pulse decreased from 100 beats/min to 80 beats/min

Pulse decreased from 100 beats/min to 80 beats/min Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased HR.

A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the client's sheets. What action should the nurse perform first? Assess the insertion site. Change the client's sheets. Put on a pair of gloves. Assess blood pressure.

Put on a pair of gloves. For the nurse's safety, he or she should put on a pair of gloves to prevent blood exposure. The other actions are appropriate as well, but first the nurse must don a pair of gloves.

A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene? Assessing the IV site before giving the drug Obtaining a programmable ("smart") IV pump Removing the IV bag from the brown plastic cover Taking and recording a baseline set of vital signs

Removing the IV bag from the brown plastic cover Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct, although a "smart" pump is not necessarily required if the facility does not have them available. The drug must be administered via an IV pump, although the programmable pump is preferred for safety.

A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? Decreased intraocular pressure Increased heart rate Short period of asystole Hypertensive crisis

Short period of asystole Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.

A nurse assesses a client's electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this client's ECG strip? Ventricular tachycardia Ventricular fibrillation Sinus rhythm with premature atrial contractions (PACs) Sinus rhythm with premature ventricular contractions (PVCs)

Sinus rhythm with premature ventricular contractions (PVCs) Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization. Ventricular tachycardia and ventricular fibrillation rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization.

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching? (Select all that apply.) Smoking cessation Stress reduction and management Avoiding vagal stimulation Adverse effects of medications Foods high in potassium

Smoking cessation Stress reduction and management Adverse effects of medications

A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is best? Ask the family members to wait in the waiting area. Inform the client that this behavior is unacceptable. Stay out of the room to decrease the client's stress levels. Tell the client that anxiety is common and that you can help.

Tell the client that anxiety is common and that you can help. Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse should reassure the client that fear is common and offer to help. The other actions will not reduce the client's anxiety.

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? Sotalol (Betapace) Warfarin (Coumadin) Atropine (Sal-Tropine) Lidocaine (Xylocaine)

Warfarin (Coumadin) Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.