Exam 3
A client taking a new prescription for propranolol calls the clinic to report a weight gain of 3 lb (1.36 kg) within 2 days, shortness of breath, and swollen ankles. What is the nurse's best action? A. Due to fluid accumulation, have the client assessed for worsening heart failure by the health care provider. B. Gather the client's dietary intake for the past 24 hours. C. Review medication administration with the client. D. Gather data about the client's knowledge of expected effect of the drug.
A. Due to fluid accumulation, have the client assessed for worsening heart failure by the health care provider.
An older adult client has a potassium level of 3.2 mEq/L (3.2 mmol/L). How should the nurse instruct the client in relation to diet? A. Increase intake of bananas and oranges. B. Avoid intake of bananas and oranges. C. Increase intake of oatmeal and apples. D. Avoid intake of oatmeal and apples.
A. Increase intake of bananas and oranges.
An average-weight client reports of generalized steady abdominal pain. The nurse should suspect an abdominal aortic aneurysm, if the abdominal pain is accompanied by which finding? A. Pulsating mass in the periumbilical area B. Elevated cardiac enzymes C. Positive Babinski's sign D. Pink, frothy sputum
A. Pulsating mass in the periumbilical area
Which information would the nurse provide to the client about prevention of cataract formation? Select all that apply. A. Wear sunglasses when outside with amber, orange, or brown lenses. B. Do not stare at a computer screen for prolonged periods of time. C. Instill saline drops twice daily into both eyes. D. Make sure eyeglasses fit well. E. Wear contact lenses rather than glasses.
A. Wear sunglasses when outside with amber, orange, or brown lenses. B. Do not stare at a computer screen for prolonged periods of time.
A client who has been prescribed nitroglycerin, metoprolol, and furosemide is dizzy and has a blood pressure of 84/50 mm Hg. Which action should the nurse take when the medications are scheduled to be provided? A. Withhold the medications, and notify the health care provider. B. Administer the furosemide and metoprolol, and withhold the nitroglycerin. C. Ensure the client takes medications while lying in bed. D. Administer the nitroglycerin and metoprolol, and withhold the furosemide.
A. Withhold the medications, and notify the health care provider.
A nurse receives a report on a client who has been diagnosed with an abdominal aortic aneurysm (AAA). The nurse would expect the client to have which underlying disease? A. atherosclerosis B. diabetes C. chronic obstructive pulmonary disease D. renal failure
A. atherosclerosis
Which condition most commonly results in coronary artery disease (CAD)? A. atherosclerosis B. diabetes C. myocardial infarction (MI) D. renal failure
A. atherosclerosis
Which signs and symptoms should the nurse expect to find in a client with angina? Select all that apply. A. chest tightness B. general muscle aching C. chest pressure D. jaw pain E. slowed respiratory rate F. bradycardia
A. chest tightness C. chest pressure D. jaw pain
An older adult client is newly diagnosed with left-sided heart failure. Which sign most commonly associated with this type of heart failure would the nurse expect to find when obtaining data for this client? A. crackles B. arrhythmias C. hepatic engorgement D. hypotension
A. crackles
The nurse is working with a client with rule-out abdominal aortic aneurysm (AAA) that reports severe, worsening back pain. The following have been ordered by the healthcare provider. Which action should the nurse delegate to the licensed practical/vocational nurse (LPN/VN)? A. inserting a urinary catheter B. administering pain medication by IV push C. placing a second IV line D. measuring vital signs
A. inserting a urinary catheter
Before administering digoxin to a client, a nurse reviews information about the drug. She learns that after digoxin is metabolized, the body eliminates remaining digoxin as unchanged drug by way of the: A. lungs. B. kidneys. C. feces. D. skin.
A. kidneys.
The clinic nurse is reinforcing teaching about symptoms of cardiovascular disease (CVD) with the client. What are common symptoms associated with cardiovascular disease? A. shortness of breath, chest discomfort/pain, palpitations B. dyspnea, headache, sputum production C. fatigue, weight changes, edema D. mood swings, vomiting, fainting
A. shortness of breath, chest discomfort/pain, palpitations
The nurse is caring for an older adult man who walks 2 miles every morning. The nurse notes that during his morning walk, he called his child and stated that he thought that he was having a heart attack. Which symptom, identified by the client, is the most common and consistent with that of a heart attack (myocardial infarction)? A. sternal pain B. dyspnea C. edema D. palpitations
A. sternal pain
A client diagnosed with acute arterial occlusive disease is scheduled to undergo an atherectomy. What is the priority nursing intervention for this client immediately after the procedure? A. Monitor vital signs every 4 hours. B. Closely monitor catheter site for bleeding. C. Ambulate the client as soon as possible. D. Teach client about the importance of exercise.
B. Closely monitor catheter site for bleeding.
A client is diagnosed with prehypertension. Which of the following would most likely be included in the client's treatment plan? A. Diuretics B. Lifestyle modification instructions C. Beta-adrenergic blockers D. Angiotensin-converting enzyme (ACE) inhibitors
B. Lifestyle modification instructions
The nurse correctly instructs a client with peripheral vascular disease that stress-reduction techniques: A. are helpful only because they assist in smoking cessation. B. are helpful because stress stimulates the release of vasoconstricting catecholamines. C. are helpful because they distract the client from focusing on claudication pain. D. haven't proved useful in clients with peripheral vascular disease.
B. are helpful because stress stimulates the release of vasoconstricting catecholamines.
A male client has been reporting chest pain and shortness of breath for the past 2 hours. He has a temperature of 99° F (37.2° C), a pulse of 96 beats/minute, respirations that are irregular and 16 breaths/minute, and a blood pressure of 140/96 mm Hg. He's placed on continuous cardiac monitoring to: A. prevent cardiac ischemia. B. assess for potentially dangerous arrhythmias. C. determine the degree of damage to the heart muscle. D. evaluate cardiovascular function.
B. assess for potentially dangerous arrhythmias.
A client is experiencing cardiac tamponade after a chest trauma. Which type of shock will the nurse monitor for? A. anaphylactic B. cardiogenic C. hypovolemic D. septic
B. cardiogenic
A client arrives in the emergency department with tachycardia, decreased urination, restlessness, and confusion. Auscultation reveals a fourth heart sound. What does the nurse suspect is occurring? A. myocardial infarction (MI) B. cardiogenic shock C. peripheral vascular disease D. abdominal aortic aneurysm (AAA)
B. cardiogenic shock
The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are: A. tracheal. B. fine crackles. C. bronchial. D. friction rubs.
B. fine crackles.
A nurse obtaining data from a client observes jugular vein distention (JVD). Which condition does the nurse suspect this client to have? A. abdominal aortic aneurysm B. heart failure C. myocardial infarction (MI) D. deep vein thrombosis
B. heart failure
A client is placed on a medication to stimulate the sympathetic nervous system. Which response should the nurse expect from this medication? A. heart rate decrease from 78 to 56 beats/minute B. heart rate increase from 60 to 88 beats/minute C. blood pressure decrease from 120/80 mm Hg to 100/56 mm Hg D. decrease of myocardial contractility
B. heart rate increase from 60 to 88 beats/minute
A nursing student is observed by the instructor obtaining a blood pressure reading. The instructor immediately intervenes when the student: A. places the stethoscope over the brachial artery. B. places the stethoscope over the brachiocephalic artery. C. uses the diaphragm of the stethoscope. D. washes her hands before taking a blood pressure reading.
B. places the stethoscope over the brachiocephalic artery.
The nurse is obtaining data from a new client in the cardiovascular clinic. When asking about childhood diseases and disorders associated with structural heart disease, the nurse should consider which finding significant? A. croup B. rheumatic fever C. severe staphylococcal infection D. medullary sponge kidney
B. rheumatic fever
A nurse is caring for a client diagnosed with myocardial infarction (MI) who is prescribed a nitrate. What does the nurse identify as the purpose of giving a nitrate to this client? A. to relieve pain B. to dilate coronary arteries C. to relieve headaches caused by other medications D. to calm and relax the client
B. to dilate coronary arteries
A hospitalized client experiences digoxin-induced premature ventricular contractions (PVCs). Which type of effect do such contractions represent? A. Toxic B. Secondary C. Iatrogenic D. Idiosyncratic
C. Iatrogenic
The nurse is reinforcing education for the client regarding the initial treatment goal of increasing myocardial oxygen supply for cardiogenic shock. The client demonstrates an understanding of this treatment goal when making which statement? A. "Increasing my oxygen will cause me to become acidotic." B. "If I get less oxygen, it will be easier on my body and I will get better quicker." C. "In a shock state, I need less oxygen." D. "A balance must be maintained between oxygen supply and demand."
D. "A balance must be maintained between oxygen supply and demand."
A client comes to the health care provider's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). The nurse gathers data regarding the knowledge of the client regarding the prescribed cardiac rehabilitation program. What statement suggests that the client needs more instruction? A. "Client performs relaxation exercises three times per day to reduce stress." B. "Client's 24-hour dietary recall reveals low intake of fat and cholesterol." C. "Client verbalizes an understanding of the need to seek emergency help if the heart rate increases markedly while at rest." D. "Client walks 4 miles (6.4 km) in 1 hour every day."
D. "Client walks 4 miles (6.4 km) in 1 hour every day."
The nurse is teaching a client who will be discharged with a prescription for warfarin. Which statement by the client indicates understanding? A. "I should increase my intake of yogurt and broccoli." B. "This drug will dissolve any clots I may still have." C. "If I miss a dose, I should double the next dose." D. "I should avoid aspirin while taking warfarin."
D. "I should avoid aspirin while taking warfarin."
A nurse is attempting to administer lisinopril to a client. The client refuses to take the pill, stating that in the past he developed a rash as an allergic reaction to the medication. Which of the following is the best response by the nurse? A. "I will check your chart for documentation of the allergy." B. "A rash is a side effect not an allergic reaction." C. "If you do not take your medication, I will report your refusal to the charge nurse." D. "I will call the physician with this information."
D. "I will call the physician with this information."
A client requested a do-not-resuscitate (DNR) order upon admission to the hospital. The client now states a desire for the medical team to do everything possible to help the client get better and is concerned about the DNR order. Which response by the nurse is best? A. "Do you want to rescind the DNR, or just change it?" B. "You know that we will do everything needed to keep you comfortable even though you have the DNR in place." C. "Have you talked this over with your family?" D. "It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away."
D. "It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away."
An older adult client informs the nurse of a "terrible ringing in the ears." Which question would be a priority for the nurse to ask the client? A. "Do you irrigate your ears?" B. "When was the last time you had an ear examination?" C. "Does anyone in your family have this problem?" D. "What medications do you take?"
D. "What medications do you take?"
A nurse is screening clients for their risk of developing cardiovascular disease. The nurse identifies which client to be at the greatest risk? A. 40-year-old white female B. 50-year-old white male C. 40-year-old black female D. 50-year-old black male
D. 50-year-old black male
A client diagnosed with angina is being discharged from the hospital with a prescription for nitroglycerin. What should the nurse be sure to include in the discharge information? A. If chest pain is experienced, immediately call the rescue squad. B. If chest pain is experienced longer than 1 hour, take a nitroglycerin. C. Store the nitroglycerin in the bathroom medicine cabinet. D. If chest pain is experienced, take 1 tablet under the tongue every 5 minutes ×3.
D. If chest pain is experienced, take 1 tablet under the tongue every 5 minutes ×3.
A client experiences orthostatic hypotension while receiving furosemide to treat hypertension. How should the nurse intervene? A. Administer I.V. fluids as ordered. B. Administer a vasodilator as prescribed. C. Insert an indwelling urinary catheter as ordered. D. Instruct the client to flex the calf muscles and then sit up for several minutes before standing.
D. Instruct the client to flex the calf muscles and then sit up for several minutes before standing.
The nurse is caring for a child with heart failure. What should the nurse recognize when monitoring administration of oxygen to avoid complications? A. Oxygen is contraindicated in this situation. B. Oxygen is given at high levels only. C. Oxygen is a pulmonary bed constrictor. D. Oxygen decreases the work of breathing.
D. Oxygen decreases the work of breathing.
After abdominal surgery, which factor would predispose a client to deep vein thrombosis? A. The client is 5' 9" tall and weighs 128 lb (58 kg). B. The client has been pregnant four times. C. The client usually walks 3 miles per day. D. The client will be immobile during and shortly after surgery.
D. The client will be immobile during and shortly after surgery.
The primary care provider orders ear irrigation for a client. Which situation requires the nurse to question this order? A. The client has a scratch on the external canal. B. The client has a foreign body in the ear. C. The ear canal has impacted cerumen. D. The eardrum may be punctured.
D. The eardrum may be punctured.
A client comes to the emergency department reporting visual changes and a severe headache. The nurse measures the client's blood pressure at 210/120 mm Hg. However, the client denies having hypertension or any other disorder. After diagnosing malignant hypertension, a life-threatening disorder, the physician initiates emergency intervention. What is the most common cause of malignant hypertension? A. Pyelonephritis B. Dissecting aortic aneurysm C. Pheochromocytoma D. Untreated hypertension
D. Untreated hypertension
Which factor is an important part of observing a child with a possible cardiac anomaly? A. skin turgor B. temperature C. pupil size and reaction to light D. blood pressure in four extremities
D. blood pressure in four extremities
The nurse is monitoring laboratory studies for a client who had a myocardial infarction. Which test will the nurse monitor that is most indicative of cardiac damage? A. arterial blood gas (ABG) levels B. complete blood count (CBC) C. complete chemistry D. creatine kinase isoenzymes (CK-MB)
D. creatine kinase isoenzymes (CK-MB)
When caring for a child diagnosed with a ventricular septal defect, how would the nurse describe this condition when talking with the parents? A. narrowing of the aortic arch B. failure of a septum to develop completely between the atria C. narrowing of the valves at the entrance of the pulmonary artery D. failure of a septum to develop completely between the ventricles
D. failure of a septum to develop completely between the ventricles
The nurse is administering enteric coated erythromycin to a client. What adverse reaction should the nurse monitor for? A. weight gain B. constipation C. increased appetite D. nausea and vomiting
D. nausea and vomiting
A client is experiencing chest pain at rest that is unresponsive to nitroglycerin. The health care provider diagnoses unstable angina and alerts the nurse that the client will require treatment with immediate surgical intervention. For which treatment does the nurse prepare the client? A. electrocardiogram B. echocardiogram C. heart transplantation D. percutaneous transluminal coronary angioplasty (PTCA)
D. percutaneous transluminal coronary angioplasty (PTCA)
When auscultating the heart of a client with pericarditis, which finding should the nurse anticipate reporting? A. A rub B. Murmur C. Gallop D. Second heart sound
A. A rub
A client is diagnosed with pulmonary edema and having pink, frothy sputum and crackles in both lungs. Which nursing intervention would be provided at this time? Select all that apply. A. Administer morphine sulfate as ordered. B. Administer furosemide (Lasix) as ordered. C. Place the legs in a dependent position. D. Administer oxygen as ordered. E. Place the client in high Fowler position.
A. Administer morphine sulfate as ordered. D. Administer oxygen as ordered. E. Place the client in high Fowler position.
A client is admitted for right leg vein ligation and stripping for varicose veins. Which nursing intervention postoperatively should the nurse include? A. Ask the client to elevate the legs when sitting. B. Ask the client to remain inactive until healing is complete. C. Apply knee-high stockings over the dressing. D. Apply ice to dressings to decrease swelling.
A. Ask the client to elevate the legs when sitting.
The licensed practical nurse discovers a client with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mm Hg and he reports dizziness. Which medication would the registered nurse use to treat the client's bradycardia? A. Atropine B. Dobutamine C. Amiodarone D. Lidocaine
A. Atropine
Which precaution should a nurse take when caring for a client with a myocardial infarction (MI) who has received a thrombolytic agent? A. Avoid puncture wounds. B. Monitor potassium level. C. Maintain a supine position. D. Encourage fluids.
A. Avoid puncture wounds.
A client who comes to the hospital reporting severe substernal chest pain that is radiating down the left arm is admitted to the coronary care unit with a diagnosis of myocardial infarction (MI). Which nursing action is a priority on admission to coronary care? A. Begin electrocardiogram (ECG) monitoring. B. Obtain information about family history of heart disease. C. Auscultate lung fields. D. Determine if the client smokes.
A. Begin electrocardiogram (ECG) monitoring.
A client who has a deep vein thrombosis (DVT) reports dyspnea and chest pain and has diminished breath sounds. Which condition does the nurse prepare treatment for? A. hemothorax B. pneumothorax C. pulmonary embolism D. pulmonary hypertension
C. pulmonary embolism
The physician prescribes digoxin for a client with heart failure. During digoxin therapy, which electrolyte imbalance may predispose the client to digoxin toxicity? A. Hypermagnesemia B. Hypercalcemia C. Hypernatremia D. Hypokalemia
D. Hypokalemia
Treatment for a child with sinus bradycardia includes atropine 0.02 mg/kg. If the child weighs 20 kg, how much is given per dose? Record your answer using one decimal place.__________ mg
0.4 mg
The nurse is administering digoxin to a client diagnosed with congestive heart failure (CHF). The health care provider has ordered digoxin 0.125 mg PO daily. Calculate how many tablets will the nurse administer from a unit dose of 0.25 mg/tablet? tablet
0.5 tablet
A preschooler with a history of heart failure is prescribed digoxin. Which nursing intervention is most important to perform before administering this drug to a child? A. Check apical heart rate for 1 minute. B. Obtain the child's blood pressure. C. Count the child's respiratory rate for 1 minute. D. Measure the child's urine output.
A. Check apical heart rate for 1 minute.
The nurse is obtaining the client's blood pressure and hears a faint, clear tapping sound. What should be the nurse's next action? A. Continue listening, as this is normal. B. Immediately get the health care provider to come check this client. C. Call a rapid response. D. Ask the client if he or she has had a myocardial infarction recently, as this is not normal.
A. Continue listening, as this is normal.
For a client with cardiomyopathy, the highest priority nursing diagnosis is: A. Decreased cardiac output related to reduced myocardial contractility. B. Excess fluid volume related to fluid retention and altered compensatory mechanisms. C. Ineffective coping related to fear of debilitating illness. D. Anxiety related to actual threat to health status.
A. Decreased cardiac output related to reduced myocardial contractility.
A client with known coronary artery disease reports intermittent chest pain, usually on exertion. The physician diagnoses angina pectoris and prescribes sublingual nitroglycerin to treat acute angina episodes. When teaching the client about nitroglycerin administration, the nurse should provide which instruction? A. "Be sure to take safety precautions because nitroglycerin may cause your blood pressure to drop when you change positions." B. "Replace leftover sublingual nitroglycerin tablets every 9 months to make sure they're fresh." C. "A burning sensation after administration indicates that the nitroglycerin tablets are potent." D. "You may take a sublingual nitroglycerin tablet every 30 minutes, if needed, to a maximum of four doses."
A. "Be sure to take safety precautions because nitroglycerin may cause your blood pressure to drop when you change positions."
The nurse is administering K-dur to a client diagnosed with hypokalemia. The health care provider has ordered K-dur 20 mEq PO tid. Calculate how many tablets will the nurse administer from a unit dose of 10 mEq/tablet?
2 tablets
Which statement by the client best indicates an understanding on how to prevent complications while taking warfarin? A. "I should use a soft toothbrush." B. "I shouldn't worry if I see a lot of bruises as my blood thins." C. "I should adjust my diet to eat less protein." D. "I should use a safety razor to shave."
A. "I should use a soft toothbrush."
A nurse is reinforcing education with a client who has hypertension. The nurse recognizes that the education has been effective when the client makes which statement? A. "I shouldn't adjust my medication without my health care provider's advice." B. "I can stop taking my medication when I no longer have headaches." C. "I should stop taking my medication if I have adverse effects." D. "I only have to take the medication when I feel bad."
A. "I shouldn't adjust my medication without my health care provider's advice."
A child is prescribed aspirin as part of the therapy for Kawasaki disease. The order is for 80 mg/kg/day orally in four divided doses until the child is afebrile. The child weighs 15 kg. How much is given in one dose? Record your answer using a whole number.
300 mg
The nurse is reinforcing discharge instructions for a client who received a mechanical heart valve. Which statement made by the client indicates to the nurse that instructions are understood? A. "I will have to take lifelong anticoagulation therapy." B. "My valve will have to be replaced within 10 years." C. "I will not be able to exercise or participate in previous activities." D. "I will have to be on immunosuppressant therapy for the duration of my life."
A. "I will have to take lifelong anticoagulation therapy."
A client having an implantable cardioverter-defibrillator asks the nurse, "What should I do if I feel a shock and am alone?" Which is the best response by the nurse? A. "Lie down and call 911." B. "Continue previous activity." C. "Chew an aspirin tablet." D. "Take an extra dose of your antiarrhythmic medication."
A. "Lie down and call 911."
A client experiences orthostatic hypotension while receiving furosemide to treat hypertension. Which statements by the nurse indicate a need for further study related to furosemide administration and orthostatic hypotension? Select all that apply. A. "You should come in and get IV fluids if you get dizzy when you stand up." B. "You should be sure to stand straight up when rising." C. "You should catheterize yourself to accurately measure your urine." D. "You should flex your leg muscles before rising." E. "You should rise slowly from lying to sitting to standing."
A. "You should come in and get IV fluids if you get dizzy when you stand up." B. "You should be sure to stand straight up when rising." C. "You should catheterize yourself to accurately measure your urine."
The nurse is assisting a visually impaired client with meals. Which nursing interventions will assist the client with maintaining independence and dignity? Select all that apply. A. Place food in the same "clock position" on the plate. B. Tell the client what is being served. C. Feed the client so food will not spill. D. Tell the client where food is located. E. Prepare finger foods so the client will not have to use utensils.
A. Place food in the same "clock position" on the plate. B. Tell the client what is being served. D. Tell the client where food is located.
The nurse observes a client with a heart rate of 76 beats per minute. Where does the nurse identify the heartbeat originates? A. Sinoatrial node (SA) B. Atrioventricular node (AV) C. Bundle of His D. Purkinje fibers
A. Sinoatrial node (SA)
The nurse is determining the location of the point of maximal impulse for a client during an examination. Where will the nurse place the stethoscope? A. The mediastinum B. The apex of the heart C. The right lower sternal border D. The left upper sternal border
A. The mediastinum
Before discharge, which instruction should the nurse give to a client receiving digoxin? A. "Take an extra dose of digoxin if you miss one dose." B. "Call the physician if your heart rate goes above 120 beats/minute." C. "Call the physician if your pulse drops below 80 beats/minute." D. "Take digoxin with meals."
B. "Call the physician if your heart rate goes above 120 beats/minute."
The nurse is talking with the parent of a 3-year-old child who has congenital heart disease. The parent reports feeling concerns that the child does not seem to be maturing emotionally in a manner that is at the same rate as the two older children in the family. Which response by the nurse is most appropriate? A. "All children mature at different rates, so comparisons are not really fair." B. "Children who have chronic health issues may experience developmental delays." C. "The emotional immaturity you are seeing may just be your child's manner of acting out in response to being sick so much." D. "You will need to lower your expectations for your child's level of maturity."
B. "Children who have chronic health issues may experience developmental delays."
The nurse is reinforcing education for a client with hypertension. Which statement made by the client indicates that further education is required? A. "I will apply methods to reduce stress in my life." B. "I don't have to take my antihypertensives if I am feeling well." C. "I will reduce the cholesterol and salt intake in my diet." D. "I will measure my blood pressure routinely at home."
B. "I don't have to take my antihypertensives if I am feeling well."
An exercise stress test has been ordered for a 12-year-old child. Which statement by the child indicates the need for further instruction? A. "I can eat after the test is finished." B. "It will be important for me to eat the breakfast my mom makes for me before I take the test." C. "If I have any pain or difficulty breathing during the test, I need to let the nurse know." D. "The test should take only about 30 to 45 minutes."
B. "It will be important for me to eat the breakfast my mom makes for me before I take the test."
A teenager with heart failure who has been prescribed digoxin asks the nurse, "What will this drug do for my heart?" What is the best response by the nurse? A. "It will cause vasodilation and help with chest pain." B. "It will decrease the workload of the heart." C. "It will cause sodium excretion." D. "It will increase your heart rate."
B. "It will decrease the workload of the heart."
A client reported chest pain and received sublingual nitroglycerin. Which statement by the client indicates that this drug is producing its therapeutic effect? A. "I have a bad headache." B. "My chest pain is decreasing." C. "I feel a tingling sensation around my mouth." D. "My blood pressure must be up because my vision is blurred."
B. "My chest pain is decreasing."
The nurse is explaining the use of transdermal nitroglycerin, which is to be applied twice daily. The client demonstrates understanding when he states: A. "I should apply the patch in the same spot all the time." B. "My wife should be careful not to touch the patch with her fingers if she helps me." C. "I will know the medication is working if I have a headache after applying it." D. "I'm using the transdermal nitroglycerin to lower my blood pressure."
B. "My wife should be careful not to touch the patch with her fingers if she helps me."
The parents of a 3-year-old with a congenital heart disease report during a checkup that they are concerned about giving a flu vaccine to their child. Which statement is appropriate for inclusion in the nurse's response? A. "Since there are troubling side effects in the vaccine for your child, I would recommend that the other members of the household be immunized instead." B. "The flu vaccine is both safe and recommended to children who have chronic illness such as heart disease." C. "You are right to be concerned since this vaccine should be provided to children who are older than 3 years of age." D. "As long as you are careful who your child is exposed to, you should be fine to avoid giving this vaccine."
B. "The flu vaccine is both safe and recommended to children who have chronic illness such as heart disease."
When obtaining data from a child with suspected Kawasaki disease, which symptom is common? A. low-grade fever B. "strawberry" tongue C. pink, moist mucous membranes D. abdominal pain
B. "strawberry" tongue
A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects which medication to be administered to the client? A. Antibiotic B. Anticoagulant C. Antihypertensive D. Anticonvulsant
B. Anticoagulant
The nurse is caring for a client who was hit in the left eye with a softball. The eye is edematous and painful to touch. Which is the priority intervention by the nurse? A. Apply a cold pack. B. Apply a warm compress. C. Have the client lay flat for 12 hr to decrease swelling. D. Place drops in the eye to decrease pain.
B. Apply a warm compress.
A client states to the nurse, "I want to quit smoking. My father had a heart attack and he was a heavy smoker." Which action by the nurse is appropriate? A. Inform the client it would be best to stop immediately without aids. B. Provide information regarding counseling and smoking cessation aids. C. Encourage the client to quit because quitting is the only way to avoid a heart attack. D. Inform the client to get a prescription for anxiety before trying to stop.
B. Provide information regarding counseling and smoking cessation aids.
A client informs the nurse that he is color blind. Which colors does the nurse determine the client will likely have difficulty distinguishing? A. White and black B. Red and green C. Blue and purple D. Orange and pink
B. Red and green
When assisting with an electrocardiogram (ECG), the nurse would expect to place the client in which position? A. Fowler's B. Supine C. Lateral D. Prone
B. Supine
A nurse is caring for a client with advanced heart failure. The client can't care for themself and hasn't been able to eat for the past week because of dyspnea. The client doesn't want a feeding tube inserted and expresses their desire for "nature to take its course." The client's family is pleading with the client to have a feeding tube inserted. What is the most appropriate action for the nurse to take? A. Ask a priest to talk with the client about the importance of preserving life. B. Talk with the client's family about the client's right to decide for themself. C. Schedule a conference to help the client and the client's family reach a consensus about the feeding tube. D. Schedule feeding tube placement and hope that the nurse can persuade the client to agree to it.
B. Talk with the client's family about the client's right to decide for themself.
The nurse is caring for a child that is undergoing cardiac surgery. Parents ask a nurse what the activity level for their child should be post-surgery. Which response would be best? A. "There are no exercise limitations." B. "The child may resume school in 3 days." C. "Encourage a balance of rest and exercise." D. "Climbing and contact sports are restricted for 1 week."
C. "Encourage a balance of rest and exercise."
A client is hospitalized with newly diagnosed hypertrophic cardiomyopathy. The nurse is reinforcing education about its causes and explains to the client about the abnormal thickening of the heart muscle. Which comment made by the client would indicate an understanding of the disease? A. "This should not affect how well the pumping chamber works." B. "I did not have this in childhood so I don't think I have this disease." C. "I can see how this would make it harder for my heart to pump blood." D. "Even though my father had the disease, it is not hereditary so I might not have it."
C. "I can see how this would make it harder for my heart to pump blood."
The nurse is talking with a client about everyday activities. Which statement made by the client indicates a risk factor for coronary artery disease (CAD)? A. "I exercise every other day." B. "My cholesterol is 180." C. "I smoke 1 ½ packs of cigarettes a day." D. "No one in my family has heart problems."
C. "I smoke 1 ½ packs of cigarettes a day."
A nurse is giving discharge instructions to the parents of a child with Kawasaki disease. Which statement by the parents shows an understanding of the treatment plan? A. "A regular diet can be resumed at home." B. "Black, tarry stools are considered normal." C. "My child should use a soft-bristled toothbrush." D. "My child can return to playing football next week."
C. "My child should use a soft-bristled toothbrush."
A client hospitalized for treatment of hypertension is being prepared for discharge. Which statement from the client indicates an understanding of discharge instructions? A. "I should avoid meat and milk." B. "I should skip my medication dose if dizziness occurs." C. "My sodium intake shouldn't exceed 2,300 mg per day." D. "I should schedule a visit once per week for IV antihypertensive medications."
C. "My sodium intake shouldn't exceed 2,300 mg per day."
The recipient of a donated organ asks the nurse, "What did the donor die from?" Which response by the nurse is most appropriate? A. "I will have the surgeon speak with you." B. "Contact between the donor and the recipient is prohibited." C. "The transplant coordinator can give you information about the donor's medical history." D. "Did you want to send the donor family a thank you card?"
C. "The transplant coordinator can give you information about the donor's medical history."
A client admitted to the hospital for an abdominal aneurysm repair tells a nurse that he has an advance directive. What action should the nurse take? A. Tell the client that the information will be noted in his chart, but it isn't necessary to include a copy of the advance directive. B. Instruct the client to give the advance directive to his lawyer. C. Ask the client for a copy of the advance directive to place on his chart. D. Tell the client that advance directives aren't valid when surgery is being performed.
C. Ask the client for a copy of the advance directive to place on his chart.
The nurse asks a client to use the eyes to follow finger movements to the left and right and then to close and open the eyes. Which cranial nerve will the nurse document as intact if the client is able to perform these movements? A. Cranial nerve I B. Cranial nerve II C. Cranial nerve III D. Cranial nerve IV
C. Cranial nerve III
The nurse is reinforcing education regarding the use of eye drops during treatment for a client who has been diagnosed with conjunctivitis. Which information will the nurse provide the client? A. Warm the solution briefly in the microwave prior to use. B. Save the unused solution for use if the infection returns. C. Ensure not to touch the eye with the dropper. D. Use the drops for the other member of the family who has conjunctivitis.
C. Ensure not to touch the eye with the dropper.
A client is admitted to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, the nurse formulates interventions with which goal in mind? A. Decreasing blood pressure and increasing mobility B. Increasing blood pressure and reducing mobility C. Stabilizing the heart rate and blood pressure and easing anxiety D. Increasing blood pressure and monitoring fluid intake and output
C. Stabilizing the heart rate and blood pressure and easing anxiety
A client is being considered as a candidate for a cochlear implant. Which data gathered by the nurse would support the client's candidacy? A. The client has mild mental retardation. B. The client has a history of schizophrenia. C. The client is unable to recognize words spoken. D. The client expects hearing will resume normally after surgery.
C. The client is unable to recognize words spoken.
A nurse is caring for a client returning from cardiac catheterization. The nurse helps transfer the client back to bed. Which transfer technique uses appropriate ergonomic principles? A. The nurse lowers the bed for transfer. The nurse raises the bed before leaving the room, making sure to place the call light within reach. B. The nurse maintains a narrow base of support during transfer and encourages the client to hold onto the staff members if the client is frightened. C. The nurse raises the bed for transfer, maintains a wide base of support during transfer, and lowers the bed before leaving the room. D. The nurse explains the procedure to the client and grabs the client under the arms to pull them over to the bed.
C. The nurse raises the bed for transfer, maintains a wide base of support during transfer, and lowers the bed before leaving the room.
The nurse is teaching a client how to take nitroglycerin to treat angina pectoris. The client verbalizes an understanding of the need to take up to three sublingual nitroglycerin tablets at 5-minute intervals, if necessary, and to notify the physician immediately if chest pain doesn't subside within 15 minutes. The nurse informs the client that nitroglycerin may cause: A. nausea, vomiting, depression, fatigue, and impotence. B. sedation, nausea, vomiting, constipation, and respiratory depression. C. headache, hypotension, dizziness, and flushing. D. flushing, dizziness, headache, and pedal edema.
C. headache, hypotension, dizziness, and flushing.
A client develops cardiac tamponade when the client's car hits a telephone pole; the client was not wearing a seatbelt. The nurse helps the health care provider perform pericardiocentesis. Which outcome would indicate that pericardiocentesis has been effective? A. neck vein distention B. pulsus paradoxus C. increased blood pressure D. muffled heart sounds
C. increased blood pressure
The nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully? A. increase in blood pressure B. increase in blood volume C. low serum potassium level D. high serum sodium level
C. low serum potassium level
An increase in the creatine kinase-MB isoenzyme (CK-MB) can be caused by: A. cerebral bleeding. B. I.M. injection. C. myocardial necrosis. D. skeletal muscle damage due to a recent fall.
C. myocardial necrosis.
A client is preparing to have an angiocardiogram in the morning. Which data would the nurse obtain in preparation for this test? A. Ask if the client has crutches or a cane to use after the test. B. Ask if the client has a family member that had this test. C. Ask if the client has received a yearly flu shot. D. Ask if the client is allergic to shellfish or iodine.
D. Ask if the client is allergic to shellfish or iodine.
The nurse is obtaining data from an older adult client. Which finding would the nurse recognize as consistent with "stiffening" of the large arteries? A. Respiratory rate of 18 breaths per minute B. Heart rate of 64 beats per minute C. Blood pressure of 100/60 mm Hg D. Blood pressure of 160/72 mm Hg
D. Blood pressure of 160/72 mm Hg
A client states to the nurse, "I am taking a trip by plane and the last time I flew, the problems with my ears were awful!" Which suggestion would the nurse provide to alleviate discomfort? A. Use a Q-tip to remove impacted wax to decrease pressure when flying. B. Insert saline drips into both ears every hour while flying. C. Irrigate the ear prior to the trip to remove wax and decrease pressure. D. Chew gum to promote swallowing.
D. Chew gum to promote swallowing.
An elderly client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism? A. Romberg's B. Phalen's C. Rinne D. Homans'
D. Homans'