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A client hospitalized for heart failure is receiving digoxin (Lanoxin) and will continue taking the drug after discharge. What should be included in the plan of care for the next few days?

Taking the apical pulse before drug administration and teaching the client how to count the pulse.

A client with a dysrhythmia is admitted to telemetry for observation. In the morning, the client asks for a cup of coffee. what is the nurse's best response?

"Coffee has caffeine, which can affect your heart. it should be avoided."

A client with newly diagnosed multiple myeloma ask, "How longs do you think I have to live?" The most appropriate response by the nuse is:

"Tell me about your concerns right now."

A client with expressive aphasia becomes agitated and upset when attempting to communicate with the nurse. To help reduce the client's frustration, the nurse should:

Allow the client adequate time to speak

A client with rheumatoid arthritis has been given a prescription for acetylsalicylic acid. The client is asks the nurse, "What kind of drug is acetylsalicylic acid?" The nurse recalls that the classification to which this drug belongs is:

Analgesics

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory state of shock?

Arteriolar contriction occurs

A client is scheduled for head and neck surgery. Although the health care provider has explained the surgery, the client still has moderate to severe anxiety. What action should the nurse take initially?

Attempt to discover what the client is concerned about.

A nurse is providing discharge instructions about digoxin (Lanoxin). Which response should a nurse include as a reason for a client to withhold the digoxin?

Blurred vision

A nurse is providing discharge instructions about digoxin. Which response should a nurse include as a reason for a client to withhold the digoxin?

Blurred vision

A hospital client puts the call light on and reports a sudden of chest pain that feels like a pressure weight on the chest. The client also states, "I feel nauseated and very week." What action should the nurse take?

Call the rapid response team

Two hours after a cardiac catheterization that was accessed through the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first?

Check the client's pedal pulses.

Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium (Coumadin) daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do?

Contact the health care provider to determine what anticoagulant therapy should be prescribed for this client.

A nurse is evaluating the results of treatment with erythropoietin. Which assessment finding indicates an improvement in the underlying condition being treated?

Decreased pallor

A client with hypertension has received a prescription for metoprolol (LOpressor). Which information should the nurse include when teaching this client about metoprolol?

Do not abruptly discontinue the medication

A client with hypertension has received a prescription for metoprolol (Lopressor). Which information should the nurse include when teaching this client about metoprolol?

Do not abruptly discontinue the medication

A client is scheduled to be transferred from the coronary care unit to a progressive care unit. The client asks a nurse, "Are you sure I'm ready for this move?" what does the nurse conclude the client most likely is experiencing?

Fear

The parent of a 5-month-old infant with heart failure questions the necessity of weighing the baby every morning. What does the nurse say to explain the importance this information to the infant's condition?

Fluid retention

During a yearly physical examination a complete blood count (CBC) is performed to determine a client's hematologic status. It is composed of several tests, one of which is the level of:

Hemoglobin (Hb)

Which phase of wound healing involves adherence of blood platelets to the walls of an injured vessel?

Hemostasis

A client experiences angina and is admitted to the telemetry unit for observation. Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain. Which instruction should the nurse include when teaching the client about the correct use of sublingual nitroglycerine?

Hold the tablet under the tongue until it is disolved

The day after a surgery a client is encouraged to ambulate. the client angrily asks the nurse, "Why am I being made to walk so soon after surgery?" The nurse explains that the primary purpose of early ambulation is to:

Keep blood from fooling in the legs to prevent clots

A client who had surgery 24 hours ago reports pain in the calf. Assessment reveals redness and swelling at the site of discomfort. What should the nurse do.

Notify the health care provider

The nurse is providing post-procedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. What action should the nurse take?

Notify the primary health care provider immediately

A client who has a hemoglobin of 6 gm/dL is refusing blood because of religious reasons. What is the most appropriate action by the nurse?

Notify the primary health care provider of the client's refusal of blood products

A nurse caring for a client with a myocardial infarction is concerned that the client may develop left ventricular failure. For which clinical manifestation should the nurse assess the client?

Paroxysmal nocturnal dyspnea

Client receives a prescription for nitroglycerin (NItrostat) sublingual as needed for anginal pain. What should the nurse include in the teaching about this medication?

Place the tablet under the tongue or between the cheek and gum

A client with a history of hypertension comes to the emergency department with double vision and a blood pressure of 260/120 mm Hg. The health care provider prescribes a sodium nitroprusside (Nitropress) infusion. The nurse recalls that sodium nitroprusside decreases blood pressure by doing what?

Relaxing arterial smooth muscles

A nurse has administered sublingual nitroglycerine. Which parameter should the nurse use to determine the effectiveness of sublingual nitroglycerin?

Relief of anginal pain

A nurse is preparing to teach a client to apply a nitroglycerin patch (Nitro-Dur) as prophylaxis for angina. Which instruction should the nurse include in the teaching plan?

Remove a previous patch before applying the next one

A client hospitalized for heart failure is receiving digoxin (Lanoxin) and will continue taking the drug after discharge. What should be included in the plan for the next few days?

Taking the apical pulse before drug administration and teaching the client how to count the pulse.

The day after surgery a client is encouraged to ambulate. The client angrily asks the nurse, "Why am I being made to walk so soon after surgery?" What does the nurse explain is the primary purpose of early ambulation?

To keep blood from pooling in the legs to prevent clots

A homosexual client is diagnosed with human immunodeficiency virus (HIV). The primary nurse informed the nursing team that the client wept when told of the diagnosis. A health care team member responded by saying, "I don't feel sorry for people like that. My philosophy is that you made your bed and now you can sleep in it." What is the basis of the team member's comment?

Values and beliefs about sexual lifestyles

The nurse is caring for an elderly client who has a right hip fracture. What intervention should be included in the plan of care?

Venous thromboembolism prevention (VTE)

A client is on cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first?

check for a pulse


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