Medsurg ATI

During the initial postoperative assessment of a client who has just been transferred to the postanesthesia care unit after repair of an abdominal aortic aneurysm, the nurse obtains these data. Which finding has the most immediate implications for the client's care? 1. Arterial line indicates a blood pressure of 190/112 mm Hg. 2. Cardiac monitor shows frequent premature atrial contractions. 3. There is no response to verbal stimulation. 4. Urine output is 40 mL of amber urine.

1

The clinic nurse is evaluating a client who had coronary artery stenting through the right femoral artery a week previously and is taking metoprolol, clopidogrel, and aspirin. Which information reported by the client is most important to report to the health care provider? 1. Stools have been black in color. 2. Bruising is present at the right groin. 3. Home blood pressure today was 104/52 mm Hg. 4. Home radial pulse rate has been 55 to 60 beats/min.

1

The nurse assesses a patient's pulse before administering digoxin and notes a rate of 55 beats/min. What is the priority intervention by the nurse? 1Withhold the dose. 2Administer the drug. 3Check potassium level before giving. 4Reduce the dose to half the prescribed dose.

1

The nurse is caring for a patient prescribed digoxin [Lanoxin] for heart failure. Which finding would require immediate attention by the nurse? 1Vomiting and diarrhea 2Heart rate of 68 beats/min 3Digoxin level of 0.7 ng/mL 4Potassium level of 3.7 mEq/L

1

The nurse is preparing to administer an oral dose of digoxin [Lanoxin]. The apical pulse rate is 64. Which nursing action is most appropriate? 1Give the medication. 2Obtain a serum digoxin level. 3Notify the healthcare provider. 4Assess for signs of digoxin toxicity.

1

The nurse is working in an outpatient clinic where many vascular diagnostic tests are performed. Which task associated with vascular testing is most appropriate to delegate to experienced unlicensed assistive personnel (UAP)? 1. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated 2. Checking blood pressure and pulse every 10 minutes in a client who is undergoing exercise testing 3. Obtaining information about allergies from a client who is scheduled for left leg contrast venography 4. Providing brief client teaching for a client who will undergo a right subclavian vein Doppler study

1

Which assessment is most important for the nurse to obtain prior to administering digoxin to a patient with heart failure? 1Pulse 2Blood pressure 3Respiratory rate 4Weight in kilograms

1

The clinic nurse obtains this information about a client who is taking warfarin after having a deep vein thrombosis. Which finding is most indicative of a need for a change in therapy? 1. Blood pressure is 106/54 mm Hg. 2. International normalized ratio (INR) is 1.2. 3. Bruises are noted at sites where blood has been drawn. 4. Client reports eating a green salad for lunch every day.

2

The nurse has just received a change-of-shift report about these clients on the coronary step-down unit. Which one will the nurse assess first? 1. A 26-year-old client with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today 2. A 45-year-old client with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change 3. A 56-year-old client who underwent coronary angioplasty and stent placement yesterday and has reported occasional chest pain since the procedure 4. A 77-year-old client who was transferred from the intensive care unit 2 days ago after coronary artery bypass grafting and has a temperature of 100.6°F (38.1°C)

2

Which topics will the nurse plan to include in discharge teaching for a client who has been admitted with heart failure? Select all that apply. 1. How to monitor and record daily weight 2. Importance of stopping exercise if heart rate increases 3. Symptoms of worsening heart failure 4. Purpose of chronic antibiotic therapy 5. How to read food labels for sodium content 6. Date and time for follow-up appointments

1356

A client seen in the clinic with shortness of breath and fatigue is being evaluated for a possible diagnosis of heart failure. Which laboratory result will be most useful to monitor? 1. Serum potassium 2. B-type natriuretic peptide 3. Blood urea nitrogen 4. Hematocrit

2

The charge nurse in a long-term care facility that employs RNs, LPNs/LVNs, and unlicensed assistive personnel (UAP) has developed a plan for the ongoing assessment of all residents with a diagnosis of heart failure. Which activity included in the plan is most appropriate to assign to an LPN/LVN team member? 1. Weighing all residents with heart failure each morning 2. Listening to lung sounds and checking for edema each week 3. Reviewing all heart failure medications with residents every month 4. Updating activity plans for residents with heart failure every quarter

2

While reviewing a hospitalized client's medical record, the nurse obtains this information about cardiovascular risk factors. Which interventions will be important to include in the discharge plan for this client? Select all that apply. Health History: Hypertension for 10 years, Takes hydrochlorothiazide 25 mg daily, Blood pressure range 110/60 to 132/72 mm Hg Family History: Client's mother and 2 siblings have had myocardial infarctions Social History: 20 pack-year history of cigarette use, Walks 2 to 3 miles daily 1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk 3. Education about the need for a change in antihypertensive therapy 4. Assistance in reducing emotional stress 5. Discussion of the risks associated with having a sedentary lifestyle

12

The nurse in the cardiovascular clinic receives telephone calls from four clients. Which client should be scheduled to be seen most urgently? 1. Client with peripheral arterial disease who complains of leg cramps when walking 2. Client with atrial fibrillation who reports episodes of lightheadedness and syncope 3. Client with a new permanent pacemaker who has severe itchiness at the wound site 4. Client with angina who took nitroglycerin twice in the last week while exercising

2

The nurse is caring for a client who has heart failure and has a new prescription for sacubitril-valsartan. Which client information is most important to discuss with the health care provider before administration of the medication? 1. The client's oxygen saturation is 92%. 2. The client receives lisinopril 10 mg/day. 3. The client's blood pressure is 150/90 mm Hg. 4. The client's potassium is 3.3 mEq/L (3.3 mmol/L).

2

The nurse is preparing to implement teaching about a heart-healthy diet and activity levels for a client who has had a myocardial infarction and the client's spouse. The client says, "I don't see why I need any teaching. I don't think I need to change anything right now." Which response is most appropriate? 1. "Do you think your family may want you to make some lifestyle changes?" 2. "Can you tell me why you don't feel that you need to make any changes?" 3. "You are still in the stage of denial, but you will want this information later on." 4. "Even though you don't want to change, it's important that you have this teaching."

2

Which client is best for the coronary care charge nurse to assign to a float RN who has come for the day from the general medical-surgical unit? 1. Client requiring discharge teaching about coronary artery stenting before going home today 2. Client receiving IV furosemide to treat acute left ventricular failure 3. Client who just transferred in from the radiology department after a coronary angioplasty 4. Client just admitted with unstable angina who has orders for a heparin infusion and aspirin

2

While working on the cardiac step-down unit, the nurse is precepting a newly graduated RN who has been in a 6-week orientation program. Which client will be best to assign to the new graduate? 1. A 19-year-old client with rheumatic fever who needs discharge teaching before going home with a roommate today 2. A 33-year-old client admitted a week ago with endocarditis who will be receiving a scheduled dose of ceftriaxone 2 g IV 3. A 50-year-old client with newly diagnosed stable angina who has many questions about medications and nursing care 4. A 75-year-old client who has just been transferred to the unit after undergoing coronary artery bypass grafting yesterday

2

The nurse is developing a standardized care plan for the postoperative care of clients undergoing cardiac surgery. The unit is staffed with RNs, LPN/LVNs, and unlicensed assistive personnel. Which nursing activity will need to be performed by RN staff members? 1. Removing chest and leg dressings on the second postoperative day and cleaning the incisions with antibacterial swabs 2. Reinforcing client and family teaching about the need to deep breathe and cough at least every 2 hours while awake 3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes 4. Administering oral analgesic medications as needed before helping the client out of bed on the first postoperative day

3

The nurse makes a home visit to evaluate a hypertensive client who has been taking enalapril. Which finding is most important to report to the health care provider? 1. Client reports frequent urination. 2. Client's blood pressure is 138/86 mm Hg. 3. Client complains about a frequent dry cough. 4. Client says, "I get dizzy sometimes if I stand up fast."

3

Two weeks ago, a client with heart failure received a new prescription for carvedilol 12.5 mg orally. Which finding by the nurse who is evaluating the client in the cardiology clinic is of most concern? 1. Reports of increased fatigue and activity intolerance 2. Weight increase of 0.5 kg over a 1-week period 3. Sinus bradycardia at a rate of 48 beats/min 4. Traces of edema noted over both ankles

3

A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. Avoid the consuming grapefruit while taking this medication. B. Monitor for the presence of black, tarry stools. C. Use an electric razor when shaving. D. Schedule a weekly PT test. E. Limit food sources containing vitamin K while taking this medication.

ab

A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary artery bypass grafting with a group of nurses. Which of the following should be included in the discussion? (Select all that apply.) A. The client's demand for oxygen is lowered. B. Motion of the heart ceases. C. Rewarming of the client takes place. D. The client's metabolic rate is increased. E. Blood flow to the heart is stopped.

abc

The nurse is ambulating a cardiac surgery client whose heart rate suddenly increases to 146 beats/min. In which order will the nurse take the following actions? 1. call the HCP 2. have the client sit down 3. check the BP 4. admin PRN O2 by NC

2431

A client whose systolic blood pressure is always higher than 140 mm Hg in the clinic tells the nurse, "My blood pressure at home is always fine!" What action should the nurse take next? 1. Instruct the client about the effects of untreated high blood pressure on the cardiovascular and cerebrovascular systems. 2. Educate the client about lifestyle changes such as low-sodium diet, daily exercise, and restricting alcohol use to no more than 2 beers per day. 3. Ask the client to obtain blood pressures twice daily with an automatic blood pressure cuff at home and bring the results to the clinic in a week. 4. Provide the client with a handout describing the various types of antihypertensive medications with the medication effects and adverse effects.

3

During a home visit to an 88-year-old client who is taking digoxin 0.25 mg/day to treat heart failure and atrial fibrillation, the nurse obtains this assessment information. Which finding is most important to communicate to the health care provider? 1. Apical pulse 68 beats/min and irregular 2. Digoxin taken with meals 3. Vision that is becoming "fuzzy" 4. Lung crackles that clear after coughing

3

The nurse is caring for a hospitalized client with heart failure who is receiving captopril and spironolactone. Which laboratory value will be most important to monitor? 1. Sodium level 2. Blood glucose level 3. Potassium level 4. Alkaline phosphatase level

3

A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should be consumed in limited quantities? (Select all that apply.) A. Cheddar cheese, 2 oz B. Hot dog C. Canned tuna, 3 oz D. Roast chicken breast, 3 oz E. Baked ham, 3 oz

abce

When the nurse is monitoring a 53-year-old client who is undergoing a treadmill stress test, which finding will require the most immediate action? 1. Blood pressure of 152/88 mm Hg 2. Heart rate of 134 beats/min 3. Oxygen saturation of 91% 4. Chest pain level of 3 (on a scale of 0 to 10)

4

A nurse is planning caring for a client who had a surgical placement of an synthetic graft to repair an aneurysm. Which of the following interventions should the nurse include in the plan of care? A. Assess pedal pulses. B. Monitor for an increase in pain below the graft site .C. Maintain client in high Fowler's position. D. Administer prescribed antiplatelet agents. E. Report an hourly urine output of 60 mL.

abd

Which patient symptoms should alert the nurse to be concerned about digoxin [Lanoxin] toxicity? Select all that apply. AFatigue BVomiting CConstipation DBlurred vision EMuscle weakness

abd

A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following are expected findings? (Select all that apply.) A. Tachypnea B. Persistent cough C. Increased urinary output D. Thick, yellow sputum E. Orthopnea

abe

which of these clinical assessment findings would alert the nurse to intervene due to complications from bleeding following surgery. select all that apply a. CVP - 2 b. UO - 60 to 38 c. BP - 140/95 d. PAWP - 15 e. HR - 80 to 120

abe

A client who is scheduled for a coronary arteriogram is admitted to the hospital on the day of the procedure. Which client information is most important for the nurse to communicate to the health care provider (HCP) before the procedure? 1. Blood glucose level is 144 mg/dL (8 mmol/L). 2. Cardiac monitor shows sinus bradycardia, rate 56 beats/min. 3. Client reports chest pain that occurred yesterday. 4. Client took metformin 500 mg this morning.

4

A patient is prescribed digoxin to treat heart failure. Which biochemical parameter should be assessed by the nurse to ensure safe drug administration? 1Liver enzyme concentration 2Blood glucose concentration 3Serum calcium concentration 4Serum potassium concentration

4

A patient's serum digoxin level is noted to be 0.5 ng/mL. Which action by the nurse is appropriate? 1Notify the provider. 2Administer an antidote. 3Hold the ordered dose of digoxin. 4Administer the ordered dose of digoxin.

4

A resident in a long-term care facility who has venous stasis ulcers is treated with an Unna boot. Which nursing activity included in the resident's care is best for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Teaching family members the signs of infection 2. Monitoring capillary perfusion once every 8 hours 3. Evaluating foot sensation and movement each shift 4. Assisting the client in cleaning around the Unna boot

4

At 10:00 am, a hospitalized client receives a new order for transesophageal echocardiography as soon as possible. Which action will the nurse take first? 1. Put the client on "nothing by mouth" (NPO) status. 2. Teach the client about the procedure. 3. Insert an IV catheter in the client's forearm. 4. Attach the client to a cardiac monitor.

4

The nurse assesses a client who has just returned to the recovery area after undergoing coronary arteriography. Which information is of most concern? 1. Blood pressure is 154/78 mm Hg. 2. Pedal pulses are palpable at + 1. 3. Left groin has a 3-cm bruised area. 4. Apical pulse is 122 beats/min and regular.

4

The nurse is preparing to administer a daily dose of digoxin [Lanoxin]. What is the priority nursing intervention? 1Check blood pressure. 2Palpate the pedal pulses. 3Assess for Homans' sign. 4Analyze heart rate and rhythm.

4

The nurse is preparing to administer the following medications to a client with multiple health problems who has been hospitalized with deep vein thrombosis. Which medication is most important to double-check with another licensed nurse? 1. Famotidine 20 mg IV 2. Furosemide 40 mg IV 3. Digoxin 0.25 mg PO 4. Warfarin 2.5 mg PO

4

The nurse reviews a patient's laboratory values and observes a digoxin level of 2.5 ng/mL and a potassium level of 5.9 mEq/L. Upon physical assessment, the patient begins to experience changes in heart rate and rhythm (dysrhythmias). Which drug should the nurse be prepared to administer? 1Digoxin 2Quinidine 3Potassium supplements 4Digoxin immune Fab

4

A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. The nurse should suspect A. retroperitoneal bleeding. B. cardiac tamponade. C. bleeding from the incisional site. D. heart failure.

c

A nurse is caring for a client in a clinic who asks the nurse why her provider prescribed 1 aspirin per day. Which of the following is an appropriate response by the nurse? A. "Aspirin reduces the formation of blood clots that could cause a heart attack." B. "Aspirin relieves the pain due to myocardial ischemia." C. "Aspirin dissolves clots that are forming in your coronary arteries." D. "Aspirin relieves headaches that are caused by other medications."

a

A nurse is caring for a client who has heart failure and asks how to limit fluid intake to 2,000 mL/day. Which of the following is an appropriate response by the nurse? A. "Pour the amount of fluid you drink into an empty 2 liter bottle to keep track of how much you drink." B. "Each glass contains 8 ounces. There are 30 milliliters per ounce, so you can have a total of 8 glasses or cups of fluid each day." C. "This is the same as 2 quarts, or about the same as two pots of coffee." D. "Take sips of water or ice chips so you will not take in too much fluid."

a

A nurse is caring for a client who has severe peripheral arterial disease (PAD). The nurse should expect that the client will sleep most comfortably in which of the following positions? A. With the affected limb hanging from the bed B. With the affected limb elevated on pillows C. With the head of the bed raised D. In a side-lying, recumbent position

a

A nurse is providing discharge teaching for a client who has a prescription for furosemide 40 mg PO daily. The nurse should instruct the client to take this medication at which of the following times of day? A. Morning B. Immediately after lunch C. Immediately before dinner D. Bedtime

a

which one of these clinical assessment findings should the nurse document and report for a client who has a diagnosis of right sided heart failure indicating a complication with cardiac perfusion? a. peripheral edema, ascites, JVD b. weight gain, crackles, JVD c. periorbital edema, moist cough, ascites d. frothy, pink sputum, RR - 30, anxious

a

A nurse is teaching a client who has a new prescription for clopidogrel (Plavix). Which of the following should be included in the teaching? (Select all that apply.) A. Effects may not be apparent for several weeks. B. Monitor for the presence of black, tarry stools. C. Instruct the client to use an electric razor. D. Schedule a weekly PT test. E. Advise the client about food sources containing vitamin K.

ab

1. A nurse is caring for a clientwho has chronic venous insufficiency and a prescription for thigh-high compression stockings. Which of the following actions should the nurse take? A. Massage both legs firmly with lotion prior to applying the stockings. B. Apply the stockings in the morning upon awakening and before getting out of bed. C. Roll the stockings down to the knees to relieve discomfort on the legs. D. Remove the stockings while out of bed for 1 hr, four times a day, to allow the legs to rest

b

A nurse is caring for a 72-year-old client who is to undergo a percutaneous balloon valvuloplasty. The client's daughter asks the nurse to explain the expected outcome of this procedure. Which of the following is an appropriate response by the nurse? A. "This will improve blood flow in your mother's coronary arteries." B. "This will permit your mother to resume her activities of daily living." C. "This will prolong your mother's life." D. "This will reverse the effects to the damaged area."

b

A nurse is caring for a client who has chronic venous insufficiency. The provider prescribed thigh-high compression stockings. The nurse should instruct the client to A. massage both legs firmly with lotion prior to applying the stockings. B. apply the stockings in the morning upon awakening and before getting out of bed. C. roll the stockings down to the knees if they will not stay up on the thighs. D. remove the stockings while out of bed for 1 hr, four times a day to allow the legs to rest.

b

A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the oxygen per protocol. Which of the following actions should the nurse take first? A. Obtain the client's weight. B. Assist the client into high-Fowler's position. C. Auscultate lung sounds. D. Check oxygen saturation with pulse oximeter.

b

A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting (CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, then refuses to cough because he is tired and it hurts too much. Which of the following is an appropriate nursing intervention? A. Allow the client to rest, and return in 1 hr. B. Administer IV bolus analgesic, and return in 15 min. C. Document the 200 mL as an appropriate inspired volume. D. Tell the client that he must try to cough if he does not want to get pneumonia.

b

A nurse is completing discharge teaching to a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following statements by the client indicates understanding of the teaching? A. "I will consume more white rice." B. "I will eat more baked potatoes." C. "I will drink more grape juice." D. "I will use more powdered cocoa mixes."

b

A nurse is providing teaching fora client who has a new diagnosis of hypertension and a new prescription for spironolactone25 mg/day. Which of the following statements by the client indicates an understanding of the teaching? A. "I should eat a lot of fruits and vegetables, especially bananas and potatoes." B. "I will report any changes in heart rate to my provider." C."I should replace the salt shaker on my table with a salt substitute." D."I will decrease the doseof this medication when I no longer have headaches and facial redness."

b

which of these statements made by the charge nurse who is conducting an orientation program on the patho of cardiogenic shock indicates an appropriate understanding of this shock? a. occurs due to a mechanical blockage of the heart b. occurs due to a pump or heart failure c. occurs due to a decrease in intravascular volume d. occurs due to a widespread vasodilation and increased permeability

b

A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following client findings pose an immediate concern? (Select all that apply.) A. Trace of bloody drainage on dressing B. Capillary refill of affected limb of 6 seconds C. Mottled appearance of the limb D. Throbbing pain of affected limb that is decreased following IV bolus analgesic E. Pulse of 2+ in the affected limb

bc

The nurse is monitoring a patient with suspected digoxin toxicity. Which assessment findings would be consistent with digoxin toxicity? Select all that apply. ADiarrhea BAnorexia CVomiting DDry cough EVisual disturbances

bce

1. A nurse is screening a male client for hypertension. The nurse should identify that which of the following actions by the client increase his risk for hypertension? (Select all that apply.) A. Drinking 8 oz nonfat milk daily B. Eating popcorn at the movie theater C. Walking 1 mile daily at 12 min/mile pace D. Consuming 36 oz beer daily E. Getting a massage once a week

bd

A nurse in an urgent care clinicis obtaining a history from aclient who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the second time in 2 weeks that the client experienced hypoglycemia. Which of the following client data should the nurse report to the provider? A. Takes psyllium daily as a fiber laxative B. Drinks skim milk daily as a bedtime snack C. Takes metoprolol daily after meals D. Drinks grapefruit juice daily with breakfast

c

A nurse in the emergency department is admitting a client who has a possible dissecting abdominal aortic aneurysm. Which of the following actions is the priority for the nurse to take? A. Administer pain medication as prescribed. B. Provide a warm environment. C. Administer IV fluids as prescribed .D. Initiate a 12‐lead ECG.

c

A nurse in the emergency department is assisting with the admission of a client who has a possible dissecting abdominal aortic aneurysm. Which of the following is the priority nursing intervention? A. Administer pain medication as prescribed. B. Ensure a warm environment. C. Administer IV fluids as prescribed. D. Initiate a 12-lead ECG.

c

A nurse is admitting a client with a suspected occlusion of a graft of the abdominal aorta. Which of the following is an expected clinical finding? A. Increased urine output B. Bounding pedal pulse C. Increased abdominal girth D. Redness of the lower extremities

c

A nurse is caring for a client who has a deep-vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin (Coumadin). The client questions the nurse about receiving both heparin and warfarin at the same time. Which of the following is an appropriate response by the nurse? A. "I will remind your provider that you are already receiving heparin." B. "Laboratory findings indicated that two anticoagulants were needed." C. "It takes three or four days before the effects of warfarin are achieved and the heparin can be discontinued." D. "Only one of these medications is being given to treat your deep-vein thrombosis."

c

A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports a headache and double vision. The client states that she ran out of her diltiazem 3 days ago, and is unable to purchase more. Which of the following actions should the nurse take first? A. Administer acetaminophen for headache. B. Provide teaching regarding the importance of not abruptly stopping an antihypertensive. C. Obtain IV access and prepare to administer an IV antihypertensive. D. Call social services for a referral for financial assistance in obtaining prescribed medication.

c

A nurse is caring for a client whohas a deep-vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin.The client asks the nurse about receiving both heparin and warfarin at the same time. Which of the following statements should the nurse give? A. "I will remind your provider that you are already receiving heparin." B. "Your laboratory findings indicated that two anticoagulants were needed." C."It takes 3 to 4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued." D."Only one of these medications is being given to treat your deep-vein thrombosis."

c

which one of these physical assessment findings should the nurse document in the chart for a client who has chronic PAD? a. peripheral edema in bilateral ankes b. calf of the right leg is larger than the left c. when the legs are dependent, the color is rubor and pale when elevated d. walking increases circulation and helps relieve pain

c

A nurse is assessing a client who has chronic peripheral arterial disease (PAD). Which of the following findings should the nurse expect? A. Edema around the ankles and feet B. Ulceration around the medial malleoli C. Scaling eczema of the lower legs with stasis dermatitis D. Pallor on elevation of the limbs, and rubor when the limbs are dependent

d

A nurse is performing a physical assessment of a client who has chronic peripheral arterial disease (PAD). Which of the following is an expected finding? A. Edema around the client's ankles and feet B. Ulceration around the client's medial malleoli C. Scaling eczema of the client's lower legs with stasis dermatitis D. Pallor on elevation of the client's limbs and rubor when his limbs are dependent

d

A nurse is teaching a client who has been a new diagnosis of severe peripheral arterial disease. Which of the following instructions should the nurse include? A. Wear tightly fitted insulated socks with shoes when going outside. B. Elevate both legs above the heart when resting. C. Apply a heating pad to both legs for comfort. D. Place both legs in dependent position while sleeping.

d

nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following is an expected finding? A. Rubor of the affected leg when elevated B. 3+ dorsal pedal pulse in left foot C. Thin, peeling toenails of left foot D. Report of intermittent claudication in the affected leg

d

which nursing plan of action indicated the LPN understands how to appropriately care for a client with PAD a. measures the diameter of the calf and compares to the other leg b. positions the affected leg above heart level c. applies compression stockings after client gets out of bed d. assists client to dangle legs off the side of the bed

d

which of these clinical findings would be a priority to report for a client who is experiencing cardiogenic shock a. CVP - 6 b. PAWP - 6 c. CO - 6 d. crackles

d

which of these plans would be a priority for a client who is bleeding following a GI surgery and presenting with a BP of 96/58 a. benadryl b. raise HOB c. decrease fluid d. supine with legs elevated

d

which one of these nursing actions, included in the quality assurance program for HF clients, is most appropriate to delegate to the UAP? a. assess breath sounds and check for edema daily b. check chats to make certain clients are receiving carvedilol as ordered c. encourage client to drink fluids hourly d. weight all clients as ordered

d

which one of these orders for a client who is in cardiogenic shock should the nurse question? a. give morphine IV b. monitor and document client's LOC c. monitor UO hourly d. start IV of NS at 150 ml/hour

d

a nurse is teaching a client schedule for catheterization, what should the patient be educated to do after

keep leg straight after