Module IV Med Surge ATI Chap24 to 31 Test#2

A nurse is assisting with the care of a client who asks why her provider prescribed a daily aspirin. Which of the following is an appropriate response by the nurse?

"Aspirin reduces the formation of blood clots that could cause a heart attack."

The nurse is participating in a teaching session on diet for a patient with hypertension. Which of the following statements if made by the patient would indicate understanding of the teaching? (Select all that apply.)

"Choose fresh or frozen fruits and vegetables." "Read food labels." "Watch for potassium in salt substitutes."

The nurse is evaluating a patient's preoperative teaching for a commissurotomy. The patient shows understanding of the purpose of this procedure by stating which of the following?

"Fused valve flaps are separated to enlarge the valve opening."

A nurse is reinforcing discharge teaching with a client following an atherectomy using the right femoral artery as an access. Which of the following client statements indicates an understanding of the teaching?

"I should restrict lifting to 5 pounds

A nurse is reinforcing teaching with a client who has angina about a new prescription for metoprolol. Which of the following statements by the client indicates understanding of the teaching?

"I will call my doctor if my pulse rate is less than 60."

A nurse is reinforcing teaching with a client scheduled for cardioversion. Which of the following client statements should the nurse identify as an indication the teaching has been understood?

"I will receive an electrocardiogram following the procedure."

A nurse is reinforcing teaching with a client who has a new diagnosis of hypertension and a new prescription for spironolactone 25 mg/day. Which of the following statements by the client indicates an understanding of the teaching?

"I will report any changes in heart rate to my provider."

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. The client asks the nurse about receiving both heparin and warfarin at the same time. Which of the following statements should the nurse give?

"It takes 3 to 4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued."

The nurse is reinforcing teaching about a high-fiber diet for a cardiac patient. The patient asks what the purpose of the diet is. Which of the following replies by the nurse would be appropriate?

"It will reduce your heart's workload."

A nurse is reinforcing discharge teaching with 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?

"Pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink."

A nurse is reinforcing teaching with a client who is scheduled for an echocardiogram. Which of the following statements should the nurse include in the teaching?

"The test allows us to see how your heart valves work."

The nurse is evaluating patient teaching for mitral valve prolapse. The patient shows understanding of the prognosis of MVP by stating which of the following?

"There are often no symptoms."

A nurse is reinforcing teaching with a client who is schedule for a stress test. Which of the following statements should the nurse include in the teaching?

"You will exercise your heart by walking on a treadmill."

The nurse is evaluating understanding after a teaching session for mechanical cardiac valve replacement surgery. Which statement by the patient indicates understanding of teaching?

"You will need anticoagulant therapy for life."

A nurse is reinforcing teaching a client who is schedule for angiography. Which of the following statements should the nurse include in the teaching?

"You will need to keep your affected leg straight following the procedure.

A nurse is reinforcing discharge teaching with a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following food selections should the nurse include as having the highest source of potassium?

1 medium baked potato

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.)

1 slice cheddar cheese 3 oz Atlantic salmon 3 oz roasted chicken breast

The nurse is obtaining BP readings for patients during a clinic visit. For which of the following BP readings should a 1-year follow-up visit be recommended in the patient's teaching plan?

138/84 mm Hg

A nurse is caring for a group of clients. Which of the following clients is at risk for development of a dysrhythmia? (Select all that apply.)

A client who has metabolic alkalosis A client who has COPD A client who underwent stent placement in a coronary artery.

Warfarin (Coumadin)

A patient is scheduled for vascular surgery. The patient is taking digoxin (Lanoxin), furosemide (Lasix), potassium, warfarin (Coumadin), and famotidine (Pepcid). Which medication would the nurse question the possible need to stop several days before surgery?

The nurse is caring for a team of patients. After completing morning rounds, which of the following patients require priority care?

A patient with aortic stenosis who is reporting chest pain

A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh-high compression stockings. Which of the following actions should the nurse take?

Apply the stockings in morning upon awakening and before getting out of bed

A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the client's oxygen per protocol. Which of the following actions should the nurse take first?

Assist the client into high-Fowler's position

A nurse is reinforcing teaching with 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.)

Avoid consuming grapefruit while taking this medication. Monitor for black, tarry stools. Use an electric razor when shaving.

The nurse is collecting data at a follow-up visit for a patient with hypertension. Which of the following data would best indicate to the nurse that the patient's BP therapy has been successful?

BP is less than 120/80 mm Hg

A nurse is caring for a client following an angioplasty through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. Which of the following complications should the nurse suspect?

Bleeding from the incisional site

The nurse is collecting data on a patient who had surgery. Which of the following signs and symptoms indicate to the nurse the possible presence of a deep venous thrombus in the patient's leg? (Select all that apply.)

Calf swelling Positive Homans'sign Warmth Redness

A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following findings pose an immediate concern? (Select all that apply.)

Capillary refill of affected limb of 6 seconds. Mottled appearance of the limb.

The nurse is reinforcing medication teaching for a patient. The nurse would include which of the following instructions to a patient receiving a diuretic?

Change positions slowly.

A nurse is reviewing a client's laboratory test results. The nurse should identify that which of the following results indicates the client is at risk for heart disease? (Select all that apply.)

Cholesterol (Total)245 mg/Dl LDL 140 mg/Dl

The nurse is checking capillary refill on a patient. If it takes longer than 3 seconds for the color to return when assessing capillary refill, the nurse would recognize that which of the following may be indicated?

Decreased arterial flow to the extremity

A nurse is collecting data on a client who has chronic peripheral arterial disease (PAD). Which of the following findings should the nurse expect?

Dependent rubbor with pallor following limb elevation

The nurse is collecting data for a patient experiencing the complication of heart failure from hypertension. Which of the following findings would the nurse expect for this patient? (Select all that apply.)

Distended jugular veins in semi-Fowler's position Bilateral ankle edema

The nurse is providing teaching for a patient undergoing a coronary angiography. Which of the following should be included in the teaching plan for a coronary angiography with femoral catheter insertion site? (Select all that apply.)

Dye injection causes hot, flushing sensation Ambulation is not possible immediately after procedure. Allergies are assessed before testing. Firm pressure must be applied to the insertion site.

The nurse is caring for a patient with cardiomyopathy. Which of the following symptoms, if reported by the patient, require priority action by the nurse?

Dyspnea

A nurse is assisting with data collection from a client who has left-sided valvular heart disease. Which of the following findings should the nurse expect? (Select all that apply)

Dyspnea on exertion Client report of fatigue Peripheral edema

A nurse is screening a client for hypertension. Which of the following actions by the client increases the risk for hypertension? (Select all that apply.)

Eating popcorn at the movie theater. Consuming 36 oz beer daily.

The nurse is reinforcing teaching on hypertension for a patient. Which of the following statements if made by the patient after a teaching session would indicate understanding of what is often the only sign of hypertension?

Elevated

A nurse is assisting in the care of a client who underwent defibrillation. Which of the following should be included in the documentation of this procedure? (Select all that apply.)

Follow-up ECG Energy settings used Skin condition under electrodes

A nurse is collecting data from a client who has pericarditis. Which of the following findings should the nurse expect?

Friction rub.

The nurse is to obtain orthostatic blood pressure measurements. Which of the following is an important safety intervention that should be used during this procedure?

Gait or walking belt

A nurse is collecting data from a client who has splinter hemorrhages in the nail beds and reports a fever. The nurse should identify these findings as manifestations of which of the following disorders?

Infective endocarditis

A nurse is contributing to the plan of care for a client who has transferred from the coronary care unit following coronary artery bypass graft surgery. Which of the following interventions should the nurse include?

Instruct the client to splint chest when deep breathing.

The nurse provides a teaching session for a newly diagnosed patient with hypertension. Which of the following statements if made by the patient would indicate the need for further teaching about the cause of primary hypertension? (Select all that apply.)

It is caused by a tumor of the adrenal gland. An arteriogram can show why hypertension is occurring. The cause can be identified with magnetic resonance imaging (MRI).

A nurse is reinforcing discharge teaching with a client who has a prescription for furosemide 40mg PO daily. The client should take this medication at which of the following times of day?

Morning

A nurse is assisting with the care of a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports running out of diltiazem 3 days ago, and inability to purchase more. Which of the following actions should the nurse take first?

Obtain IV access and ask the charge nurse to administer an IV antihypertensive.

A nurse is caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/min and notifies the provider. The nurse should anticipate that which of the following management strategies will be used for this client?

Pacemaker insertion

The nurse evaluates the patient as understanding how to prevent rheumatic fever if the patient states that rheumatic fever can be prevented by treating streptococcal infections with which of the following?

Penicillin

A nurse is reinforcing teaching with a client who has a new diagnosis of severe peripheral arterial disease. Which of the following instructions should the nurse include?

Place both legs in dependent position while sleeping

Which of the following would the nurse reinforce after a teaching session as the most important lifestyle modification for the patient who is age 59, 5'11", weighs 280 pounds, and is hypertensive?

Reduce weight.

A nurse is collecting data from a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following findings should the nurse expect?

Report of intermittent claudication in the affected leg.

The nurse reviews medication orders and is to give warfarin (Coumadin). Which of the following actions should the nurse take first?

Review international normalized ratio result.

The nurse is caring for a patient on bed rest who is on diuretic therapy. In which area should the nurse check for the presence of edema?

Sacrum

During a health screening, a patient's BP is confirmed by two nurses to be 210/120 mm Hg. Which of the follow- ingactions should the nurse recommend to the patient?

Sit quietly while we call 911 to request an ambulance

A nurse is assisting with admission of a client who has a suspected myocardial infarction (MI) and a history of angina from an MI?

Stable angina can be relieved with rest and nitroglycerin.

A nurse is reviewing the health record of a client who is being evaluate for possible valvular heart disease. Which of the following date are risk factors for this condition? (Select all that apply.)

Surgical repair of an atrial septal defect at age 2. Hypertension for 5 years. Diastolic murmur.

A nurse is assisting with the admission data collection of a client who has suspected pulmonary edema. Which of the following are expected findings? (Select all that apply.)

Tachypnea Persistent cough Orthopnea

A nurse in an urgent care clinic is obtaining a history from a client 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?

Takes metoprolol daily after meals.

A nurse is observing a cardioversion procedure and hears the team call out, "Stand clear." The purpose of this action is to alert personnel of which of the following?

They cannot be in contact with equipment connected to the client.

A nurse is assisting with the admission of a client who has suspected rheumatic endocarditis. The nurse should expect a prescription for which of the following laboratory tests to assist in confirmation of this diagnosis?

Throat culture

A nurse is assisting with a community education program on recommended lifestyle changes to prevent angina and myocardial infarction. Which of the following changes should the nurse recommend be made first?

Tobacco cessation

The nurse is contributing to the plan of care for a patient with heart disease. Which of the following is a modifiable cardiovascular risk factor identified during patient data collection that should be included in the teaching plan?

Tobacco use

A nurse is reviewing the laboratory findings of a client who has myocardial infarction(MI) and reports that dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the MI occurred 14 days ago?

Troponin T

A nurse is assisting in the care of a client who began having chest pain 2 hr ago. Which of the following laboratory findings should the nurse identify as an indication the client has sustained injury to the heart?

Troponin T 0.8 ng/mL