MS Week 5 Practice Assessment ATI
A nurse is caring for an older adult client who has left-sided failure. Which of the following findings should the nurse expect? A) Frothy sputum B) Dependent edema C) Nocturnal polyuria D) Jugular distention
ANS: A) Frothy sputum RATIONALE: Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness.
A nurse is reviewing blood pressure classification with a client who has been diagnosed with hypertension. Which of the following should the nurse include as an example of stage 1 hypertension? A) 108/60 mm Hg B) 128/88 mm Hg C) 154/96 mm Hg C) 164/104 mm Hg
ANS: C) 154/96 mm Hg RATIONALE: Stage 1 hypertension includes systolic BP 140 to159 mm Hg or diastolic BP 90 to 99 mm Hg. This is an appropriate example for the nurse to include.
A nurse is collecting data from a client who has heart failure, prior to the administration of furosemide. For which of the following findings should the nurse withhold the medication? A) Blood pressure of 80/40 mm/Hg B) Serum potassium level of 4.8 mEq/L C) Oxygen saturation of 95% Serum sodium level of 140 mEq/L D) Serum sodium level of 140 mEq/L
ANS: A) Blood pressure of 80/40 mm/Hg RATIONALE: Hypotension is an adverse effect of furosemide. The nurse should withhold the medication and notify the provider for a client who is hypotensive.
A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use? A) Slow B) Not palpable C) Irregular D) Bounding
ANS: C) Irregular RATIONALE: With atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions and thus an irregular pulse.
A nurse is reinforcing teaching with a client about nutrition. The client has hypertension and is taking potassium-wasting diuretic. Which of the following dietary instructions should the nurse include in the teaching? A) Increase consumption of canned tuna and salmon. B)Limit intake of dried fruits. C) Avoid cow's milk. D) Consume oranges and bananas
ANS: D) Consume oranges and bananas RATIONALE: Clients taking a potassium-wasting diuretic are at risk for hypokalemia. Therefore, the nurse should encourage the client to consume products high in potassium, such as oranges and bananas.
A nurse is collecting data from a client who has hypertension and a prescription for propranolol. A history of which of the following conditions should be reported to the provider? A) Migraine B) Glaucoma C) Depression D) Heart failure
ANS: D) Heart failure RATIONALE: Propranolol is used with caution in clients who have heart failure due to the depressive effect on myocardial contractility; therefore, the nurse should report this finding to the provider.
A nurse is reinforcing teaching with a client who has hypertension and a new prescription for verapamil. The nurse should instruct the client to avoid taking this medication with which of the following? A) Milk B) Orange juice C) Cranberry juice D) Grapefruit juice
ANS: D) Grapefruit juice RATIONALE: The nurse should instruct the client to avoid taking verapamil with grapefruit juice. Grapefruit juice can inhibit the metabolism of verapamil, a calcium channel blocker, and cause an increase in verapamil blood level. This excess amount of medication can cause severe hypotension and cardiotoxicity.
A nurse in a provider's office is collecting data from a client who reports dyspnea and fatigue. The nurse determines that the client also has tachycardia and edema. Which of the following disorders should the nurse suspect? A) Asthma B) Aortic valve regurgitation C) Heart failure D) Aortic stenosis
ANS: C) Heart failure RATIONALE: Fatigue and tachycardia are early manifestations of heart failure, which also causes dyspnea and peripheral edema.
A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? A) Productive cough B) Hepatomegaly C) Dizziness D) Crackles
ANS: B) Hepatomegaly RATIONALE: Hepatomegaly, or liver enlargement, is a manifestation of right-sided heart failure. This occurs as a result of the inability of the right side of the heart to work effectively as a pump. The systemic blood flow accumulates in the liver and spleen, resulting in hepatomegaly and splenomegaly.
A nurse is caring for a client who has hypertension and experiences acute epistaxis. What is the sequence of steps the nurse should follow when caring for this client? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) - Apply direct pressure to the client's nares. - Place ice on the bridge of the client's nose - Initiate standard precautions for the client. - Tilt the client's head forward.
ANS: - Initiate standard precautions for the client. - Tilt the client's head forward. - Apply direct pressure to the client's nares. - Place ice on the bridge of the client's nose RATIONALE: The first step the nurse should take for this client is to initiate standard precautions. These precautions are designed to reduce the risk of transmission from recognized and unrecognized infectious sources. Standard precautions apply to blood, bodily fluids, secretions and excretions, non-intact skin, and mucous membranes. The next step the nurse should take is to tilt the client's head forward. Tilting the client's head forward will decrease the risk of aspiration and swallowing of blood. The use of gravity will force the blood to drain through the nares. The next step the nurse should take is to apply direct pressure to nares. Applying direct pressure to the nose will help to clot the blood. The pressure should be firm and consistent for several minutes until coagulation occurs. The next step the nurse should take is to place ice on the bridge of the client's nose. An ice pack will constrict the blood vessels, which will decrease bleeding. A barrier such as a wash cloth should be used to avoid skin damage from the direct application of ice to the skin. Ice packs should not be left on the skin for more than 20 min. The nurse also should instruct the client to avoid blowing the nose.
A nurse is assisting with the plan of care for a client immediately following a cardiac catherization with coronary angiography. An arterial closure device as used to close the access site. Which of the following interventions should the nurse recommend? A) Have the client rest in bed for 2 hr. B) Insert an indwelling urinary catheter 1 hr postprocedure. C) Elevate the head of the bed 45 degrees. D) Limit fluid intake for 4 hr after the procedure.
ANS: A) Have the client rest in bed for 2 hr. RATIONALE: Clients who had manual or mechanical pressure after catheter removal require 6 hr of bed rest. Those who had a closure device or patch only need 2 hr of bed rest.
A nurse on a telemetry unit is reviewing laboratory results for a client who has atrial fibrillation and is taking warfarin. Which of the following laboratory values should the nurse report to the provider? A) PT 45 seconds B) Hgb 16 g/dL C) aPTT 36 seconds D) Platelets 190,000/mm3
ANS: A) PT 45 seconds RATIONALE: The expected reference range for PT is 11 to 12.5 seconds. During therapy, the nurse should expect to see the values increase 1.5 to 2.5 times the baseline. Therefore, the nurse should withhold the warfarin and notify the provider.
A nurse is planning to administer digoxin to a client who has heart failure. Which of the following laboratory results is the priority for the nurse to review prior to administering the medication? A) Potassium level B) Hemoglobin level C) Creatinine D) Blood urea nitrogen
ANS: A) Potassium level RATIONALE: Digoxin is a cardiac glycoside medication used to improve myocardial contractility, increasing stroke volume and cardiac output in a client who has heart failure. During therapy, the nurse should closely monitor the client's potassium level as hypokalemia increases the risk of digitalis toxicity and cardiac arrhythmias.
A nurse is caring for a client who is receiving furosemide to treat heart failure. Which of the following laboratory values should the nurse monitor for tis client? A) Serum potassium B) Serum amylase C) Serum triglyceride D) Serum cholesterol
ANS: A) Serum potassium RATIONALE: Furosemide is a loop diuretic that promotes the excretion of potassium. The nurse should be aware that a very low serum potassium level can cause cardiac dysrhythmias. The greatest risk to the client is injury from cardiac dysrhythmias; therefore, this is the priority laboratory value to monitor.
A nurse is reinforcing teaching about the Mediterranean diet with a client who is at risk for hypertension. Which of the following statements by the client indicates a need for further teaching? A) "I will limit my intake of red meat to two times per week." B) "I should cook with olive oil." C) "I will limit my intake of eggs." D) "I can drink wine in moderation."
ANS: A) "I will limit my intake of red meat to two times per week." RATIONALE: The client who follows the Mediterranean diet should limit red meat to twice per month, which indicates a need for further teaching.
A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.) A) "I must stop smoking." B) "I should lower my HDL cholesterol level." C) "I will stop consuming alcohol." D) "I need to monitor my weight." E) "I am limiting my intake of fast foods."
ANS: A, D, E RATIONALE: "I must stop smoking." is correct. Smoking places the client at three to four times higher risk for developing coronary disease, but the benefits of stopping smoking occur almost immediately. "I need to monitor my weight." is correct. Obesity, or an increase in weight, is a significant factor in developing coronary artery disease. Weight management is vital to decreasing the risk of coronary artery disease. "I am limiting my intake of fast foods." is correct. Fast foods typically are prepared with high sodium and high fat, which increase the risk of atherosclerosis and coronary artery disease. To promote cardiovascular health, clients should select healthier food options, such as fruits and vegetables, or foods prepared by baking or broiling.
A nurse is reinforcing teaching with a client who has a new diagnosis of heart failure. Which of the following tools should the nurse use when speaking with client? (Select all that apply.) A) Materials should be culturally diverse. B) Information must be accurate and current. C) Materials should be written at the eighth-grade level. D) Materials should be written in the client's spoken language. E) Materials should be distributed to the client in advance.
ANS: A, B, D, E RATIONALE: Materials should be culturally diverse is correct. The nurse needs to have knowledge of the client's cultural background and beliefs as well as the client's ability to understand instructions developed outside of her native language. When educating the client, the nurse must be aware of the distinctive aspects of each culture, being careful not to stereotype clients. Information must be accurate and current is correct. Current evidence-based practice is essential in health care. It is imperative for educational materials to be accurate and current. If they are not current, the nurse could possibly be providing outdated and incorrect information. Materials should be written in the client's spoken language is correct. The materials must be provided to the client in her spoken language so that she can review the materials. If the materials were in another language, she would not understand the information. Therefore, the client may consent to a procedure without understanding everything about it. In addition, the nurse should not assume the client can read. Materials should be distributed to the client in advance is correct. The written educational materials must be given to the client in advance to allow her an opportunity to review the materials so she can ask any questions prior to providing consent.
A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? A) "Why have you changed your mind about the surgery?" B) "Bypass surgery must be very frightening for you." C) "Your provider would not have scheduled the surgery unless you needed it." D) "I will call your doctor and have him discuss your surgery with you."
ANS: B) "Bypass surgery must be very frightening for you." RATIONALE: This response is therapeutic because it shows empathy and focuses on the client's feelings in a nonthreatening way, and it encourages the client to express his feelings.
A nurse is caring for a client who has hypertension and recently developed drooping facial features. When contacting the provider, which of the following statements should the nurse include as part of the background component of the SBAR communication tool? A) "The client may benefit from a neurology consult." B) "The client has a history of hypertension." C) "The client has developed drooping facial features." D) "The client is disoriented and pupils are slow to respond to light."
ANS: B) "The client has a history of hypertension." RATIONALE: The nurse should include pertinent medical history, such as the client's history of hypertension when giving background information using the SBAR tool. Other information that should be included is previous laboratory tests, treatments, allergies, and code status of the client.
A nurse is reinforcing teaching to a client who is postmenopausal about reducing the risk of coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? A) "A weight loss program will increase my LDL cholesterol levels." B) "Exercising regularly will bring down my HDL cholesterol levels." C) "Adding foods containing omega-3 fatty acids to my diet will lower my risk of heart disease." D) "Increasing the intake of foods containing trans-fatty acids in my diet can lower my risk of heart disease."
ANS: C) "Adding foods containing omega-3 fatty acids to my diet will lower my risk of heart disease." RATIONALE: Including foods in the diet that contain omega-3 fatty acids, such as salmon, mackerel, and tuna, will lower the risk of coronary artery disease.
A nurse is reviewing a provider's admission orders for a client who has acute heart failure. For which of the following prescriptions should the nurse obtain clarification? A) Morphine sulfate 2 mg IV bolus every 2 hr PRN pain B) Laboratory testing of serum potassium upon admission C) Ambulate three times daily D) Bumetanide 1 mg IV bolus every 12 hr
ANS: C) Ambulate three times daily RATIONALE: The nurse should clarify the prescription to ambulate the client three times daily. The client in acute heart failure is weak and activity is limited to minimize shortness of breath and cardiac workload. Instead, the client is placed into a high-Fowler's position and provided with oxygen to relieve dyspnea and hypoxia. Activity is gradually increased as the client's condition improves.
A nurse is reinforcing teaching with a client who has hypertension and asks if there is a herbal supplement he can use to help lower blood pressure. The nurse should identify that the client can use which of the following herbal supplement to help lower blood pressure? A) Valerian B) Probiotics C) Garlic D) Ginger root
ANS: C) Garlic RATIONALE: Clients can use garlic to decrease triglyceride and LDL cholesterol levels and increase HDL cholesterol, lower BP, inhibit platelet aggregation, and decrease atherosclerotic plaque. It might also have antimicrobial and anticancer effects. These effects occur from the actions of sulfides in garlic oil, which can interfere with cholesterol synthesis in the liver, inhibiting thromboxane synthesis, and cause vasodilation.
A nurse is reinforcing health screening education with a group of clients. The nurse should recognize that which of the following clients has the greatest risk for hypertension? A) A client who is of Asian ethnicity B) A female client who is 44-years-old C) A male client who is 53-years-old D) A client who is African American
ANS: D) A client who is African American RATIONALE: The incidence of hypertension is highest in African Americans compared to European Americans. African Americans tend to develop hypertension at an earlier age and experience complications, such as stroke, heart disease, and kidney disease. Hypertension-related deaths are also higher among African Americans.
A nurse is collecting data from a client who reports a sudden onset of shortness of breath, fatigue, and dizziness. Electrocardiography indicates the client is experiencing atrial fibrillation. Which of the following medications should the nurse expect to administer? A) Vitamin K B) Digoxin C) Atropine D) Magnesium
ANS: B) Digoxin RATIONALE: The client who is experiencing atrial fibrillation has an elevated heart rate that is irregular due to rapid impulses being sent to the atrioventricular (AV) node. Digoxin decreases the heart rate and the rate of AV conduction. This medication is used in the treatment of atrial fibrillation and heart failure.
A nurse is caring for a client who has heart failure and is taking furosemide. For which of the following findings should the nurse withhold the medication? A) Crackles in bases of lungs B) Peripheral edema C) Ascites D) Potassium 2.8 mEq/L
ANS: D) Potassium 2.8 mEq/L RATIONALE: Furosemide promotes the excretion of potassium. A potassium level of 2.8 indicates hypokalemia, which places the client at risk for cardiac dysrhythmias and possibly death. The nurse should withhold the medication and contact the provider. Crackles in bases of lungs Left-sided heart failure can result in crackles in lung bases from the back up of blood in the pulmonary system. Clients can benefit from furosemide, a loop diuretic that promotes reabsorption of water and promotes excretion, thus ridding the body of excess fluid. Peripheral edema Right-sided heart failure can result in peripheral edema, jugular vein distention, anorexia, and nausea. Furosemide can promote fluid excretion and relieve these signs and symptoms of heart failure. Ascites Right-sided heart failure can result in ascites, abdominal distention, and liver and spleen enlargement and tenderness. Furosemide can promote fluid excretion and relieve these signs and symptoms of heart failure.
A nurse is reinforcing discharge teaching with a client who recently diagnosed with heart failure. Which of the following statements should the nurse include in the teaching? A) "Begin exercising twice per week." B) "Consume a low-residue diet." C) "Weigh yourself every 2 days." D) "Limit sodium intake to 3.5 g daily."
ANS: A) "Begin exercising twice per week." RATIONALE: The nurse should reinforce to the client to begin walking twice a week, then gradually build tolerance to increase walking to at least three times weekly, increasing distance as the client is able.
A nurse is reinforcing teaching about a heart healthy diet with a group of clients who have hypertension? Which of the following statements by the clients indicates a need for further teaching? A) "I can have a cola drink twice a day." B) "Fresh fruits are good to include with meals." C) "I will replace table salt with dried herbs." D) "I can eat frozen juice bars for a snack."
ANS: A) "I can have a cola drink twice a day." RATIONALE: A client who is on a heart-healthy diet should avoid sugar-sweetened beverages because they increase caloric intake therefore.
A nurse is caring for a client who has hypertension and is afraid to take medication. Which of the following nursing responses uses reflection? A) "You seem upset about your blood pressure." B) "What time do you take your medication?" C) "How do you feel when you take the medication?" D) "I understand your reluctance to use medication."
ANS: A) "You seem upset about your blood pressure." RATIONALE: The nurse is using a reflective comment that describes the client's feelings. A reflective comment repeats what a client has said or describes the client's feelings.
A nurse is caring for a client who has hypertension and is to start taking atenolol. The nurse should instruct the client to monitor for which of the following findings as an adverse effect of this medication? A) Bradycardia B) Headache C) Cough D) Constipation
ANS: A) Bradycardia RATIONALE: Atenolol is a beta-adrenergic blocking agent, which slows the heart rate and can lead to bradycardia. The nurse should instruct the client to check his heart rate before each dose and to notify the provider if the rate is below his usual rate.
A nurse is caring for a client who has heart failure. The client states she has recently been bothered by a non-productive cough. Which of the following medications should the nurse associate with the non-productive cough? A) Captopril B) Furosemide C) Digoxin D) Metoprolol
ANS: A) Captopril RATIONALE: The nurse should recognize that ACE inhibitors such as captopril cause vasodilation and decrease blood pressure and fluid retention in the client who has heart failure. One of the adverse effects of ACE inhibitors is a dry, non-productive cough. Furosemide The nurse should recognize that loop diuretics such as furosemide reduce fluid retention in the lungs. Clients taking furosemide should be monitored for ototoxicity. Digoxin The nurse should recognize that digoxin is an inotropic agent that strengthens the contraction of the heart. Clients taking digoxin should be monitored for digoxin toxicity; however, a dry, non-productive cough is not an adverse effect of this medication. Metoprolol The nurse should recognize that beta-adrenergic blockers such as metoprolol are used to slow the heart rate. Clients who are taking beta-adrenergic blockers should be monitored for fluid retention and heart block.
A nurse is reviewing the medication record of a client who has heart failure and has potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as a possible cause of the client's potassium level? A) Furosemide B) Nitroglycerin C) Metoprolol D) Spironolactone
ANS: A) Furosemide RATIONALE: Furosemide is a high-ceiling loop diuretic that inhibits the reabsorption of sodium and chloride and results in diuresis. Potassium is lost through excretion in the distal nephrons when the client receives this medication. This laboratory result is interpreted as hypokalemia, which is an adverse effect associated with the administration of furosemide.
A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 124/84 mm Hg places him in which of the following categories? A) Prehypertension B) Within the expected reference range C) Hypertension stage 1 D) Hypertension stage 2
ANS: A) Prehypertension RATIONALE: A blood pressure reading of 124/84 mm Hg places this client in the prehypertension category. This includes a systolic pressure of 120 to130 mm Hg and a diastolic pressure of 80 to 89 mm Hg. Within the expected reference range The expected reference range for blood pressure is less than 120 mm Hg systolic and less than 80 mm Hg diastolic. Hypertension stage 1 Stage 1 hypertension presents with a systolic pressure of 140 to159 mm Hg and a diastolic pressure of 90 to 99 mm Hg. Hypertension stage 2 Stage 2 hypertension presents with a systolic pressure of greater than 60 mm hg and a diastolic pressure of greater than 100 mm Hg.
A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? A) Establish IV access. B) Feel for a carotid pulse. C) Establish an open airway. D) Auscultate for breath sounds.
ANS: B) Feel for a carotid pulse RATIONALE: The priority action the nurse should take when using the compressions-airway-breathing approach to client care is to feel for a carotid pulse for 5 to 10 seconds to determine the immediate need for chest compressions.
A nurse is reviewing the laboratory values for a client who has heart failure and is taking bumetanide. For which of the following results should the nurse notify the provider? A) Sodium 136 mEq/L B) Potassium 2.3 mEq/L C) Magnesium 1.4 mEq/L D) Calcium 10 mg/dL
ANS: B) Potassium 2.3 mEq/L RATIONALE: The nurse should recognize that bumetanide is a loop-diuretic and eliminates potassium in the urine. This client's potassium level is below the normal reference range of 3.5 to 5.0 mEq/L. The nurse should assess the client for manifestations of hypokalemia, such as abdominal pain, muscle weakness, urinary retention, lethargy, confusion, and heart dysrhythmias and contact the provider with the findings.
A nurse is preparing to administer digoxin to a client who has heart failure. For which of the following findings should the nurse withhold the medication and report to the provider? A) Heart rate 66/min B) Report of blurred vision C) Urine output 35 mL/hr D) Serum potassium 4.8 mEq/L
ANS: B) Report of blurred vision RATIONALE: The nurse should monitor the client for cardiac and noncardiac adverse effects that can indicate toxicity. Nausea, vomiting, anorexia, fatigue and visual disturbances, such as blurred vision can be early indicators of toxicity. The nurse should withhold the medication and contact the provider.
A nurse is reinforcing teaching with a client who is about to start taking captopril to treat hypertension. Which of the following instructions should the nurse include to help the client manage this medication's adverse effects? A) Use salt substitutes while taking this medication. B) Take the medication on an empty stomach. C) Expect a dry cough when taking this medication. D) Expect to gain weight while taking this medication.
ANS: B) Take the medication on an empty stomach. RATIONALE: The client should take captopril on an empty stomach because food reduces the medication's absorption by 30 - 40%.
A nurse is planning to perform an electrocardiogram (ECG) for a client who has a history of coronary heart disease. Which of the following actions should the nurse take? (Select all that apply.) A) Keep the client NPO after midnight. B) Inspect the electrode pads. C) Use alcohol to wipe the skin before placing the electrodes. D) Instruct the client to breath normally. E) Administer an analgesic prior to the procedure.
ANS: B, C, D RATIONALE: Inspect the electrode pads is correct. The nurse should inspect the electrode pads to check that the gel is present because the gel is necessary to promote electrical conduction between the skin and the electrodes. Use alcohol to wipe the skin before placing the electrodes is correct. The nurse should wipe the skin where she will place the electrodes to ensure the skin is free of oils and other matter. Instruct the client not to talk is correct. The nurse should instruct the client to lie quietly, not talk, or move to prevent the recording of artifact.
A nurse is reinforcing teaching with a client who has hypertension and is taking propranolol. Which of the followings statements by the client indicates an understanding of the teaching? A) "I should weigh myself on the same day once a week." B) "I will not take my medicine if my heart rate is greater than 70/min." C) "I will sit on the side of the bed before I stand up." D) "I should expect to develop a slight cough while taking this medication."
ANS: C) "I will sit on the side of the bed before I stand up." RATIONALE: The nurse should instruct the client to change positions slowly to prevent fainting and to sit or lie down for signs of hypotension such as light-headedness or dizziness.
A nurse in a clinic is caring for a client who has heart failure and is taking digoxin. Which of the following statements by the client indicates the client is experiencing digoxin toxicity? A) "I am gaining weight." B) "I am constipated." C) "My vision seems yellow." D) "My tongue is red and beefy."
ANS: C) "My vision seems yellow." RATIONALE: The nurse should identify that changes in vision, such as double, blurred, or colored vision, are an indication of digoxin toxicity. Other manifestations include headache, confusion, and new dysrhythmias.
A nurse is reinforcing teaching with a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following food choices reflects the client's understanding of these dietary instructions? A) Liver B) Milk C) Beans D) Eggs
ANS: C) Beans RATIONALE: Beans do not contain animal products. Therefore, they do not contain cholesterol. Beans are a good source of protein for a client who follows a low-cholesterol diet. Liver Cholesterol is in all animal tissue. Therefore, a client who needs a low-cholesterol diet should avoid organ meats. Milk Cholesterol is in all animal tissue, including foods that come from animal sources. Therefore, a client who needs a low-cholesterol diet should avoid milk and dairy products. Eggs Cholesterol is in all animal tissue, including foods that come from animal sources. Therefore, a client who needs a low-cholesterol diet should avoid eggs.
A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? A) Suggest that the client rests before eating the meal. B) Request a dietary consult. C) Check the client's vital signs. D) Request an order for an antiemetic.
ANS: C) Check the client's vital signs. RATIONALE: When using the airway, breathing, circulation approach to client care, the nurse should place the priority on obtaining vital signs. Nausea is a manifestation of digoxin toxicity, along with other manifestations such as muscle weakness, confusion, abdominal cramping, and changes in vision.
A nurse is reinforcing teaching with a middle-age client about hypertension. Which of the following information should the nurse include in the teaching? A) Set your goal body weight within 25% of ideal body weight. B) Limit alcohol consumption to 3 drinks a day when hypertensive. C) Plan to have potassium blood levels checked when taking a thiazide diuretics. D) Plan to lower sodium intake to 3,000 mg each day.
ANS: C) Plan to have potassium blood levels checked when taking a thiazide diuretics. RATIONALE: The nurse should include in the teaching to have the client plan to have potassium blood levels checked periodically when taking a thiazide diuretic. Thiazide diuretics can deplete the client of potassium through excretion by the kidney.
A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority? A) ECG tracing shows irregularly irregular heart rate without P waves. B) aPTT result of 70 seconds C) Slurred speech D) Urine output is cloudy and odorous
ANS: C) Slurred speech RATIONALE: Slurred speech can indicate the client is at greatest risk for stroke; therefore, this is the priority finding. In addition to these findings the client might appear confused, have sudden weakness, numbness, tingling or loss of feeling in the face, arm, or leg, and loss of balance.
A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? A) To provide analgesia B) To reduce inflammation C) To prevent blood clotting D) To prevent fever
ANS: C) To prevent blood clotting RATIONALE: Aspirin is used to prevent clot formation by reducing platelet aggregation. Therefore, the nurse should instruct the client the aspirin is prescribed for clients who have coronary artery disease to prevent myocardial infarction caused by clots in the coronary arteries.
A nurse is collecting data from a client who is at 18 weeks of gestation and tells the nurse that she felt light fluttering in her stomach the previous day. The nurse should use which of the following terms to document this finding? A) Ballottement B) Lightening C) Quickening D) Chloasma
ANS: C) Quickening RATIONALE: Clients often describe quickening as a fluttering sensation they first perceive as early as the 14th week of gestation. It reflects fetal movement. Ballottement Ballottement is passive movement of the fetus when the examiner performs a vaginal examination and gently pushes on the fetus with a fingertip. LighteningLightening is the beginning of fetal descent during the final weeks of a term pregnancy. Chloasma Chloasma is a brown pigmentation over the forehead, nose, and cheeks of a client who is pregnant.
A nurse is reinforcing teaching about warfarin with a client who has a new onset of atrial fibrillation. Which of the following statements should the nurse include in the teaching? A) "This medication will help maintain a normal heart rhythm." B) "Warfarin dissolves clots in the bloodstream." C) "This medication slows the response of the ventricles to the fast atrial impulses." D) "Warfarin helps prevent strokes in clients who have atrial fibrillation."
ANS: D) "Warfarin helps prevent strokes in clients who have atrial fibrillation." RATIONALE: Clients who have atrial fibrillation are at an increased risk for thrombus formation and subsequent embolization to the brain. Anticoagulants, such as warfarin, help prevent thrombosis formation.
A nurse is assisting in the plan of care for a client who is receiving digoxin to treat heart failure. Which of the following actions should the nurse plan to take? A) Withhold the medication if the client's heart rate is above 100/min. B) Instruct the client to eat foods that are low in potassium. C) Measure the client's apical pulse rate for 30 seconds before administration. D) Monitor the client for nausea, vomiting, and anorexia.
ANS: D) Monitor the client for nausea, vomiting, and anorexia. RATIONALE: Loss of appetite, nausea, vomiting, and blurred or yellow vision are manifestations of digoxin toxicity. Digoxin toxicity can cause cardiac dysrhythmias and should be reported immediately.
A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily for heart failure. The client's current vital signs are: BP 144/96, heart rate 54/min, respiration 18/min, and temperature 37 degrees C (98.6 degree F). Which of the following actions should the nurse take? A) Administer digoxin 0.125 mg. B) Administer digoxin 0.25 mg. C) Withhold the digoxin dose for elevated BP. D) Withhold the digoxin dose for decreased heart rate.
ANS: D) Withhold the digoxin dose for decreased heart rate. RATIONALE: The nurse should withhold the prescribed dose of digoxin as the heart rate is less than 60/min. The nurse should immediately notify the provider.
A nurse is assisting with the care of a client who has hypertension and chronic kidney disease. The client is scheduled for hemodialysis. Which of the following actions should the nurse plan to take while caring for this client? (Select all that apply.) A) Document vital signs. B) Obtain the client's weight. C) Verify the glomerular filtration rate. D) Administer a sedative to the client. E) Check the graft site for a palpable thrill.
ANS: A, B, E RATIONALE: Document vital signs is correct. The client's vital signs should be taken and documented prior to dialysis for baseline data. The client's blood pressure, in particular, should be monitored prior to, during, and after dialysis due to the potential for hypotension during and after the treatment. If the blood pressure drops too low, an infusion of intravenous normal saline may be required to replace fluid volume and restore the blood pressure. Obtain the client's weight is correct. Hemodialysis shunts the client's blood from the body through a dialyzer and back into the client's circulation. During hemodialysis, the blood is passed through the dialysis machine to remove waste products and excess fluid. The amount of fluid to be removed is determined by the client's weight immediately prior to dialysis. The client's dry weight, which is determined by the provider, is subtracted from the weight immediately prior to the start of dialysis. For example, if the dry weight is 70 kg (154.32 lb) and the current weight is 72 kg (158.73 lb), the dialysis machine is programmed to remove 2 kg (4.4 lb), or 2 L (0.5 gal) of fluid. Check the graft site for a palpable thrill is correct. Hemodialysis requires access to the client's blood by way of a graft, arteriovenous (AV) fistula, or central venous access device. The nurse should check patency of the access site (presence of bruit, palpable thrill, distal pulses, and circulation). This ensures vascular flow and proper functioning of the graft prior to the dialysis procedure. If a thrill is not found, this can indicate the graft has clotted and hemodialysis will not be possible. This would need to be reported to the provider. Measures to protect the graft include avoiding taking blood pressure, administering injections, performing venipuncture, or inserting IV lines on an extremity with an access site.
A nurse is caring for a client who has a heart failure notices that the client did not receive his scheduled dose of furosemide. When filling out an incident report about the occurrence, which of the following information should the nurse include? (Select all that apply.) A) Client's breath sounds clear bilaterally. B) The nurse documents the incident in the client's medical record. C) The nurse documents the client's status as a result of the occurrence. D) The client is informed of the incident report's contents. E) The client's statement about the occurrence.
ANS: A, C, E RATIONALE: Clients breath sounds clear bilaterally is correct. If a medication error occurs, the nurse should monitor the client for adverse effects. Furosemide is a loop diuretic and is used in clients who have heart failure to help eliminate excess fluid. The client missed a dose of furosemide, so the nurse should monitor for signs of fluid volume excess such as crackles and peripheral edema. It is appropriate for the nurse to document this finding in the incident report. The nurse documents the client's status as a result of the occurrence is correct. Factual information should be included in the incident report with details about the impact on the client. This is a factual statement, but the statement itself is not pertinent to the client response to the missed dose or medication. The client's statement about the occurrence is correct. The client's statement should be included in the incident report.
