NCLX

The nurse has completed counseling about smoking cessation with a client with coronary artery disease (CAD). The nurse determines that the client has understood the material best if the client makes which statement? "A smoker has twice the risk of having a heart attack as a nonsmoker." "I may try just cutting down first, because the damage has already been done." "I don't think I want to quit because none of the effects are reversible anyway." "I'm never going to start again because I can cut my risk of cardiovascular disease to zero within a year."

"A smoker has twice the risk of having a heart attack as a nonsmoker."

An ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Which question best assists the nurse to discriminate pain caused by a noncardiac problem? "Can you describe the pain to me?" "Have you ever had this pain before?" "Does the pain get worse when you breathe in?" "Can you rate the pain on a scale of 1 to 10, with 10 being the worst?"

"Does the pain get worse when you breathe in?"

The nurse has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? "I need to substitute eggs and milk for meat." "I will eliminate all cholesterol and fat from my diet." "I should routinely use polyunsaturated oils in my diet." "I need to seriously consider becoming a strict vegetarian."

"I should routinely use polyunsaturated oils in my diet."

The nurse determines that a client with coronary artery disease (CAD) needs further teaching about disease management if the client makes which statement? "I will watch my weight gain." "I will avoid walking for exercise." "I will monitor my cholesterol intake." "I will follow a low-fat, low-salt diet."

"I will avoid walking for exercise."

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving if which breath sounds are noted? Rhonchi Wheezes Crackles in the lung bases Crackles throughout the lung fields

Crackles in the lung bases

A client complaining of chest pain has an as-needed (PRN) prescription for sublingual nitroglycerin. Before administering the medication to the client, the nurse should first check which parameter? Blood pressure Cardiac rhythm Respiratory rate Peripheral pulses

Blood pressure

A client is admitted to the hospital with a venous stasis leg ulcer. The nurse is reviewing the physical examination in the medical record. Which symptom is least likely to be noted by the primary health care provider? Itchy scaly skin Lower leg edema Sharp pain in the leg Brownish skin discoloration

Brownish skin discoloration

A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN should assist the RN by placing the bed in which position for the reading? Flat Semi-Fowler's Trendelenburg's Reverse Trendelenburg's

Flat

The client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. The nurse takes which action before surgery to address this risk? Having the client void before surgery Completing a preoperative checklist Marking the location of the pedal pulses on the right leg Checking the results of any baseline coagulation studies

Marking the location of the pedal pulses on the right leg

The nurse is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia? Tall, peaked T waves ST-segment depression Prolonged P-R interval Widening of the QRS complex

Tall, peaked T waves

The nurse is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia? Tall, peaked T waves ST segment depressions Shortened P-R intervals Shortening of the QRS complex

Tall, peaked T waves

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. Next, the nurse should check the client's medical history for which item? Smoking history Recent exposure to allergens History of recent insect bites Familial tendency toward peripheral vascular disease

Smoking history

The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse? Blood pressure Status of airway Oxygen flow rate Level of consciousness

Status of airway

A client is admitted to the hospital with possible rheumatic endocarditis. The nurse should check for a history of which type of infection? Viral infection Yeast infection Streptococcal infection Staphylococcal infection

Streptococcal infection

The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use? Surgical tourniquet Dry sterile dressings Incentive spirometer Over-the-bed trapeze

Surgical tourniquet

The nurse is providing discharge teaching for a post-myocardial infarction (MI) client who will be taking 1 baby aspirin a day. The nurse determines that the client understands the use of this medication if the client makes which statement? "I will take this medication every day." "I will take this medication every other day." "I will take this medication until I feel better." "I will take this medication only when I have pain."

"I will take this medication every day."

The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to the client to try to motivate the client to quit smoking? "If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years." "Since the damage has already been done, it will be all right to cut down a little at a time." "None of the cardiovascular effects are reversible, but quitting might prevent lung cancer." "If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."

"If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."

The clinic nurse is obtaining cardiovascular data on a client. The nurse prepares to check the client's apical pulse and places the stethoscope in which position? Midsternum equal with the nipple line At the midaxillary line on the left side of the chest At the midline of the chest just below the xiphoid process At the mid clavicular line at the fifth left intercostal space

At the midclavicular line at the fifth left intercostal space

A client is scheduled for a dipyridamole thallium scan. The nurse should check to make sure that the client has not consumed which substance before the procedure? Caffeine Fatty meal Excess sugar Milk products

Caffeine

A client has received instructions about an upcoming cardiac catheterization. The nurse determines that the client has the best understanding of the procedure if the client knows to report which symptoms? Chest pain Urge to cough Warm, flushed feeling Pressure at the insertion site

Chest pain

The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse should expect to note which specific characteristic of this condition? Dyspnea Hacking cough Dependent edema Crackles on lung auscultation

Dependent edema

A client admitted to the hospital with coronary artery (CAD) disease complains of dyspnea at rest. The nurse determines that which would be of most help to the client? Providing a walker to aid in ambulation Elevating the head of the bed to at least 45 degrees Performing continuous monitoring of oxygen saturation Placing an oxygen cannula at the bedside for use if needed

Elevating the head of the bed to at least 45 degrees

The nurse is assisting in developing a plan of care for a client who will be returning to the nursing unit following a cardiac catheterization via the femoral approach. Which nursing intervention should be included in the postprocedure plan of care? Place the client's bed in the Fowler's position. Encourage the client to increase fluid intake. Instruct the client to perform range-of-motion exercises of the extremities. Hold regularly scheduled medications for 24 hours following the procedure.

Encourage the client to increase fluid intake.

The nurse is assisting with caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? Limiting movement and abduction of the left arm Limiting movement and abduction of the right arm Assisting the client to get out of bed and ambulate with a walker Having the physical therapist do active range of motion to the right arm

Limiting movement and abduction of the right arm

The nurse is preparing to provide a therapeutic environment for a client who recently had a myocardial infarction (MI). Which are characteristics of a therapeutic environment? No stimulus, no stress Low stimulus, low stress High stimulus, low stress Moderate stimulus, low stress

Low stimulus, low stress

A client with infective endocarditis is at risk for heart failure. The nurse monitors the client for which signs and symptoms of heart failure? Lung crackles, peripheral edema, and weight gain Confusion, decreasing level of consciousness, and aphasia Respiratory distress, chest pain, and the use of accessory muscles Flank pain with radiation to the groin, accompanied by hematuria

Lung crackles, peripheral edema, and weight gain

The nurse is caring for a client who is developing pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client's baseline. As an immediate action before help arrives, the nurse should perform which action? Suction the client vigorously. Place the client in high-Fowler's position. Begin assembling medications that are anticipated to be given. Call the respiratory therapy department to request a ventilator

Place the client in high-Fowler's position.

The nurse is teaching a hospitalized client who has had aortoiliac bypass grafting about measures to improve circulation. The nurse should tell the client to do which? Bend the leg at the hip. Keep the ankles uncrossed. Place two pillows under the knees. Use the knee gatch on the bed controls.

Place two pillows under the knees.

A client is scheduled for a cardiac catheterization using a radiopaque dye. The nurse checks which most critical item before the procedure? Intake and output Height and weight Peripheral pulse rates Prior reaction to contrast media

Prior reaction to contrast media

A client has been diagnosed with Prinzmetal's angina. The nurse reviews the medical record and notes which accompanying characteristics? Select all that apply. Relieved by rest Occurs after exercise Prolonged severe pain Nitroglycerine relieves the pain Happens at the same time each day

Prolonged severe pain Happens at the same time each day

A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client? Reports the client to the police for illegal drug use Explains to the client the damage that cocaine does to the heart Tells the client it is imperative to stop before myocardial infarction occurs Teaches about the effects of cocaine on the heart and offers referral for further help

Teaches about the effects of cocaine on the heart and offers referral for further help

A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled and cool, and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings? The boot has not yet dried. The boot is controlling leg edema. The boot is impairing venous return. The boot has been applied too tightly.

The boot has been applied too tightly.

Acetylsalicylic acid is prescribed for a client before a percutaneous transluminal coronary angioplasty (PTCA). When the nurse takes the aspirin to the client, the client asks the nurse about its purpose. What is the purpose of the aspirin? To prevent the formation of clots To relieve pain at the injection site To prevent a fever after the procedure To prevent inflammation of the injection site

To prevent the formation of clots

The health care provider is discharging a client with a diagnosis of chronic heart failure. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply. Obtain annual influenza vaccination. Restrict fluid intake to 1000 mL per day. Avoid adding salt to foods or in cooking. Report a weight gain of 3 or more pounds in a week. Take an extra dose of prescribed diuretic for swollen ankles

Obtain annual influenza vaccination. Avoid adding salt to foods or in cooking. Report a weight gain of 3 or more pounds in a week.

The nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse should do which intervention to effectively accomplish this goal? Provide a quiet and low-stimulus environment. Encourage the family to come visit very frequently. Encourage the client to call friends and relatives each day. Recommend that the client watch TV as a constant diversion.

Provide a quiet and low-stimulus environment.

A client asks the nurse about metabolic syndrome and what it means. The teaching plan should include which characteristics that define metabolic syndrome? Select all that apply. The triglyceride level is not considered in the diagnosis of metabolic syndrome. Blood pressure is elevated with systolic values greater than 130 mm Hg and diastolic values greater than 85 mm Hg. Fasting blood glucose levels are greater than 200 mg/dL or the client is taking medication for glucose control. The client has abdominal obesity with a waist greater than 40 inches in males and greater 35 inches in females. High density lipoprotein (HDL) cholesterol is greater than 40 mg/dL for males or 50 mg/dl in females or on drug treatment.

Blood pressure is elevated with systolic values greater than 130 mm Hg and diastolic values greater than 85 mm Hg. The client has abdominal obesity with a waist greater than 40 inches in males and greater 35 inches in females.

The licensed practical nurse (LPN) is assisting in caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The registered nurse administers morphine sulfate to the client as prescribed by the health care provider. Following administration of the morphine sulfate, the LPN plans to monitor which indicator(s)? Mental status Urinary output Respirations and blood pressure Temperature and blood pressure

Respirations and blood pressure

The nurse carries out a standard prescription for a stat electrocardiogram (ECG) on a client who has an episode of chest pain. The nurse should take which action next? Do a repeat 12-lead ECG. Wait to see whether the pain resolves. Report the episode of chest pain to the health care provider. Give sublingual nitroglycerin per the health care provider's prescriptions.

Give sublingual nitroglycerin per the health care provider's prescriptions.

A client in a long-term care facility who has a history of angina pectoris wants to go for a short walk outside with a family member. It is a sunny but chilly December day. The nurse should perform which intervention to care for this client in a holistic manner? Tell the client that this is not allowed. Tell the family member not to take the client outdoors. Give the client a cup of hot coffee before going outside. Instruct the family member to dress the client warmly before going outside.

Instruct the family member to dress the client warmly before going outside.

The nurse has given simple instructions on preventing some of the complications of bed rest to a client who experienced a myocardial infarction. The nurse should intervene if the client were performing which of these contraindicated activities? Deep breathing and coughing Repositioning self from side to side Isometric exercises of the arms and legs Ankle circles, plantar, and dorsiflexion exercises

Isometric exercises of the arms and legs

The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage does the nurse instruct the client to select from the menu? Tea Cola Coffee Lemonade

Lemonade

A client who is 36 hours post-myocardial infarction has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation is made? The skin is cool but slightly diaphoretic. Dyspnea is noted only at the end of the exercise. The preactivity pulse rate is 86 beats per minute; the postactivity pulse rate is 94 beats per minute. The preactivity blood pressure (BP) is 140/84 mm Hg; the postactivity BP is 110/72 mm Hg.

The preactivity pulse rate is 86 beats per minute; the postactivity pulse rate is 94 beats per minute.

A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The nurse should take which action first? Check the client's vital signs. Assist the client to sit or lie down. Administer sublingual nitroglycerin. Apply nasal oxygen at a rate of 2 L/min.

Assist the client to sit or lie down.

The nurse is caring for a client diagnosed with Buerger's disease. Which finding should the nurse determine is a potential complication associated with this disease? Pain with diaphoresis Discomfort in one digit Numbness and tingling in the legs Cramping in the foot while resting

Numbness and tingling in the legs

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed, the nurse places a sign above the bed stating that the client should remain on bed rest and in which position? In semi-Fowler's position With the head of the bed elevated 45 degrees With the head of the bed elevated no more than 15 degrees With the foot of the bed elevated as much as tolerated by the client

With the head of the bed elevated no more than 15 degrees

A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action? Assist the client to get back into bed. Report the chest pain episode to the health care provider. Tell the client to stand still, and take the client's blood pressure. Give a nitroglycerin tablet, and assist the client to the bathroom.

Assist the client to get back into bed.