Perfusion and Protection Quiz

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?

0.9% normal saline IV at 50 mL/hr continuous

A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose of the infant's apical heart rate is less than what rate?

90

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

CD4-T-cell count 180 cells/mm3

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?

Defibrillation

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective?

Increased urine output

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take?

Obtain an EKG

A nurse is teaching a client who has rheumatoid arthritis about increasing physical rest as part of her treatment plan. Which of the following outcomes of this intervention should the nurse document as a goal for this client?

Reduced joint stress

A nurse is caring for a client who is prescribed diphenhydramine to relieve pruritus. The client asks the nurse how he can minimize the daytime sedation he is experiencing. Which of the following responses should the nurse give?

Take most of the daily dose at bedtime

A nurse is assessing a client for early manifestations of rheumatoid arthritis. Which of the following changes is an early manifestation of RA?

Fatigue

A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?

Hepatomegaly

A nurse is caring for a client who has had myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response?

Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Check the client's vital signs.

A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2 mg/min. When the client asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions?

prevents dysrhythmias

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

Metformin

A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?

Orthopnea

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

irregular

A nurse is teaching a client who has a new prescription for bumetanide. Which of the following instructions should the nurse include in the teaching?

"Report changes in hearing."

A nurse is performing discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include?

"Wash your hair with a mild protein shampoo."

While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following?

A systolic murmur

A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload?

Dyspnea Jugular vein distention Confusion

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

Elective cardioversion

A nurse in a cardiac care unit is caring for a client with right-sided heart failure. Which of the following findings should the nurse expect?

Elevated central venous pressure (CVP)

A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?

Erythrocyte sedimentation rate (ESR)

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE?

Exercise

A nurse is assessing a client prior to administering atenolol. Which of the following findings should prompt the nurse to withhold the medication?

Heart rate 46/min

A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?

Hemolytic

A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication?

I feel nauseated and have no appetite

A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?

I plan to slow down if I am tired the day after exercising

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first?

Initiate oxygen therapy

A nurse at a provider's office receives a phone call from a client who reports nausea and unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?

Instruct the client to call 911

A nurse in a provider's office is assessing a client who has AIDS. The nurse notes that the client has multiple and widespread raised, purplish-brown skin lesions. The nurse should recognize that these findings indicate which of the following conditions?

Kaposi's sarcoma

A nurse in a provider's office is assessing a client who has rheumatoid arthritis (RA). Which of the following findings is a late manifestation of this condition?

Knuckle deformity

A nurse in a provider's office is assessing a client who reports occasional atypical chest pain, palpitations, and exercise intolerance. On auscultation, the nurse notes a systolic click. The nurse should recognize this finding as a manifestation of which of the following conditions?

Mitral valve prolapse

A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety?

Morphine

A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity?

My vision seems yellow

A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI?

Nausea Tachycardia Diaphoresis

A nurse is reviewing laboratory results of a client who has atrial fibrillation and is taking warfarin. For which of the following results should the nurse notify the provider?

PT 45 seconds

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?

Potassium

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider?

Presence of peripheral edema

A nurse is teaching a client who has rheumatoid arthritis about self-care strategies for managing the disease. Which of the following activities should the nurse include in the teaching?

Press water from a sponge rather than wringing it.

A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?

Serum creatinine

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse priority

The client experiences sudden weakness of one arm and leg

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include?

The client should hold his cell phone on the side opposite the ICD

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?

These tests help determine the degree of damage to the heart tissues

A nurse is caring for a client who has a delayed hypersensitivity reaction. The nurse should expect which of the following manifestations?

Tissue damage at the site

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe?

Troponin 1

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client?

Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart

A nurse is providing discharge teaching to a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include?

Wash the hair with a mild protein shampoo

A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme-linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis?

Western blot analysis

A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity?

Anorexia

A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as the cause of the client's low potassium level?

Furosemide

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Hacking cough

A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

A dry, red rash across the bridge of the nose and on the cheeks.

A nurse is caring for a client who received an injection of penicillin G procaine. The client begins to experience dyspnea and tongue swelling. Which of the following actions should the nurse perform first?

Administer epinephrine subcutaneously

A nurse is assessing a client who is to have IV urography. Which of the following data should indicate to the nurse that this procedure is contraindicated for this client?

Allergy to shellfish

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?

Atropine

A nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission?

Auscultating the rate and characteristics of the child's heart sounds

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions?

Heart failure

A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following instructions should the nurse include?

Do not drink alcoholic beverages while taking this medication Report unexplained bruising to the provider Avoid people who have infections

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?

Frothy sputum