Units 2&3

A client has a right subclavian central venous catheter. When reconnecting a new administration set, which of the following instructions should the nurse give the client?

"Bear down while holding breath."

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

"You might have to stop taking this medication 5 days before any planned surgeries."

A nurse is providing discharge instructions to a client following a cardiac catheterization. Which of the following information should the nurse include?

"You will notice a small hematoma at the incision site."

A nurse is caring for a client is who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)

24 mL/hr

A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan?

Apply pressure to needlestick sites for 10 min.

60. A nurse is caring for a client who has a central venous catheter and reports hearing a gurgling sound on the side of the catheter insertion. Which of the following complications should the nurse suspect?

Catheter migration

A nurse is caring for four clients. After administering morning medications, she realizes that the nifedipine prescribed for one client was inadvertently administered to another client. Which of the following actions should the nurse take first?

Check the client's vital signs.

A nurse is caring for a client who has bleeding esophageal varices and is being treated with a Sengstaken-Blakemore tube. Which of the following actions should the nurse perform?

Maintain constant observation while the balloons are inflated.

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

Measure the circumference of both upper arms.

A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?

Provide frequent oral and nares care.

A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer?

Vitamin K

A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?

"Heparin does not dissolve clots. It stops new clots from forming."

A nurse is teaching a client who takes warfarin daily. Which of the following statements by the client indicates a need for further teaching?

"I have started taking ginger root to treat my joint stiffness."

A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching?

"I will apply heat."

A nurse is providing discharge teaching to a client who has a new prescription for verapamil for angina. Which of the following instructions should the nurse include?

"Increase your daily intake of dietary fiber."

A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse expect? (Select all that apply.) A. Hypotension B. Bradycardia C. Clubbing of the nail beds D. Weak pulses E. Murmur

A D E

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 assisting with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation. 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. Wash the skin with plain water before placing the electrodes. D. Instruct the client not talk during the test. E. Administer an analgesic prior to the procedure.

B D

A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?

Call the emergency response team.

A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?

Cold and numb numbness distal to the fistula site

A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

Eat foods that contain plenty of potassium.

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

Excessive thrombosis and bleeding

A nurse is reviewing the laboratory values of a client who is at risk for disseminated intravascular coagulopathy. Which of the following values should the nurse report to the provider?

Fibrinogen 85 mg/dL

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?

Hemolytic

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

Hypotension

A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse's priority?

Increase the client's IV fluid rate.

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?

Perform neurovascular checks with vital signs.

A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin?

Prothrombin time (PT)

A nurse is teaching with a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client?

Sublingual

A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

The laboratory values are prolonged.

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

Use an electric razor while on this medication.