ATI w5 Assessment

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?

"Adding foods containing omega-3 fatty acids to my diet will lower my risk of heart disease."

a nurse is reinforcing discharge teaching with a client who has recently diagnosed with heart failure. Which of the following statements should the nurse include in the teaching?

"Begin exercising twice per week."

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?

"Bypass surgery must be very frightening for you."

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?

"I can have cola twice a day."

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 the need for further teaching?

"I will limit my intake of red meat to two times per week."

a nurse is reinforcing teaching with a client who has hypertension and is taking propranolol. Which of the following statements by the client indicates an understanding of the teaching?

"I will sit on the side of the bed before I stand up."

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?

"My vision is yellow."

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 a part of the background component of the SBAR communication tool?

"The client has a history of hypertension."

a nurse is reinforcing reaching 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?

"Warfarin helps prevent strokes in clients who have atrial fibrillation."

a nurse is caring for a client who has hypertension and is afraid to take medication. Which of the following nursing response uses reflection?

"You seem upset about your blood pressure."

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)

-"I must stop smoking." -"I need to monitor my weight." -"I am limiting my intake of fast foods."

a nurse is caring for a client who has 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?

-client's breath sounds clear bilaterally -the nurse documents the client's status as a result of the occurrence. -the client's statement about the occurrence

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)

-document vital signs -obtain the client's weight -check the graft site for a palpable thrill

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?

-initiate standard precautions -tilt the client's head forward -apply direct pressure to the client's nares -place ice on the bridge of the client's nose.

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)

-inspect the electrode pads. -use alcohol to wipe the skin before placing th electrodes -instruct the client to breath normally

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)

-materials should be culturally diverse -information must be accurate and current -materials should be written in the client's spoken language -materials should be distributed to the client in advance

a nurse is reviewing blood pressure classifications with a client who has been newly diagnosed with hypertension. Which of the following should the nurse include as an example of stage 1 hypertension?

154/90 mmHg

a nurse on a telemetry unit is reviewing laboratory results for a client who has atrial fibrillation and is takin warfarin. Which of the following laboratory values should the nurse report to the provider?

PT 45 seconds

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 client who is African American

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?

ambulate three times daily

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?

beans

a nurse is collecting data from a client who had heart failure, prior to the administration of furosemide. For which of the following findings should the nurse withhold the medication?

blood pressure of 80/40 mm Hg

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?

bradycardia

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?

captopril

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?

check the client's vital signs

a nurse is reinforcing teaching with a client about nutrition. The client has hypertension and is taking a potassium-wasting diuretic. Which of the following dietary instructions should be the nurse include in the teaching?

consume oranges and bananas

a nurse is collecting data from a client who reports a sudden onset 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?

digoxin

a nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first?

feel the carotid pulse

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

frothy sputum

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?

furosemide

a nurse is reinforcing teaching with a client who has hypertension and asks if there is 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?

garlic

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 foods?

grapefruit juice

a nurse is assisting with the plan of care for a client immediately following a cardiac catheterization with a coronary angiography. An arterial closure device was used to close the access site. Which of the following interventions should the nurse recommend?

have the client rest in bed for 2 hr

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?

heart failure

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?

heart failure

a nurse is collecting data from a client who has right sided heart failure. Which of the following findings should the nurse expect?

hepatomegaly

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?

irregular

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?

monitor the client for nausea, vomiting, and anorexia

a nurse is reinforcing teaching with a middle aged client about hypertension. Which of the following information should the nurse include in the teaching?

plan to have potassium blood levels checked when taking thiazide diuretics.

a nurse is reviewing a laboratory value for a client who has heart failure and is taking bumetanide. For which of the following results should the nurse notify the provider?

potassium 2.3 mEq/L

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?

potassium 2.8 mEq/L

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 level

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?

prehypertension

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?

quickening

a nurse is preparing to administer digoxin to a client who has a heart failure. For which of the following findings should the nurse withhold the medication and report to the provider?

report of blurred vision

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 this client?

serum potassium

a nurse is caring for a client who had atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?

slurred speech

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 effect?

take the medication on an empty stomach

a nurse is caring for a client who asks why she is being prescribed aspirin 325mg daily following myocardial infarction. The nurse should instruct the client that the aspirin is prescribed for clients who have coronary artery disease for which of the following effects?

to prevent blood clotting

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: BP144/96, HR 54/min, R 18/min TEMP is 98.6. Which of the following actions should the nurse take?

withhold the digoxin dose for decreased heart rate