Cardio and Hematology (PN)

A nurse is talking with a client who is about to start using transdermal nitroglycerin (Nitro-Dur) to treat angina pectoris. Which of the following is an appropriate instruction for this medication therapy?

Apply the transdermal patch in the morning

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

Shortness of breath while lying down

A nurse at an urgent care clinic is caring for a client who is experiencing chest pain. While waiting for emergency services to arrive, the nurse administers total of 3 nitroglycerin (Nitrostat) 0.4 mg tablets sublingually. The nurse should report that the client has received a total of how many mg of nitroglycerin?

1.2 mg

A nurse is caring for a client receiving IV dextrose 5% in 0.9% sodium chloride at 75 mL/hr. When the nurse checks the client's IV bag at 0700, there are 300 mL remaining in the bag. At what time does the nurse anticipate needing to hang a new bag of D5NS?

1100

A nurse is caring for a client who has an IV fluid prescription for 1,00 mL lactated Ringer's, followed 1,000 mL dextrose 5% in 0.9% sodium chloride, then followed by 1,000 mL dextrose 5% in water. The three solutions are to infuse over 24 hr. The drop factor on the manual IV tubing is 10 gtt/mL. The nurse should adjust the IV flow rate to deliver how many gtt/min?

21 gtt/min

A nurse receives a unit of packed red blood cells from the blood bank and notes that the time on the clock reads 4:10 PM. Which of the following times must the blood transfusion begin infusing?

4:40 PM

A nurse is caring for a client who has rhabdomyolysis. The provider prescribes 0.9% sodium chloride to infuse at a rate of 200 mL/hr. How many hours will it take for a 1-L bag of IV fluid to infuse?

5 hr

A nurse is caring for a newborn and calculating the Apgar score. At one-minute after delivery, the following is noted: heart rate of 110; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the Apgar score.

6

A nurse is reviewing the morning laboratory results of electrolytes of four cardiac clients who are receiving digoxin (Lanoxin). Which of the clients should the nurse identify as being at risk for developing digoxin toxicity?

A client taking furosemide (Lasix) for chronic hypertension

A nurse is obtaining vital signs on a client who is 3 days postoperative following a coronary artery bypass graph surgery (CABG), and notes that the client has an irregular radial pulse of 92/min. Which of the following actions should the nurse take first?

Count the apical heart rate for 1 minute

A nurse is preparing a presentation for coworkers about the various herbal remedies clients might report using. Which of the following should she include as an herbal supplement clients might use to help lower blood pressure?

Garlic

A client has developed agranulocytosis as a result of taking propylthiouracil (PTU) to treat hyperthyroidism. When preparing to reinforce teaching with the client, the nurse should base her instructions on the fact that the client is at serious risk for which of the following?

Infection

A nurse is caring for a client who has heart failure. The client's arterial blood gas values reveal a pH of 7.24, PaCO2 of 53, and an HCO3 of 24. The nurse recognizes that the client is experiencing which of the following?

Respiratory acidosis

A nurse is teaching a group of nursing students about the various routes of medication administration. The nurse should explain that, of the following routes, the one that results in the most rapid absorption of the medication into the bloodstream is

Sublingual

A nurse is assessing a client before administering a unit of RBC. Which of the following data are most important prior to transfusing the RBC?

Temperature

A nurse is assessing a client before administering a unit of RBC. Which of the following data are most important prior transfusing the RBC?

Temperature

A nurse is caring for client who has a prescription for digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg tab. The client's current vital signs are: blood pressure 144/96, heart rate 54/min, respirations 18/min, and temperature 98.6 F. Which of the following actions should the nurse take?

Withhold the digoxin dose for decreased pulse rate

A client complains of shortness of breath and chest pain the first day following multiple long bone fractures. The nurse would consider which of the following client complications when assessing the client?

Fat emboli

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 group of clients on a surgical unit. Which of the following should be the nurse's initial action?

Assessing a client who experiences unilateral calf pain when ambulating

A nurse is caring for a client who recently had a permanent pacemaker placed. The nurse is reinforcing teaching following the initial pacemaker check. Which of the following statements by the client indicates understanding?

"The pacemaker can be checked from home by using the telephone."

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI) and is reviewing the provider's orders. Which of the following prescriptions by the provider requires clarification?

0.9% normal saline IV at 50 mL/hr continuous

A nurse has received shift report and is preparing her assignment. Which of the following client's should the nurse assess first?

A client who was admitted for chest pain with a troponin level of 0.6 ng/mL and complaining of indigestion

An adult client is scheduled for surgery. Which of the following sites should the nurse assess for possible placement of an IV catheter?

Cephalic vein Basilic vein

During report, the nurse is informed that a client's IV has 900 mL of fluid left in the bag. The nurse makes rounds 30 min later and notes the IV bag is empty. Which of the following is an appropriate nursing action?

Check the client's respiratory rate and lung sounds

A nurse enters a client's room and finds him unresponsive. Which of the following actions should the nurse take first?

Check the client's respiratory status

A nurse is giving a presentation about preventing deep-vein thrombosis. Which of the following should the nurse includes as a risk factor for this disorder?

Dehydration Oral contraceptive use Immobility

A nurse is assisting with the care of a child who is receiving a blood transfusion. Which of the following indicates the child is experiencing a complication?

Difficulty breathing

A nurse is assisting with the care of a client who is receiving a blood transfusion. Which of the following indicates the client is experiencing a complication?

Difficulty breathing

A client who is 7 days postpartum calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest?

Elevate her leg

A client is taking hydrochlorothiazide (Hydrodiuril) for management of hypertension. The nurse should recognize which medication will decrease the therapeutic effect?

Ibuprofen (Advil)

A nurse is caring for a client who is 1 wk postpartum and notes unilateral leg edema with associated pain and a low-grade temperature. The nurse should advise the client to avoid which of the following?

Massaging the painful area of the leg

A nurse is preparing to administer heparin intravenously to a client. Which of the following is an appropriate nursing action?

Obtain an infusion pump to regulate the continuous flow of the medication

A nurse is caring for a toddler who had a cast applied 2 hr ago due to multiple fractures of the right hand. Which of the following findings should the nurse report immediately to the charge nurse?

Right hand fingers have capillary refill of 4 seconds

A nurse is assisting with the care of a client following surgery who has antiembolism stockings in place. Which of the following is the purpose for this device?

To prevent venous stasis

A nurse is reviewing the initial laboratory values for partial thromboplastin time, prothrombin time, and thrombin time on a client who has an acute episode of disseminated intravascular coagulation (DIC). The nurse should expect the laboratory values to be

prolonged

A nurse is preparing educational material for a client who has a thrombocytopenic disorder. Which of the following information should the nurse include?

Notify the dentist of condition prior to invasive procedure

A nurse is caring for a client who has hypovolemic shock. Which of the following is an expected finding?

Oliguria

Prior to transfusing a unit of blood, a nurse is selecting a qualified staff member to double check the blood label with the patient ID bracelet. Which of the following are qualified?

Oncology nurse

A nurse is assessing a client's wife on how to take a blood pressure. Which of the following actions by the wife indicates a need for further instruction?

Place the client arm above the level of the heart

A client is scheduled to receive digoxin (Lanoxin). Which of the following laboratory data is most important for the nurse to review?

Potassium

A nurse in the recovery room is planning care for a client who had a subtotal thyroidectomy. Which of the following are appropriate positions for the client?

Semi-Fowler's

A nurse is administering a cold application to a client. Which of the following manifestations indicates the need to discontinue the application due to a systemic response by the client?

Shivering

A client is requesting information regarding serum troponin test. Which of the following is the nurse's best response?

"The slightest elevation in troponin levels will prompt treatment to prevent complications of cardiovascular disease."

A nurses is assessing for the development of disseminated intravascular coagulation (DIC) in a client who has septic shock. Which of the following nursing statements indicates an understanding of the condition?

"DIC is caused by abnormal coagulation involving fibrinogen"

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

"Exercise at least three times per week."

A nurse is assisting with the admission of a 9-year-old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions?

"Has your son had a sore throat recently?"

A nurse is caring for a toddler who is dehydrated and has an order for 100 mL of 0.9% sodium chloride IV over 4 hr. A microdrip set with a drop factor of 60 gtt/mL is being used. The nurse should regulate the IV to deliver how many drops per minute?

25 gtt/min

A nurse is reading a client's ECG tracing. There are nine QRS complexes in a 6-second interval. What is the client's heart rate?

90 per min

A nurse is reinforcing teaching for a client has a new diagnosis of aplastic anemia. When discussing the pathology of this disease, which of the following is appropriate to include in the teaching?

Aplastic anemia results from decreased bone marrow production of RBC

While reading a client's ECG tracing, the nurse should understand that the P wave reflects which of the following cardiac electrical activities?

Atrial depolarization

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

Atropine

A nurse in the emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following is the priority intervention?

Auscultate for wheezing

A nurse is planning care on the first postoperative day for a client who had a detached retina. Which of the following actions should the nurse include?

Avoid reading and writing

A nurse is planning caring for a client who has thrombocytopenia. The nurse understands that the client's plan of care should include which of the following?

Avoiding venipunctures whenever possible

The nurse is helping with the admission of a client from the emergency department. The client is prescribed clopidogrel bisulfate (Plavix). Which of the following precautions should the nurse anticipate?

Bleeding

A nurse is caring for a client who has mild dementia and reports taking the over-the-counter supplement gingko biloba. Which of the following should the nurse instruct the client to report immediately to the provider?

Bleeding gums

A nurse is collecting data from a client who has hypertension and has a prescription for propranolol (Inderal). A history of which of the following conditions should be reported to the provider?

Heart failure

A nurse collecting data from a newborn finds an apical pulse of 130/min. Which of the following is the appropriate nursing action?

Document this as an expected finding

A nurse is caring for a client who is post-operative following a total knee replacement. Which of the following actions should the nurse implement to prevent deep vein thrombophlebitis?

Encourage increased fluid intake

A nurse is talking with a client who is about to undergo hip arthroplasty. The nurse explains that the surgeon will prescribe anticoagulant therapy to prevent deep-vein thrombosis postoperatively. The nurse should explain that the client will not require frequent clotting time determinations because the surgeon plans to prescribe which of the following medications?

Enoxaparin (Lovenox)

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

Ensure a patent airway

A client experiences anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?

Epinephrine

A nurse is caring for a client who is at 6 weeks of gestation and has pneumonia. While the nurse is obtaining the client's history, she tells the nurse that she takes the herb feverfew for migraine headache. Which of the following actions should the nurse take?

Explain that she should not take this herb while she is pregnant.

A nurse is preparing a client for magnetic resonance imaging (MRI) of the heart and great vessels. Which of the following instructions should the nurse include about this test?

It requires removing metal objects like jewelry

A nurse is collecting data from an infant. Which of the following is clinical manifestation of a large patent ductus arteriosus?

Machinery-like murmur

To prevent venous stasis, a client is to be measured for knee-high anti-embolus stockings. Which of the following are appropriate nursing actions?

Measure from heel to the popliteal space

A nurse is caring for a client who receives digoxin (Lanoxin). Before administering this medication, which of the following actions should the nurse take?

Measure the client's apical pulse

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

Narrowing pulse pressure

A nurse is administering platelets to a client who reports feeling chilled and is itching. Which of the following is a priority nursing action?

Stop the infusion.

A nurse is monitoring a client who is receiving packed RBCs. Which of the following findings is expected during blood administration?

The packed RBCs are connected by Y tubing to normal saline.

A client who has just had abdominal surgery returns to the unit from the postanesthesia care unit with an IV fluid infusion and NG tube in place. Which of the following is the data collection priority for the nurse who is caring for the client?

The surgical dressing

A nurse is collecting data from a client who is postoperative following abdominal surgery. Which of the following findings should make the nurse suspect deep-vein thrombosis?

Unilateral leg edema

A nurse is reinforcing teaching with a client who has angina pectoris about starting therapy with nitroglycerin (Nitrostat). The nurse should remind the client to take the medication

at the first indication of chest pain

A nurse is reinforcing teaching with an older adult client who has just undergone insertion of a permanent pacemaker. The nurse should emphasize that a sign of pacemaker malfunction the client should report to the provider is

fatigue

A nurse who is administering vitamin K to a newborn understands that this is done to

decrease the newborn's risk of hemorrhagic disorders

A nurse is assigned to care for a client suspected of having diabetes insipidus. The nurse should frequently check the client for the development of

hypotension

A client tells the nurse that he is concerned because his doctor told him he has a heart murmur. The nurse should explain to the client that a murmur

indicates turbulent blood flow through a valve

To evaluate a client following cardiac catherization with a left antecubital insertion site, the nurse should palpate the

radial pulse in the left arm

To evaluate a client following cardiac catheterization with a left antecubital insertion site, the nurse should palpate the

radial pulse in the left arm