Cardio uworld
A client is 48 hours post abdominal aneurysm repair. Which assessment by the nurse is cause for greatest concern? 1. Diminished breath sounds in bilateral lung bases 2. Hypoactive bowel sounds in all 4 quadrants 3. Urinary output of 90 mL in the past 4 hours 4. Warm extremities with 1+ bilateral pedal pulses
3
A client with a history of diabetes mellitus, hypertension, and chronic tobacco use reports leg pain during walking and a wound on the right 5th toe. On assessment of the wound, the nurse notes a small, circular, and deep ulcer with little drainage at the tip of the 5th toe. Based on the history and assessment, which statement would be mostappropriate to document? 1. "A suspected arterial ulcer is present on the right 5th toe." 2. "A suspected pressure ulcer is present on the right 5th toe." 3. "A suspected vascular ulcer is present on the right 5th toe." 4. "A suspected venous ulcer is present on the right 5th toe."
1
A client with aortic stenosis is scheduled for surgery in 2 weeks. The client reports episodes of angina and passing out twice at home. Which would be the best response by the nurse to explain the appropriate activity for this client at this time? 1. "Avoid strenuous activity before the surgery." 2. "Continue to exercise, even if angina occurs. It will strengthen your heart muscles." 3. "Take short walks 3 times a day." 4. "There are no activity restrictions unless angina occurs."
1
A client with dilated cardiomyopathy has the rhythm shown in the exhibit. Which action should the nurse take first? Exhibit: https://drive.google.com/open?id=0B40rfZ_HhbqwZmFvcVZoT05sTnM 1. Assess the client for a pulse 2. Assess the oxygen saturation 3. Initiate cardiopulmonary resuscitation (CPR) 4. Prepare to defibrillate the client
1
A client with myocardial infarction (MI) underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider (HCP) about resuming sexual relations after an MI. What teaching should the nurse initiate with this client? 1. If the client is able to climb 2 flights of stairs without symptoms, the client may be ready for sexual activity if approved by the HCP 2. Inform the client that medications such as sildenafil or tadalafil are available as prescriptions from the HCP 3. It will be 6 months before the heart is healthy enough for sexual activity 4. The client will be ready for sexual activity after completion of cardiac rehabilitation
1
Four clients enter the emergency department at the same time. Which should the triage nurse see first? 1. 25-year-old client with sudden-onset chest pain and heart rate of 110/min 2. 45-year-old client with type 2 diabetes who is traveling and has lost insulin glargine 3. 60-year-old client with pain, swelling, erythema, and warmth in the right leg 4. 70-year-old client with left lower abdominal pain and diarrhea for 2 days
1
The emergency nurse is triaging clients. Which report is most concerning and would be given priority for definitive diagnosis and care? 1. Abrupt, tearing, moving (upper to lower) back pain 2. Severe lower back pain after lifting heavy boxes 3. Sharp calf ache with ambulation that improves with rest 4. Unilateral leg swelling with 2+ pitting edema after an airplane trip
1
The home health nurse is visiting a client discharged 2 days ago after a coronary artery bypass graft. The client reports fatigue and palpitations, and the nurse connects the client to a portable heart monitor. The nurse recognizes the displayed rhythm as which rhythm? Click on the exhibit button for additional information. Exhibit: https://drive.google.com/open?id=0B40rfZ_HhbqwUmpMM2VUZHo3WXc 1. Atrial fibrillation 2. Atrial flutter 3. Complete heart block 4. Second-degree atrioventricular (AV) block, type 2
1
The nurse is caring for a client on the organ donation waiting list for cardiac transplantation. Which teaching topic is most important for the nurse to emphasize at this time? 1. Immunosuppressive therapy as a lifelong commitment 2. Importance of accurate daily weight monitoring 3. Importance of periodic endomyocardial biopsies 4. Maintenance of meticulous surgical incision care
1
The nurse is caring for a client who has been admitted to the hospital for an acute exacerbation of heart failure. Blood pressure is 104/62 mm Hg, pulse is 96/min, respirations are 22/min, and oxygen saturation is 91%. Which of these findings supports the diagnosis of acute heart failure exacerbation? 1. B-type natriuretic peptide (BNP) 1382 pg/mL [1382 pmol/L] 2. Flat jugular veins when seated at a 45-degree angle 3. Sodium 150 mEq/L [150 mmol/L] 4. Urine output greater than 100 mL/hr
1
The nurse is caring for a client who just had aortic valve replacement surgery. Which assessment information is most important to report to the health care provider (HCP)? 1. Chest tube output of 175 mL in past hour 2. International Normalized Ratio (INR) of 1.5 3. Temperature of 100.3 F (37.9 C) 4. Total urine output of 85 mL over past 3 hours
1
The nurse is caring for a client with chronic, stable angina. The client takes the long-acting nitrate isosorbide mononitrate. Which client outcome indicates that the drug is effective? 1. Client is able to shower, dress, and fix hair without any chest pain 2. Client reports a reduction in stress level and anxiety 3. Client reports being able to sleep through the night 4. Client's blood pressure is 128/78 mm Hg and heart rate is 82/min
1
The nurse is caring for a client with newly diagnosed infective endocarditis (IE). Which assessment finding by the nurse is the highest priority to report to the health care provider (HCP)? 1. Pain and pallor in one foot 2. Pain in both knees 3. Splinter hemorrhages in the nail beds 4. Temperature of 102.2 F (39 C)
1
The nurse is developing a teaching plan for a 65-year-old African American male client with a BMI of 30 kg/m2 and a strong family history of cardiovascular disease. Which risk factor for coronary artery disease (CAD) should the nurse focus on during teaching? 1. Client's BMI of 30 kg/m2 2. Client's ethnicity 3. Client's gender 4. Client's strong family history of cardiovascular disease
1
The nurse observes the rhythm shown in the exhibit on a client's cardiac monitor. The client reports palpitations and lightheadedness. Which intervention does the nurse anticipate? Click on the exhibit button for additional information. Exhibit: https://drive.google.com/file/d/0B40rfZ_HhbqwMzhrQ0lwU2hXRjg/view?usp=sharing 1. Adenosine IVP 2. Atropine IVP 3. Defibrillation 4. External pacing
1
The unlicensed assistive personnel reports a client blood pressure of 90/60 mm Hg to the nurse. The client's prescriptions say to notify the health care provider (HCP) if systolic blood pressure is <100 mm Hg. What should the nurse do first? 1. Assess the client for other signs and symptoms 2. Immediately notify the client's HCP 3. Notify the charge nurse on duty for the shift 4. Review the client's medication administration record
1
A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure? 1. Arterial blood gases (ABGs) 2. B-type natriuretic peptide (BNP) 3. Cardiac enzymes (CK-MB) 4. Chest x-ray
2
A client with ST elevation myocardial infarction is due for the 09:00 AM medications. Based on the data shown in the exhibit, which medications should the nurse administer? Select all that apply. Click on the exhibit button for additional information. Exhibit: Vital signs at 0800 Temperature 98.4 F (36.9 C) Blood pressure 110/72 mm Hg Heart rate 52/min Respirations 16/min Laboratory results at 0600 Hematocrit 40% (0.40) Hemoglobin 14.0 g/dL (140 g/L) Platelets 200,000/mm3 (200 × 109/L) Potassium 4.0 mEq/L (4.0 mmol/L) Medication administration record Allergies: None Medications = Time Aspirin: 81 mg by mouth, daily = 0900 Docusate sodium: 100 mg by mouth, daily = 0900 Lisinopril: 5 mg by mouth, daily = 0900 Metoprolol: 100 mg by mouth, twice daily = 0900 and 1700 Simvastatin: 20 mg by mouth, daily = 2000 1. Aspirin 2. Docusate sodium 3. Lisinopril 4. Metoprolol 5. Simvastatin
1,2,3
The nurse is planning discharge teaching for a client who just received a permanent pacemaker. Which topics should the nurse include? Select all that apply. 1. Avoid magnetic resonance imaging (MRI) scans 2. Do not place cell phones directly over the pacemaker 3. Notify airline security when travelling 4. Perform shoulder range-of-motion exercises 5. Refrain from using microwave ovens
1,2,3
A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply. 1. Amphetamine use 2. Cigarette smoking 3. Cold exposure 4. Deep sleep 5. Sexual intercourse
1,2,3,5
A client is scheduled for a coronary arteriogram procedure. Which information should the nurse provide to the client prior to the procedure? Select all that apply. 1. Client may be required to lie flat for several hours following the procedure 2. Client may feel warm or flushed when contrast dye is injected during the procedure 3. Client should expect to stay in the hospital for 1-3 days following the procedure 4. Client should not eat or drink anything for 6-12 hours before the procedure 5. Client will receive general anesthesia and will not be awake during the procedure
1,2,4
The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment findings would indicate possible graft leakage and require a report to the primary care provider? Select all that apply. 1. Ecchymosis of the scrotum 2. Increased abdominal girth 3. Increased urinary output 4. Report of groin pain 5. Report of increased thirst and appetite loss
1,2,4
The nurse is preparing to discharge a client who developed heart failure after a myocardial infarction. Based on the discharge data, the nurse plans to include which topics during teaching? Select all that apply. Click on the exhibit button for additional information. Exhibit: Vital signs Temperature 98.2 F ( 36.7 C ) Blood pressure 108/72 mm Hg Heart rate 62/min Respirations 16/min SpO2 96% on room air Discharge medications Captopril: 12.5 mg by mouth, 3 times daily Digoxin: 0.25 mg by mouth, daily Spironolactone: 25 mg by mouth, twice daily Carvedilol: 12.5 mg by mouth, twice daily 1. Daily weighing 2. How to take own pulse 3. Need for monthly International Normalized Ratio (INR) 4. Need to increase foods high in potassium 5. Reduction of sodium in diet 6. Use of home oxygen
1,2,5
40. The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply. 1. "I will apply moisturizing lotion on my legs every day." 2. "I will elevate my legs at night when I am sleeping." 3. "I will keep my legs below heart level when sitting." 4. "I will start walking outside with my neighbor." 5. "I will use a heating pad to promote circulation."
1,3,4
A 28-year-old female client has been diagnosed with Raynaud phenomenon (RP). The nurse is teaching the client about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply. 1. Avoid excess caffeine 2. Immerse hands in cold water 3. Practice yoga 4. Squeeze and release a tennis ball 5. Wear gloves when handling cold objects
1,3,5
A client is hospitalized with worsening chronic heart failure. Which clinical manifestations does the admitting nurse most likely assess in this client? Select all that apply. 1. Crackles on auscultation 2. Dry mucous membranes 3. Increased jugular venous distention (JVD) 4. Rhonchi on auscultation 5. Skin "tenting" 6. 3+ pitting edema of the lower extremities
1,3,6
A cardiac catheterization was performed on a client 2 hours ago. The catheter was inserted into the left femoral artery. What signs of potential complications should the nurse report immediately to the health care provider (HCP)? Select all that apply. 1. Bleeding at the catheterization site 2. Client lying down and quietly watching television 3. Client taking only sips of fluids 4. Left foot remarkably cooler than right foot 5. Urine output of 100 mL since the procedure
1,4
A client with severe vomiting and diarrhea has a blood pressure of 90/70 mm Hg and pulse of 120/min. IV fluids of 2-liter normal saline were administered. Which parameters indicate that adequate rehydration has occurred? Select all that apply. 1. Capillary refill is less than 3 seconds 2. Pulse pressure is narrowed 3. Systolic blood pressure drops only when standing 4. Urine output is 360 mL in 4 hours 5. Urine specific gravity is 1.020
1,4,5
What clinical symptoms might the nurse expect to find in a client with a central venous pressure (CVP) of 24 mm Hg? Select all that apply. 1. Crackles in lungs 2. Dry mucous membranes 3. Hypotension 4. Jugular venous distension 5. Pedal edema
1,4,5
A 62-year-old client is scheduled for open abdominal aneurysm repair. What key assessment should be made by the nurse preoperatively? 1. Assess and compare blood pressure in each arm 2. Assess character and quality of peripheral pulses 3. Assess for presence or absence of hair on lower extremities 4. Assess for presence of bowel sounds
2
A client comes to the emergency department in acute decompensated heart failure. The client is very anxious, with a respiratory rate of 30/min and pink, frothy sputum. After placing the client on oxygen via nasal cannula, which of these actions is the next priority? 1. Administer digoxin 0.25 mg 2. Administer furosemide 40 mg IV push 3. Initiate dopamine infusion at 5 mcg/kg/min 4. Obtain blood sample for arterial blood gases
2
A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the health care provider (HCP). Which assessment data is most important for the nurse to report to the HCP? 1. Blood pressure (BP) of 140/86 mm Hg 2. Difficulty swallowing 3. Dry, hacking cough 4. Low back pain
2
A client with peripheral arterial disease is visiting the health clinic. The nurse completes a health assessment. Which statement by the client indicates a priority need for follow-up teaching? 1. "I always take my simvastatin in the evening." 2. "I prop my legs up in the recliner and use a heating pad when my feet are cold." 3. "I've been walking on my treadmill at home for 15 minutes each day." 4. "I've noticed that I don't have much hair on my lower legs anymore."
2
A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off? 1. Hematocrit of 30% (0.30) 2. Partial thromboplastin time of 110 seconds 3. Platelet count of 80,000/mm3 (80 x 109/L) 4. Prothrombin time of 11 seconds
2
A nurse in the cardiology clinic is admitting a client with a history of hypertension. The client takes hydrochlorothiazide and clonidine and has a blood pressure reading of 190/102 mm Hg. The client also reports a headache that has lasted for several days. What additional data is most important for the nurse to collect next? 1. Ask the client if any over-the-counter medications have been ingested 2. Ask the client if medications are being taken as prescribed 3. Assess the client for the presence of peripheral edema 4. Question the client about recent stress levels
2
A nurse is making initial client rounds at the beginning of the shift. Which client should the nurse see first? 1. 36-year-old client with endocarditis who has a temperature of 100.6 F (38.1 C), chills, malaise, and a heart murmur 2. 40-year-old client with pericardial effusion who has blood pressure of 84/62 mm Hg and jugular venous distension 3. 67-year-old client admitted for pneumonia with new-onset atrial fibrillation, who has blood pressure of 130/90 mm Hg and heart rate of 110/min 4. 70-year-old client with advanced heart failure who is receiving intravenous (IV) diuretics, has blood pressure of 80/60 mm Hg, and is watching TV
2
A nurse receives an electrocardiogram of a client with type 2 diabetes, heart failure, and hypothyroidism. Based on the findings, which of the following medications should the nurse suspect as the most likely cause? Click the exhibit button for more information. Exhibit: https://drive.google.com/open?id=0B40rfZ_HhbqwcGswMlg1UGhpVzQ 1. Captopril 2. Carvedilol 3. Glimepiride 4. Levothyroxine
2
An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit. Which assessment technique by the new nurse requires intervention by the RN? 1. Nurse carefully auscultates for heart murmurs at Erb's point 2. Nurse palpates bilateral carotid arteries simultaneously to assess for symmetry 3. Nurse places client in semi-Fowler's position to assess for jugular venous distension 4. Nurse positions client supine to assess the point of maximal impulse
2
The clinic nurse is providing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client? 1. How to transmit the readings over the phone 2. Keep a diary of activities and any symptoms experienced 3. Refrain from exercising while wearing the monitor 4. The monitor may be removed only when bathing
2
The nurse assesses a client diagnosed with acute pericarditis. Which assessment would require immediate follow-up? 1. Client reports chest pain that is worse with deep inspiration 2. Distant heart tones and jugular venous distension 3. ECG showing ST-segment elevations in all leads 4. Pericardial friction rub auscultated at the left sternal border
2
The nurse assesses pitting edema of the extremities, dyspnea, bilateral crackles posteriorly, and a serum sodium level of 130 mEq/L (130 mmol/L) in a client with chronic heart failure. The nurse should question which prescription? 1. Furosemide 20 mg IV push twice daily 2. Maintenance IV line of 0.9% normal saline at 85 mL/h 3. Potassium chloride 20 mEq orally twice daily 4. Sodium-restricted diet
2
The nurse in the outpatient clinic is reviewing phone messages. Which client should the nurse call back first? 1. Client post kidney transplant who reports white spots in the oral cavity 2. Client with a history of mitral valve regurgitation who reports fatigue 3. Client with erythema and purulent drainage at the site of a spider bite 4. Client with hypertension who reports a cold and nasal congestion
2
The nurse is admitting a client with heart failure-related fluid overload. Which action should the nurse complete first? 1. Administer oxygen 2. Assess the client's breath sounds 3. Initiate cardiac monitoring 4. Insert a peripheral IV catheter
2
The nurse is assessing a diabetic client for pain following right total knee replacement surgery. The client reports "numbness and tingling" in the bilateral lower extremities. Pedal pulses are strong bilaterally, and capillary refill is <3 seconds in the right great toe. Which action should the nurse take? 1. Ask if the client wants pain medication for the "numbness and tingling" 2. Ask the client if the "numbness and tingling" were present before surgery 3. Continue assessment by observing the surgical dressing 4. Notify the health care provider (HCP) immediately
2
The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac arrest. The client does not follow commands and remains comatose. What intervention does the nurse anticipate being added to the client's plan of care? 1. Assisting the health care provider in discussing a do-not-resuscitate order with the family 2. Obtaining equipment and cold fluids for induction of therapeutic hypothermia 3. Placing a small-bore nasogastric feeding tube for enteral nutrition 4. Planning for passive range-of-motion exercises to prevent contractures
2
The nurse is performing a cardiac assessment on a client. The nurse auscultates a loud blowing sound at the second intercostal space, right sternal border. How should the nurse document this finding? 1. Arterial bruit 2. Murmur heard at the aortic area 3. Pericardial friction rub 4. S3 gallop heard at the mitral area
2
The nurse is preparing to perform cardioversion in a client in supraventricular tachycardia shown in the exhibit that has been unresponsive to drug therapy. The client has become hemodynamically unstable. Which step is most important in performing cardioversion? Click on the exhibit button for additional information. Exhibit: https://goo.gl/photos/ERhTPbj7acTtTMMc9 1. Charge the defibrillator 2. Push the synchronize button 3. Sedate the client 4. Select energy level
2
The telemetry nurse reports the cardiac monitor rhythms of 4 clients to the medical unit nurse assigned to care for them. The nurse should assess the client with which rhythmfirst? 1. Atrial fibrillation with a pulse of 76/min in a client prescribed rivaroxaban 2. Bradycardia in a client with a demand pacemaker set at 70/min 3. First-degree atrioventricular block in a client prescribed atenolol 4. Sinus tachycardia in a client with gastroenteritis and dehydration
2
A client is in suspected shock state from major trauma. Which parameters best indicate the adequacy of peripheral perfusion? Select all that apply. 1. Apical pulse 2. Capillary refill 3. Lung sounds 4. Pupillary response 5. Skin color and temperature
2, 5
The nurse provides discharge instructions to a client who was hospitalized for deep venous thrombosis (DVT) that is now resolved. Which instructions does the nurse include to prevent the reoccurrence of DVT? Select all that apply. 1. "Do not travel by car or airplane for at least 3-4 weeks." 2. "Drink plenty of fluids every day and limit caffeine and alcohol intake." 3. "Elevate legs on a footstool when sitting and dorsiflex the feet often." 4. "Resume walking or swimming exercise program as soon possible after getting home." 5. "Sit in a cross-legged yoga position for 5-10 minutes as it is good for circulation."
2,3,4
The registered nurse (RN) is providing discharge instructions to a client who has had coronary artery bypass grafting (CABG). Which teaching is correct? Select all that apply. 1. No sexual activity for at least 6 weeks postoperatively 2. Notify health care provider (HCP) of redness, swelling, or drainage at the incision site 3. Refrain from lifting objects weighing >5 lb (2.26 kg) until approved by the HCP 4. Take a shower daily without soaking chest and leg incisions 5. Use lotion on incision sites with dressing changes if the area is dry
2,3,4
A client is diagnosed with lower-extremity deep venous thrombosis (DVT) after a cross-country road trip. Which clinical manifestations most characteristic of a DVT does the nurse expect to assess? Select all that apply. 1. Blue, cyanotic toes 2. Calf pain 3. Dry, shiny, hairless skin 4. Edema 5. Warmth and erythema
2,4,5
A client admitted to the cardiac care unit with markedly elevated blood pressure and heart failure is receiving a continuous infusion of nitroprusside. Thirty minutes later, theclient appears pale with cold, clammy skin and reports being lightheaded. Which is the priority nursing action? 1. Auscultate the client's lungs 2. Check the client's capillary refill 3. Measure the client's blood pressure 4. Review the client's electrocardiogram (ECG)
3
A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client? 1. Bronchial breath sounds at lung periphery 2. Clear vesicular breath sounds at lung bases 3. Diffuse bilateral crackles at lung bases 4. Stridor in upper airways
3
A client comes to the emergency department with crushing, substernal chest pain. Temperature is 98.6 F (37 C), blood pressure is 173/84 mm Hg, pulse is 92/min, and respirations are 24/min. Oxygen saturation is 95% on room air. What is the nurse's next priority action? 1. Attach defibrillator pads to the client's chest 2. Check the lipid profile laboratory results 3. Obtain a 12-lead electrocardiogram (ECG) 4. Prepare to administer a heparin drip
3
A client has heart failure and has gained 5 lb (2.26 kg) over the last 3 days. Blood laboratory results from today are shown in the exhibit. What medication administration does the nurse anticipate? Click on the exhibit button for additional information. Exhibit: Laboratory results Sodium 126 mEq/L (126 mmol/L) Potassium 4.8 mEq/L (4.8 mmol/L) Calcium 9.0 mg/dL (2.25 mmol/L) 1. 0.2% intravenous normal saline 2. Calcium gluconate 3. Furosemide 4. Sodium polystyrene
3
A client in the emergency department has an acute myocardial infarction (MI). The health care provider (HCP) has prescribed thrombolytic therapy. Which assessment data should the nurse report immediately to the HCP? 1. Client is currently menstruating 2. Client rates chest pain at a 8 out of 10 on pain scale 3. Client reports a history of cerebral aneurysm at age 20 4. Current blood pressure is 170/96 mm Hg, heart rate is 110/min
3
A client is seen following a motor vehicle collision. An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital. The IV line is now infusing at 200 mL/hr. Which assessment finding alerts the nurse to the development of hypovolemic shock? 1. Jugular venous distension 2. Mean arterial blood pressure 65 mm Hg 3. Urine output <0.5 mL/kg/hr 4. Warm, flushed skin
3
A client is started on lisinopril therapy. Which assessment finding requires immediate action? 1. Blood pressure 129/80 mm Hg 2. Heart rate 100/min 3. Serum creatinine 2.5 mg/dL (221 µmol/L) 4. Serum potassium 3.5 mEq/L (3.5 mmol/L)
3
A client taking a diuretic for chronic heart failure experiences constipation. What is the nurse's best recommendation? 1. Drink 2 extra glasses of water with each meal 2. Exercise for longer periods 3. Include more fiber in the diet 4. Take warm baths to relax the abdomen
3
A client with mitral valve prolapse (MVP) has been experiencing occasional palpitations, lightheadedness, and dizziness. The health care provider prescribes a beta blocker. What additional teaching should the nurse include for this client? 1. Avoid aerobic exercise 2. Ensure you receive antibiotics prior to dental work 3. Stay well hydrated and avoid caffeine 4. Wear a medical alert bracelet
3
A client with unstable angina and chronic kidney disease is receiving a continuous infusion of unfractionated heparin. Which value for activated partial thromboplastin time (aPTT) would indicate to the nurse that the heparin therapy is at an optimal therapeutic level? 1. 30 seconds 2. 35 seconds 3. 60 seconds 4. 85 seconds
3
A graduate student, who has been studying for final exams and using energy drinks to stay awake, comes to the clinic reporting a fluttering feeling in the chest. The student is connected to the cardiac monitor that displays the rhythm in the exhibit. The nurse recognizes this as which rhythm? Click on the exhibit button for additional information. Exhibit: https://drive.google.com/open?id=0B40rfZ_HhbqwTkxtRl8ybkZ2Tmc 1. Atrial flutter 2. Sinus rhythm with premature atrial contractions (PACs) 3. Sinus rhythm with premature ventricular contractions (PVCs) 4. Ventricular tachycardia
3
A nurse is making a home visit to a client with chronic venous insufficiency (CVI). The home health (HH) aide is there with the client. Which action by the HH aide would require intervention by the nurse? 1. Applying lotion to the client's dry, cracked skin on lower extremities 2. Assisting the client with placing medications in a daily pill reminder box 3. Cutting the client's fingernails and toenails 4. Putting compression stockings on the client
3
An elderly client tells the nurse "I have experienced leg pain for several weeks when I walk to the mailbox each afternoon, but it goes away once I stop walking." What is thepriority assessment the nurse should perform? 1. Assess for dry, scaly skin on the lower legs 2. Assess for presence or absence of hair growth on lower extremities 3. Check for presence and quality of posterior tibial and dorsalis pedis pulses 4. Obtain a dietary history
3
An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit. The new RN is measuring orthostatic blood pressure (BP) for a client. Which situation would warrant intervention by the experienced nurse? 1. Nurse has client lie supine for 5-10 minutes prior to starting procedure 2. Nurse interprets a decrease in systolic BP by 10 mm Hg as a normal finding 3. Nurse starts by measuring BP and heart rate (HR) with the client standing 4. Nurse takes BP and HR after standing at 1- and 3-minute intervals
3
Four clients come to the emergency department simultaneously. Which client should the nurse see first for definitive care? 1. 6-month-old with a temperature of 101 F (38 C) who is rubbing the ears and being fussy 2. 10-day-old client with a red mark (stork bite) on the neck, the mother is concerned 3. A client who took a handful of amitriptyline pills, a tricyclic antidepressant drug 4. A client who tripped and hit the head but is alert with no loss of consciousness, currently takes warfarin
3
The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention? 1. The client cannot remember what was done yesterday 2. The client has a painful red area on the buttocks 3. The client has new dependent edema of the feet 4. The client has strong, foul smelling urine
3
The nurse has just received report on the telemetry unit. Which client should be seen first? 1. The client 2 days post coronary artery bypass; the night shift nurse reports diminished lung sounds in the bases 2. The client 4 hours post permanent pacemaker insertion that is 100% paced 3. The client with a deep venous thrombosis (DVT) who has a dose of enoxaparin due 4. The client with coronary artery disease and atrial fibrillation who has a dose of warfarin due
3
The nurse is caring for a client with advanced heart failure on an inpatient hospice unit. The client is having trouble breathing. Which comfort intervention should the nurse implement first? 1. Administer as-needed (prn) albuterol by nebulizer 2. Administer prn intravenous (IV) furosemide 3. Elevate the head of the bed 4. Give prn sublingual morphine
3
The nurse is caring for a client with an implantable cardioverter defibrillator (ICD). The client goes into ventricular tachycardia and is pulseless. The ICD has fired twice. What action should the nurse take? 1. Administer epinephrine 1 mg IV push 2. Deactivate the ICD with a magnet 3. Initiate chest compressions 4. Take no action and let the ICD work
3
The nurse is preparing to administer a unit of packed red blood cells to a 16-year-old with blood loss anemia. The client currently has D5W infusing through a 20-gauge IV catheter. What action should the nurse take? 1. Attach the blood transfusion set to the port closest to the client on the existing IV tubing 2. Discontinue the 20-gauge IV catheter and restart an 18-gauge IV catheter 3. Discontinue the D5W, flush the IV catheter with normal saline, and start the transfusion 4. Run the blood transfusion as an IV piggyback through the infusion pump
3
The nurse should plan to teach which client about the need for prophylactic antibiotics prior to dental procedures? 1. Client who had a large anterior wall myocardial infarction (MI) with subsequent heart failure 2. Client who had a mitral valvuloplasty repair 3. Client with a mechanical aortic valve replacement 4. Client with mitral valve prolapse with regurgitation
3
The nurse working in the intensive care unit hears an alarm coming from a client's room. On entering the room, the nurse sees the rhythm displayed in the exhibit on the monitor. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information. Exhibit: https://drive.google.com/open?id=0B40rfZ_HhbqwWGlyYm9KMW1aUTQ 1. Asystole 2. Atrial fibrillation 3. Ventricular fibrillation (VF) 4. Ventricular tachycardia
3
Which client is in need of follow-up education by the nurse? 1. Client with peripheral arterial disease (PAD) who insists on dangling leg over the side of the bed when sleeping 2. Client with Raynaud's phenomenon who routinely soaks hands in warm water before going out 3. Client with venous leg ulcer who refuses to wear elastic compression stockings during the day 4. Postsurgical client who points and flexes feet when lying in bed
3
A 62-year old client was admitted to the telemetry unit after having an acute myocardial infarction 3 days ago. The client reports to the nurse that the left calf is very tender and feels warm to the touch. Which assessment by the nurse is the priority? 1. Ask the client how long the leg has been tender and warm 2. Assess the electrocardiogram (ECG) for any ectopic beats 3. Check vital signs including pulse oximetry 4. Complete neurovascular assessment on lower extremities
4
A client asks the nurse what is required in preparation for a calcium scoring CT examination. What information should the nurse give the client? 1. The client should not eat or drink for 6-12 hours before the procedure 2. The client should not take cardiac medications 24 hours before the procedure 3. The client will have an IV line started on arrival at the clinic 4. The client will not need any special preparation for the procedure
4
A client develops sinus bradycardia with blood pressure of 90/40 mm Hg and a heart rate of 46/min. Which of the following actions should the nurse take? 1. Give scheduled dose of metoprolol 50 mg orally 2. Instruct client to cough forcefully 3. Place client in reverse Trendelenburg position 4. Prepare to administer atropine 0.5 mg intravenous (IV) push
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A client diagnosed with a ST-segment elevation myocardial infarction (STEMI) is receiving an intravenous thrombolytic infusion. In evaluating the client's response to treatment, which assessment finding by the nurse is the best indicator that reperfusion has occurred? 1. Increase in troponin level 2. Nonsustained ventricular tachycardia 3. Reduction of chest pain 4. Return of ST segment to baseline
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A client in the emergency department is admitted with a diagnosis of rule out myocardial infarction (MI). Which laboratory test should the nurse monitor to determine if the client has had an MI? 1. D-dimer test 2. Low-density lipoprotein (LDL) 3. Myoglobin 4. Troponin
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A client is diagnosed with Buerger's disease (thromboangiitis obliterans). The nurse anticipates teaching the client about which treatment option? 1. Avoidance of warm temperatures 2. Initiation of statin 3. Initiation of warfarin 4. Smoking cessation
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A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse explains that the pain will improve with which of the following? 1. Coughing and deep breathing 2. Left lateral position 3. Pursed-lip breathing 4. Sitting up and leaning forward
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A client with hypertension is prescribed lisinopril. The nurse instructs the client to notify the health care provider immediately if which adverse effect occurs when taking this medication? 1. Cough 2. Dizziness 3. Rapid-onset confusion 4. Swelling of the lips and tongue
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A client with mitral valve disease is experiencing uncontrolled atrial fibrillation (AF) for 3 days that has been unresponsive to drug therapy. The client is scheduled for electrical cardioversion. What other procedure or test does the nurse anticipate that this client will require? 1. Chest x-ray 2. Exercise stress test 3. Insertion of a central venous access 4. Transesophageal echocardiogram (TEE)
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A nurse is caring for a client on the first day postop after having minimally invasive direct coronary artery bypass (MIDCAB) grafting. The client thought that this surgery was supposed to have a much easier recovery and asks the nurse why it is so painful to take deep breaths. What is the best response by the nurse? 1. "I am sorry you have so much pain. I'll go get your pain medication right now." 2. "Let me call the health care provider (HCP) to see if we can increase the dose of your pain medicine." 3. "Take deep breaths while splinting your chest with a pillow, and use your incentive spirometer every 2 hours. This will help your recovery." 4. "The overall recovery time is expected to be shorter, but initial postop pain can actually be higher with MIDCAB because the incisions are made between the ribs."
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A nurse is discussing discharge education with a client after his fifth hospitalization for pulmonary edema caused by his congestive heart failure. Which of the following statements indicates that further teaching is required? 1. "I should supplement my potassium intake." 2. "I should weigh myself daily." 3. "Moderate exercise may be helpful in my condition." 4. "Potato chips are an acceptable snack in moderation."
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After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is most concerning? 1. Client rates leg pain as "7" 2. Negative Homan sign 3. Prominent varicose veins bilaterally 4. Right calf is 4 cm larger than left calf
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The cardiac care unit has standing instructions that the health care provider (HCP) should be notified of an abnormal mean arterial pressure (MAP). The nurse will need to notify the HCP about which client? 1. A client from the cardiac catheterization lab with a blood pressure (BP) of 102/58 mm Hg 2. A client just admitted from the emergency department with a BP of 150/72 mm Hg 3. A client with a BP of 92/60 mm Hg who just received a dose of nitroglycerin 4. A client with heart failure on metoprolol with a BP of 106/42 mm Hg
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The client was diagnosed 6 months ago with hypertension and had a recent emergency department visit for a transient ischemic attack (TIA). The client's blood pressure today is 170/88 mm Hg. What teaching topic is a priority for the nurse to discuss with this client? 1. Decreasing sodium intake 2. Decreasing stress levels at work and home 3. Increasing activity level 4. Taking blood pressure medications as prescribed
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The clinic nurse is caring for an elderly client who is overweight and being treated for hypertension. What is most important for the nurse to emphasize to prevent a stroke (acute brain attack)? 1. Consume a low-fat, low-salt diet 2. Do not smoke cigarettes 3. Exercise and lose weight 4. Take prescribed antihypertensive medications
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The nurse is assessing a client with a possible diagnosis of peripheral artery disease. Which client statement is consistent with the diagnosis? 1. "At the end of the day, my shoes and socks are tight." 2. "I have a slow-healing sore right above my ankle." 3. "My legs ache when I stand for extended periods." 4. "When I sit down to rest and elevate my legs, the pain increases."
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The nurse is assigned to the following clients. Which client does the nurse assess/identify as being at greatest risk for the development of a deep venous thrombosis (DVT)? 1. A 25-year-old client with abdominal pain who smokes cigarettes and takes oral contraceptives 2. A 55-year-old ambulatory client with exacerbation of chronic bronchitis and hematocrit of 56% 3. A 72-year-old client with a fever who is 2 days post coronary stent placement 4. An 80-year-old client who is 4 days postoperative from repair of a fractured hip
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The nurse is caring for a client recently diagnosed with an active deep vein thrombosis (DVT). Which action by the client would require an immediate intervention by the nurse? 1. The client has a temperature of 100 F (37.7 C) 2. The client is ambulating up and down the hallways 3. The client is breathing at a rate of 16/min 4. The client is massaging the leg at the site of inflammation
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The nurse is reviewing laboratory data of a client who is receiving warfarin therapy for atrial fibrillation. Today's INR is 5.0. What action should the nurse take? 1. Administer the next scheduled dose of warfarin 2. Anticipate infusing fresh, frozen plasma 3. Call the pharmacy to see if protamine is available 4. Request a prescription from the health care provider (HCP) for vitamin K
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The nurse is reviewing the telemetry strips of assigned clients. The rhythm strip displayed in the exhibit is given to the nurse by the telemetry technician. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information. Exhibit: https://drive.google.com/open?id=0B40rfZ_HhbqwZGc5UHhFd0hwbEE 1. Atrial fibrillation 2. 1st-degree atrioventricular (AV) block 3. Sinus bradycardia 4. Sinus rhythm
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The nurse reviews laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires the most immediate action by the nurse? 1. Glucose 200 mg/dL (11.1 mmol/L) 2. Hematocrit 38% (0.38) 3. Potassium 3.4 mEq/L (3.4 mmol/L) 4. Troponin 0.7 ng/mL (0.7 mcg/L)
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