Care Exam 3

A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take first?

Assess the client's respiratory status.

A nurse is caring for four clients. Which one would the nurse see first?

Client who had a first dose of captopril and needs to use the bathroom.

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best?

Consult with the wound care nurse.

A client is receiving an infusion of alteplase for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse is most important?

Notify the Rapid Response Team.

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings would alert the nurse to the possibility of heart transplant rejection? (Select all that apply.)

a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia f. Fatigue

A nurse assesses a client who has a history of heart failure. Which question would the nurse ask to assess the extent of the client's heart failure?

"Are you still able to walk upstairs without fatigue?"

A nurse is providing discharge teaching to a client recovering from a heart transplant. Which statement would the nurse include?

"Avoid large crowds and people who are sick."

A nurse is teaching a client with heart failure who has been prescribed enalapril. Which statement would the nurse include in this client's teaching?

"Avoid using salt substitutes."

A nurse teaches a client with heart failure about energy conservation. Which statement would the nurse include in this client's teaching?

"Begin walking 200 feet a day three times a week."

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" What is the best response by the nurse?

"Blood clots form more easily in artificial replacement valves."

A nurse is assessing a client with peripheral artery disease (PAD). The client states that walking five blocks is possible without pain. What question asked next by the nurse will give the best information?

"Could you walk further than that a few months ago?"

A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse include in this client's teaching?

"Do not take this medication within 1 hour of taking an antacid."

A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the best response by the nurse?

"I can stay if you would you like to talk more about this."

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities?

"I can use a heating pad on my legs if it's set on low."

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?

"I must stop halfway up the stairs to catch my breath."

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching?

"I will have my teeth cleaned by my dentist in 2 weeks."

A client asks what "essential hypertension" is. What response by the registered nurse is best?

"It is hypertension with no specific cause."

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?

"Most people with hypertension do not have symptoms."

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care?

"My hands shake when I try to do things requiring coordination."

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure?

"My shoes fit really tight lately."

A client is taking warfarin and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best?

"No, it may interfere with the warfarin."

A nurse is teaching a female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best?

"No, women should only have one beer a day as a general rule."

A nurse teaches a client who has a history of heart failure. Which statement would the nurse include in this client's discharge teaching?

"Weigh yourself daily while wearing the same amount of clothing."

A nurse cares for a client with right-sided heart failure. The client asks, "Why do I need to weigh myself every day?" How would the nurse respond?

"Weight is the best indication that you are gaining or losing fluid."

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How would the nurse respond?

"Would you like information about advance directives?"

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How would the nurse respond?

"Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes."

A nurse assesses clients on a cardiac unit. Which client would the nurse identify as being at greatest risk for the development of left-sided heart failure?

A 36- year old woman with aortic stenosis

A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take?

Administer PRN acetaminophen.

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience would the nurse provide this service?

African-American churches

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the assistive personnel (AP)?

Apply a warm moist pack.

A client had a femoral-popliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection?

Appropriate hand hygiene before giving care

A nurse is working with a client who takes clopidogrel. The client's recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?

Ask if the client eats grapefruit.

A client is 4 hours postoperative after a femoral-popliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse is most important?

Assess distal pulses and skin color.

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next?

Assess for symptoms of left-sided heart failure.

The nurse is assessing a client on admission to the hospital. The client's leg appears as shown below:

Assess the client's ankle-brachial index.

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril and warfarin. The client reports new-onset cough. What action by the nurse is most appropriate?

Assess the client's lung sounds and oxygenation.

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin. The client is adamant about refusing the drug because "it's dangerous." What action by the nurse is best?

Assess the reason behind the client's fear.

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best?

Assist in finding one change the client can control.

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia would the nurse assess?

Atrial fibrillation

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates that the client is managing this condition well with diet?

Baked chicken breast, broccoli, tomatoes

A client had a percutaneous angioplasty for renovascular hypertension 3 months ago. What assessment finding by the nurse indicates that an important outcome for this client has been met?

Client is able to decrease blood pressure medications.

A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would alert the nurse to the possibility that the client's stenosis has progressed?

Dyspnea on exertion

A nurse assesses a client with pericarditis. Which assessment finding would the nurse expect to find?

Friction rub at the left lower sternal border.

The nurse is caring for four hypertensive clients. Which drug-laboratory value combination would the nurse report immediately to the health care provider?

Furosemide/potassium: 2.1 mEq/L

After administering the first dose of captopril to a client with heart failure, the nurse implements interventions to decrease complications. Which intervention is most important for the nurse to implement?

Instruct the client to ask for assistance when rising from bed.

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 lb (9.09 Kg) since the last visit. What action by the nurse is best?

Measure for new compression stockings.

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates that an important outcome has been met?

Oxygen saturation of 98%

A new nurse is caring for a client with an abdominal aneurysm. What action by the new nurse requires the nurse's mentor to intervene?

Palpates the abdomen in four quadrants.

A nurse is assessing the peripheral vascular system of an older adult. What action by the nurse would cause the supervising nurse to intervene?

Palpating both carotid arteries at the same time

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal?

Participate in blood pressure screenings at the mall.

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure would the nurse implement?

Sit the client up with a pillow to lean forward on.

A nurse cares for a client with infective endocarditis. Which infection control precautions would the nurse use?

Standard Precautions

A nurse prepares to discharge a client who has heart failure. Which questions would the nurse ask to ensure this client's safety prior to discharging home? (Select all that apply.)

a. "Are your bedroom and bathroom on the first floor?" b. "What social support do you have at home?" d. "What spiritual beliefs may impact your recovery?"

After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.)

a. "I'll read the nutritional labels on food items for salt content." d. "I will eat oatmeal for breakfast instead of ham and eggs." e. "Substituting fresh vegetables for canned ones will lower my salt intake."

A nurse collaborates with assistive personnel (AP) to provide care for a client with congestive heart failure. Which instructions would the nurse provide to the AP when delegating care for this client? (Select all that apply.)

a. "Reposition the client every 2 hours." c. "Accurately record intake and output." d. "Use the same scale to weigh the client each morning."

A nurse assesses clients on a cardiac unit. Which clients would the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.)

a. A 36-year-old woman with systemic lupus erythematosus (SLE) b. A 42-year-old man recovering from coronary artery bypass graft surgery d. An 80-year-old man with a bacterial infection of the respiratory tract

A nurse is caring for a client who was admitted with hypertrophic cardiomyopathy (HCM). What interprofessional care does the nurse anticipate providing? (Select all that apply.)

a. Administering beta blockers c. Preparing for a cardiac catheterization e. Instructing the client to avoid strenuous excersize

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the assistive personnel (AP) for deep vein thrombosis (DVT) prevention? (Select all that apply.)

a. Apply compression stockings. b. Assist with ambulation. d. Offer fluids frequently.

A nurse is caring for a client with a nonhealing arterial ulcer. The primary health care provider has informed the client about possibly needing to amputate the client's leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.)

a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires.

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client's plan of care? (Select all that apply.)

a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. d. Use an IV pump for the infusion.

The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.)

a. Atherosclerosis d. History of hypertension e. History of smoking f. Hyperlipidemia

A client is being discharged on warfarin therapy. What discharge instruction is the nurse required to provide? (Select all that apply.)

a. Dietary restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication

The nurse is reviewing risk factors in a client who has atherosclerosis. Which findings are most concerning? (Select all that apply.)

a. Elevated low-density lipoprotein (LDL-C) b. Decreased levels of high-density lipoprotein cholesterol (HDL-C) d. History of smoking

A nurse evaluates laboratory results for a client with heart failure. Which results would the nurse expect? (Select all that apply.)

a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L (130 mmol/L) e. Proteinuria f. Microalbuminuria

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations would the nurse assess? (Select all that apply.)

a. Pulmonary crackles b. Confusion e. Cough that worsens at night

What nonpharmacologic comfort measures would the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.)

b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises

A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.)

b. Assess distal pulses every 10 minutes. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.

A client presents to the emergency department with a thoracic aortic aneurysm. Which findings are most consistent with this condition? (Select all that apply.)

b. Difficulty swallowing e. Hoarseness

A nurse prepares to discharge a client who has heart failure. Based on national quality measures, what actions would the nurse complete prior to discharging this client? (Select all that apply.)

b. Ensure that the client is prescribed a beta blocker. c. Document a discussion about advanced directives. d. Confirm that a postdischarge nurse visit has been scheduled. f. Care transition record transmitted to next level of care within 7 days of discharge.

Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.)

c. "I will keep my feet dry, especially between the toes." d. "Lotion is important to keep my feet smooth and soft." e. "Washing my feet in room-temperature water is best."

A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.)

d. Raising the side rails on the bed e. Recording baseline vital signs