CMG 4: Week 7 (23), CMG 4: Week 5 (15), CMG 4: Week 6 (20)

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.) A. "' must stop smoking." B. "I am limiting my intake of fast foods. C. "I will stop consuming alcohol." D. "I need to monitor my weight." E. "I should limit my exercise."

A. "' must stop smoking." B. "I am limiting my intake of fast foods. D. "I need to monitor my weight."

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care? A. Impaired tissue perfusion B. Alteration in body image C. Alteration in activity tolerance D. Impaired skin integrity

A. Impaired tissue perfusion

A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include? A. "Apply ice packs to your legs." B. "Use elastic stockings." C. "Remain on bed rest." D. "Place your legs in a dependent position while in bed."

B. "Use elastic stockings."

A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include? A. "Take this medication with food." B. "You might have to stop taking this medication 5 days before any planned surgeries." C. "Take this medication three times daily." D. "Expect to have black-colored stools while taking this medication."

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

A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching? A. Apply a heating pad on a low setting to help relieve leg pain. B. Adjust the thermostat so that the environment is warm. C. Wear antiembolic stockings during the day. D. Rest with the legs above heart level.

B. Adjust the thermostat so that the environment is warm.

A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing? A. Kidney beans B. Grilled salmon C. Peanut butter D. Raw spinach

B. Grilled salmon

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? A. "DIC is controllable with lifelong heparin usage." B. "DIC is characterized by an elevated platelet count." C. "DIC is caused by abnormal coagulation involving fibrinogen." D. "DIC is a genetic disorder involving a vitamin K deficiency."

C. "DIC is caused by abnormal coagulation involving fibrinogen."

A nurse is teaching a client who has angina pectoris about starting therapy with SL nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication? A. "Take this medication after each meal and at bedtime." B. "Take one tablet every 15 min during an acute attack." C. "Take one tablet at the first indication of chest pain." D. "Take this medication with 8 ounces of water."

C. "Take one tablet at the first indication of chest pain."

A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflects the client's understanding of these dietary instructions? A. Liver B. Milk C. Beans D. Eggs

C. Beans

A nurse is preparing to administer heparin subcutaneously to a client who has a deep vein thrombosis. Which of the following techniques should the nurse use? A. Cleanse the skin with an alcohol swab, insert the needle, aspirate, and inject the heparin. B. Cleanse the skin with an alcohol swab, insert the needle, aspirate, inject the heparin, and massage the site. C. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and observe for bleeding. D. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, aspirate, and observe for bleeding.

C. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and observe for bleeding.

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? A. A raised red rash around the fistula site B. Pain in the right arm proximal to the fistula site C. Cold and numb numbness distal to the fistula site D. Foul-smelling drainage from the fistula site

C. Cold and numb numbness distal to the fistula site

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? A. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. B. Troponin is a lipid whose levels reflect the risk for coronary artery disease. C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. D. Troponin is a protein that helps transport oxygen throughout the body.

C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.

A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make? A. "Perhaps you should discuss this with your physician." B. "Of course you aren't going to die, at least not in the immediate future." C. "I recommend you exercise daily and avoid smoking to decrease your risk." D. "Tell me more about these fears of dying from a heart attack."

D. "Tell me more about these fears of dying from a heart attack."

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? A. Raise the foot of the bed to a 90° angle. B. Remove the dressing to inspect the wound. C. Prepare to insert a central line. D. Administer oxygen via nasal cannula.

D. Administer oxygen via nasal cannula.

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? A. Cryoprecipitates B. Platelets C. Albumin D. Packed RBCs

D. Packed RBCs

A nurse is caring for a 74-year-old female client who reports experiencing increased shortness of breath. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. condition: action 1: action 2: parameter 1: parameter 2:

condition: worsening related to their congestive heart failure . action 1: Apply O2 at 2L/min via nasal cannula action 2: elevate. the head of the client's bed because the client's condition is worsening related to their congestive heart failure. parameter 1: respiratory rate parameter 2: oxygen saturation

A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response? A. "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." B. "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." C. "Exercise is good for you and good for your heart." D. "Your doctor is the expert here, and I'm sure he would only recommend what is best for you."

A. "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely."

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? A. "These tests help determine the degree of damage to the heart tissues." B. "Cardiac enzymes will identify the location of the MI." C. "These tests will enable the provider to determine the heart structure and mobility of the heart valves." D. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion."

A. "These tests help determine the degree of damage to the heart tissues."

A nurse is assessing a client who has an infection. Which of the following findings is a manifestation of sepsis? (Select All that Apply.) A. Altered mental status B. Hypertension C. Vomiting D. Hypoglycemia E. Elevated WBC's count

A. Altered mental status C. Vomiting E. Elevated WBC's count

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? A. Confusion B. Blood pressure 84/50 mm Hg C. Anuria D. Petechiae

A. Confusion

A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take? A. Have the client lie flat in bed. B. Keep the affected leg slightly flexed. C. Elevate the head of the bed 45°. D. Keep the client NPO for 4 hr.

A. Have the client lie flat in bed.

A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.) A. Have the client remain in bed up to 6 hr. B. Check peripheral pulses in the affected extremity. C. Keep the client's hip and leg extended. D. Place the client in high-Fowler's position. E. Measure the client's vital signs every 4 hr.

A. Have the client remain in bed up to 6 hr. B. Check peripheral pulses in the affected extremity. C. Keep the client's hip and leg extended.

A nurse in an emergency department (ED) is admitting a client. Select the 3 findings that require immediate follow-up. A. Heart rate B. Neurological assessment C. 12 Lead EKG report D. Temperature E. Respiratory assessment

A. Heart rate C. 12 Lead EKG report E. Respiratory assessment

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock? A. Increased heart rate B. Widening pulse pressure C. Increased deep tendon reflexes D. Pulse oximetry 96%

A. Increased heart rate

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease? A. Intermittent claudication B. Dependent rubor C. Rest pain D. Foot ulcers

A. Intermittent claudication

A nurse is caring for a 73-year-old client in the emergency department (ED). It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications. (SATA) A. Measure lactate level. B. Obtain a wound culture. C. Obtain blood cultures. D. Administer broad-spectrum antibiotics. E. Insert a nasogastric (NG) tube. F. Rapidly administer 30 mL/kg of normal saline. G. Type and cross-match for 2 units of packed RBCS. H. Obtain a urine specimen.

A. Measure lactate level. C. Obtain blood cultures. D. Administer broad-spectrum antibiotics. F. Rapidly administer 30 mL/kg of normal saline.

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? A. Obtain a pair of slipper-socks for the client. B. Rub the client's feet briskly for several minutes. C. Increase the client's oral fluid intake. D. Place a moist heating pad under the client's feet.

A. Obtain a pair of slipper-socks for the client.

A nurse in the emergency department is caring for a client who has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. Which of the following interventions is the nurse's priority? A. Provide the client with supplemental oxygen at 5 L/min via facemask. B. Place the client in high-Fowler's position with their legs in a dependent position. C. Give the client sublingual nitroglycerin. D. Administer morphine sulfate IV.

A. Provide the client with supplemental oxygen at 5 L/min via facemask.

A nurse is caring for a male client who has peripheral vascular disease (PVD), is taking dietary supplements, and has a new prescription for warfarin. The nurse should instruct the client to stop which of the following supplements prior to starting the warfarin? (Select all that apply.) A. Saw palmetto B. Flaxseed oil C. Black cohosh D. Gingko biloba E. Glucosamine

A. Saw palmetto D. Gingko biloba E. Glucosamine

A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury. Which of the following findings should the nurse identify as indicating an increased risk of acute kidney injury (AKI)? A. Serum creatinine 1.8 mg/dL B. Serum Osmolality 290 mOsm/kg H,0 C. Blood urea nitrogen (BUN) 20mg/dL D. Magnesium 2.0 mEq/L

A. Serum creatinine 1.8 mg/dL

A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instructions should the nurse include in the teaching? A. Apply a new transdermal patch once a week. B. Apply the transdermal patch in the morning. C. Apply the transdermal patch in the same location as the previous patch. D. Apply a new transdermal patch when chest pain is experienced.

B. Apply the transdermal patch in the morning.

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect? A. Mottled skin B. Blood pressure 115/68 mmHg C. Heart rate 160/min D. Hypokalemia

B. Blood pressure 115/68 mmHg

A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take? A. Administer 50,000 units of heparin by IV bolus every 12 hr. B. Check the activated partial thromboplastin time (aPTT) every 4 hr. C. Have vitamin K available on the nursing unit. D. Use IV tubing specific for heparin sodium when administering the infusion.

B. Check the activated partial thromboplastin time (aPTT) every 4 hr.

A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the nurse's priority intervention? A. Insert an IV line. B. Count the respiratory rate. C. Administer oxygen. D. Prepare equipment for intubation.

B. Count the respiratory rate.

A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select All that Apply.) A. Orthopnea B. Diaphoresis C. Headache D. Nausea E. Tachycardia

B. Diaphoresis D. Nausea E. Tachycardia

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect? A. Dependent rubor B. Edema C. Hair loss D. Thick, deformed toenails

B. Edema

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? A. It decreases the client's level of anxiety. B. It facilitates the client's deep breathing. C. It enhances the client's ability to sleep. D. It reduces the client's blood pressure.

B. It facilitates the client's deep breathing.

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? A. Instruct the client to perform range-of-motion exercises to his lower extremities. B. Perform neurovascular checks with vital signs. C. Ambulate the client 1 hr following the procedure. D. Restrict the client's fluid intake.

B. 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? A. Hemoglobin (Hgb) B. Prothrombin time (PT) C. Bleeding time D. Activated partial thromboplastin time (aPTT)

B. Prothrombin time (PT)

A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first? A. Urticaria B. Stridor C. Vomiting D. Hypotension

B. Stridor

A nurse is reviewing the health history for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the history should the nurse report to the provider? A. The client has a history of hypothyroidism. B. The client has a history of bronchial asthma. C. The client has a history of hypertension. D. The client has a history of migraine headaches.

B. The client has a history of bronchial asthma.

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? A. Mild nosebleeds are common during initial treatment. B. Use an electric razor while on this medication. C. If a dose of the medication is missed, double the dose at the next scheduled time. D. Increase fiber intake to reduce the adverse effect of constipation.

B. Use an electric razor while on this medication.

A nurse is teaching a client who takes aspirin daily for coronary artery disease about herbal supplements. The nurse should instruct the client that which of the following herbal supplements may interact adversely with aspirin? A. Cranberry juice B. Aloe vera C. Feverfew D. Flaxseed

C. Feverfew

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? A. Hypotension B. Anuria C. Increased respiratory rate D. Decreased level of consciousness

C. Increased respiratory rate

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first? A. Attach the leads for a 12-lead ECG. B. Obtain a blood sample. C. Initiate oxygen therapy. D. Insert the IV catheter.

C. Initiate oxygen therapy.

A nurse is reviewing the laboratory results of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify that which of the following results places the client at risk? A. Triglycerides 130 mg/dL B. Blood glucose 92 mg/dL C. LDL 172 mg/dL D. HDL 84 mg/dL

C. LDL 172 mg/dL

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding? A. Hypertension B. Flushing of the skin C. Oliguria D. Bradypnea

C. Oliguria

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? A. Check the client's blood pressure. B. Auscultate heart tones. C. Perform a 12-lead ECG D. Determine if pain radiates to the left arm.

C. Perform a 12-lead ECG

The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate? A. Brachial pulse in the left arm B. Brachial pulse in the right arm C. Radial pulse in the left arm D. Radial pulse in the right arm

C. Radial pulse in the left arm

A nurse is providing care for a group of clients in the emergency department. Which of the following clients is at risk for developing neurogenic shock? A. The client experiencing an asthma attack B. The client who has chronic kidney disease C. The client who has Guillain-Barré syndrome D. The client who has a severe burn injury

C. The client who has Guillain-Barré syndrome

A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? A. analgesic B. anti-inflammatory C. antiplatelet aggregate D. antipyretic

C. antiplatelet aggregate

A nurse is providing teaching to a client who is taking warfarin about monitoring its therapeutic effects. Which of the following explanations should the nurse provide about the international normalized ratio (INR) test? A. "The INR also monitors heparin therapy if the provider switches the medication prescription." B. "The INR is the only test available for anticoagulant therapy monitoring." C. "You will only need the test twice per month." D. "The INR is a standardized test that eliminates the variations between laboratories reports in prothrombin times."

D. "The INR is a standardized test that eliminates the variations between laboratories reports in prothrombin times."

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first? A. Dobutamine B. Methylprednisolone C. Furosemide D. Epinephrine

D. Epinephrine

A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. Which of the following information should the nurse include about anginal pain? A. The pain usually lasts longer than 20 min. B. Pain can often be relieved by sitting up. C. The pain persists with rest and organic nitrates. D. Exertion and anxiety can trigger the pain.

D. Exertion and anxiety can trigger the pain.

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? A. Decrease in the respiratory rate from 20 to 16/min. B. Decrease in the urinary output from 50 mL to 30 mL per hour. C. Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F). D. Increase in the heart rate from 88 to 110/min.

D. Increase in the heart rate from 88 to 110/min.

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? A. Decreased heart rate B. Dyspnea C. Increased blood pressure D. Weak pulse

D. Weak pulse

A nurse is caring for a client who has acute pancreatitis. Click to highlight the information in the Nurses Note and Vital Signs that indicate the client is progressing. Day 2: Heart rate: 92/min Respiratory rate: 20/min BP: 122/58 mm Hg Oxygen saturation: 96% on room air Nurses Notes: Oriented to person, place, and time; reports extreme fatigue. Client rates pain as 3 on a 0 to 10 pain scale following administration of pain medication 30 min ago. S1, S2 noted on auscultation. Pulses palpable. Respirations even, unlabored. Chest clear on auscultation. Bowel sounds hypoactive in all four quadrants. Client vomiting brown liquid and reports continuing nausea. Reports passing flatus. Urinating without difficulty, urine is clear yellow.

Day 2: Heart rate: 92/min Respiratory rate: 20/min BP: 122/58 mm Hg Oxygen saturation: 96% on room air Nurses Notes: Oriented to person, place, and time; reports extreme fatigue. Client rates pain as 3 on a 0 to 10 pain scale following administration of pain medication 30 min ago. S1, S2 noted on auscultation. Pulses palpable. Respirations even, unlabored. Chest clear on auscultation. Bowel sounds hypoactive in all four quadrants. Client vomiting brown liquid and reports continuing nausea. Reports passing flatus. Urinating without difficulty, urine is clear yellow.

A nurse in the emergency department is admitting a client. For each of the following findings in the client's medical record, click to specify if they are consistent with angina or a myocardial infarction (MI). Each finding may support more than one disease process. Findings [Angina or Myocardial Infarction] Provider consult 口 12 Lead EKG report 口 Result of nitroglycerin therapy口 Client's initial report of manifestations口 Treadmill stress test口

Findings [Angina or Myocardial Infarction] Provider consult 口Both 12 Lead EKG report 口Both Result of nitroglycerin therapy口Angina Client's initial report of manifestations口Both Treadmill stress test口Angina