evolve

After a myocardial infarction, a client asks the nurse, "What's the chance of my having another heart attack if I watch my diet and stress levels carefully?" What is the most appropriate initial response by the nurse?

Identifying the concerns and helping the client explore feelings

Which assessment technique will the nurse avoid in a client with a suspected hematological disease?

Palpating the abdominal left upper quadrant

Which criteria indicate that a client on a cardiac monitor is in sinus rhythm? Select all that apply. One, some, or all responses may be correct.

The RR intervals are relatively consistent. One P wave precedes each QRS complex.

When laboratory results of a client's bloodwork after chemotherapy indicate bone marrow depression, which activities would the nurse reinforce? Select all that apply. One, some, or all responses may be correct.

soft toothbrush and read ingredients

A 68-year-old client has multiple risk factors for peripheral arterial disease, including client age, siblings with diabetes, a sedentary lifestyle, and family history of heart disease. Which risk factor is the highest priority for client teaching?

Low activity level

The nurse is discussing discharge instructions with a client who had a myocardial infarction. The client asks, "When will it be safe to have sex again?" Which response by the nurse is best?

One indication that your heart has healed enough for sexual activity is being able to climb two flights of stairs."

When the home health nurse is caring for a client with chronic occlusive arterial disease, which finding will be of most concern?

Pale and dry-appearing ulcer on great toe

The cardiac monitor shows sudden bursts of a regular heart rhythm with a rate of 220 beats/minute, normal QRS duration, and P waves that are difficult to see. Which rhythm is the client experiencing?

Paroxysmal supraventricular tachycardia (PSVT)

Which foods will the nurse recommend to a client with iron deficiency anemia? Select all that apply. One, some, or all responses may be correct.

spinach and beef liver

After consistently obtaining a blood pressure of 140/76 mm Hg for a client, which stage of hypertension will the nurse document?

stage 2

Which is the most definitive test to confirm a diagnosis of multiple myeloma?

Bone marrow biopsy

Which action would the nurse take before developing the teaching plan for a client who has had a myocardial infarction?

Correct1 Identify the learning needs of the client

Which meal selection by a client on a 2-g sodium diet indicates that more diet teaching is needed?

Cottage cheese, crackers, relish dish (celery, olives, sweet pickles)

Which action would the nurse take when administering a transfusion of 2 units of packed red blood cells (PRBCs) to a client?

Infuse the blood at a slow rate during the first 15 minutes.

How will the nurse document this rhythm for a client in the emergency department? .

Normal sinus rhythm

The parents of a child who has just been diagnosed with hemophilia A ask the nurse what symptoms of bleeding they should look for in the future. Which symptoms would the nurse list? Select all that apply. One, some, or all responses may be correct

Nosebleeds Blood in the urine Painful and swollen joints Easy bruising Dark-colored tarry stools

Which action would the nurse anticipate taking when a client develops third degree atrioventricular block with a heart rate of 30 beats/minute?

Obtain the transcutaneous pacemaker

Which finding in a client who has just been admitted indicates that the nurse will anticipate assisting with insertion of a temporary pacemaker?

Third-degree heart block

Which laboratory test is most important for the nurse to monitor when a client is admitted with acute coronary syndrome?

Troponin

Which action by a client with peripheral arterial disease indicates that more teaching about how to manage the disease is needed?

using a heating pad to warm

Before a femoral arteriogram is started, which would the nurse teach the client regarding the procedure?

Local anesthesia will be used to decrease pain at the site.

For which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? Select all that apply. One, some, or all responses may be correct.

unusal fatigue, dependent edema, nocturnal dyspena

When caring for a client who was admitted with heart failure, which action by the nurse will be most effective in determining whether the client's fluid overload is improving?

weighing the client

To evaluate the effectiveness of treatment for a client with exacerbation of left ventricular failure, which clinical indicators will the nurse monitor? Select all that apply. One, some, or all responses may be correct

Lung sounds Heart sounds Heart rate Dyspnea on exertion Jugular vein distension

When a client has venous insufficiency, which finding by the nurse will be of most concern?

Calf pain when the feet are dorsiflexed

Which diet choices by a client who has heart failure indicate that the nurse's teaching about diet has been effective? Select all that apply. One, some, or all responses may be correct.

lean steak, fruit salad, broiled chicken, roasted potato

When a client is admitted with dehydration, which clinical manifestations would the nurse expect to find? Select all that apply. One, some, or all responses may be correct.

oliguria, hypotension, skin turgor

A 30-year-old client who is diagnosed with hyperlipidemia and hypertension asks the nurse to explain why treatment is important, stating "I feel fine, so I don't really see the need to make any changes." Which response would the nurse make?

"Both high blood pressure and high cholesterol contribute to development of heart disease."

When the pulse rate for a client with a recent myocardial infarction increases from 70 beats/minute to 135 beats/minute while climbing the stairs, which instruction would the cardiac rehabilitation nurse give to the client?

"Stand still and rest."

When a client with a prosthetic heart valve asks the nurse why it is important to take antibiotics before a dental procedure, which response by the nurse is accurate?

"The antibiotic is taken to prevent infection around your artificial heart valve."

Which information would the nurse include in postprocedure teaching for a client who had sclerotherapy for varicose veins?

"Walk for several minutes every hour when awake."

After experiencing acute coronary syndrome, a client who has begun an exercise program asks the nurse how to tell whether the exercise is helping. Which response would the nurse make?

"You will be able to walk progressively longer distances before tiring

After emptying the drainage collection chamber for a postoperative client's portable closed suction wound drainage device, how will the nurse create negative pressure in the system?

Compressing the device while closing the air plug

Which finding will the nurse expect when caring for a client who is in hypovolemic shock?

Cool skin temperature

Which type of shock would the nurse monitor for in a client with a ruptured abdominal aortic aneurysm?

Hypovolemic

Which condition unrelated to cardiac disease is the major cause of right ventricular failure?

COPD

The spouse of a client who had coronary artery bypass graft (CABG) surgery asks why there is a dressing on the client's left leg. Which explanation would the nurse give?

A vein in the leg was used to bypass the coronary artery.

When caring for an older adult with coronary artery disease, which modification in the plan of care would the nurse make because of the client's age?

Assess for less common anginal symptoms like shortness of breath and gastric discomfort.

Which action will the nurse take when caring for a client who has just returned from having a femoral angiogram?

Assess the catheter insertion site at frequent intervals

Which information will the nurse include when teaching a client with intermittent claudication in the lower legs?

Assess the feet daily for injuries

Before administration of packed red blood cells to a client, which is the nurse's priority action?

Determining proper typing and crossmatching of blood

The blood pressure for a client with possible ruptured spleen after a motor vehicle accident is 100/60 mm Hg. Based on this information, which additional assessment finding will the nurse expect?

Reduced peripheral pulses

Which assessment finding indicates a need for the nurse to consult with the health care provider before administering the prescribed metoprolol to a client with stable angina?

Sinus bradycardia, rate 54 on monitor

How would the nurse document this rhythm seen in a client on the telemetry unit?

Sinus tachycardia

A client with chronic venous insufficiency has ankle edema. Which action would the nurse take?

Elevate the legs.

Which finding will the nurse expect when analyzing the cardiac rhythm for a client with first degree atrioventricular (AV) block?

Every P wave is conducted to the ventricles

When a client with heart failure is seen in the clinic with new onset ankle edema, the nurse would question the client about which lifestyle factors that may have contributed to the ankle swelling? Select all that apply. One, some, or all responses may be correct.

Intake of salty foods Medication compliance Recent travel

When a client with peripheral arterial disease tells the nurse about having leg pain and weakness after walking a short distance, how will the nurse document this information?

Intermittent claudication

Which dietary choices would the nurse teach for the client with peripheral arterial disease? Select all that apply. One, some, or all responses may be correct.

Limit salt intake.' Choose foods high in calcium. Eat whole-grain breads Use liquid vegetable oils. Avoid processed meats.

A client with heart failure weighed 175 lb (79.4 kg) yesterday, and today's weight is 181 lb (82.1 kg). How many milliliters of fluid has the client retained? Record your answer using a whole number. ___mL

One liter of fluid equals 1000 mL; each liter of fluid is equal to 1 kg of weight.82.1 kg - 79.4 kg = 2.7 kg = 2700 mL.

When teaching an unlicensed health care worker about blood pressure (BP) measurement, which information will the nurse include? Select all that apply. One, some, or all responses may be correct.

Support the client's arm at heart level when taking BP. Have the client rest for 5 minutes before measuring BP

Which topics will the nurse include in discharge teaching for a client who has had a mitral valve replacement with a mechanical valve? Select all that apply. One, some, or all responses may be correct.

Symptoms of infection Use of pain medications Purpose of anticoagulant medications

Which clinical manifestations would the nurse expect when assessing a client who is diagnosed with cardiogenic shock? Select all that apply. One, some, or all responses may be correct.

Tachycardia Restlessness Decreased urinary outpu

When taking the health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report?

Using several pillows at night to sleep

Which clinical manifestations will the nurse expect when caring for a client with a diagnosis of pulmonary edema? Select all that apply. One, some, or all responses may be correct.

crackles, coughing, orthopnea

A client has a tentative diagnosis of Hodgkin disease. How would the nurse expect the diagnosis to be confirmed?

lymph node