Final exam and NCLEX study guide for Complex Needs

A client seeks treatment in a vascular surgeon's office for unsightly varicose veins, and radiofrequency ablation (RFA) is recommended. Before leaving the examining room, the client says to the nurse, "Can you tell me again how this is done?" Which statement should the nurse make? 1. "The varicosity is surgically removed." 2."A heating element is used to occlude the vein." 3."The vein is tied off at the upper end to prevent stasis from occurring." 4."The vein is tied off at the lower end to prevent stasis from occurring."

a heating element is used to occlude the vein

The nurse is preparing to care for a client with esophageal varices who needs a Sengstaken-Blakemore tube inserted because other treatments were unsuccessful. The nurse gathers supplies, knowing that which item must be kept at the bedside at all times? 1.An obturator 2.A Kelly clamp 3.An irrigation set 4.A pair of scissors

a pair of scissors

A client with rapid-rate atrial fibrillation has a new prescription for diltiazem hydrochloride by intravenous (IV) bolus followed by a continuous IV infusion of the same medication. What should the nurse plan for with the administration of this medication? 1.Applying a nonrebreather mask 2.Discontinuing the infusion after 24 hours 3.Monitoring the cardiac rhythm every hour 4.Administering the IV bolus over 2 to 3 seconds

discontinue the infusion after 24 hours

The nurse provides instructions to the client about nicotinic acid prescribed for hyperlipidemia. Which statement by the client indicates understanding of the instructions? 1. "The medication should be taken with meals to decrease flushing." 2. "It is not necessary to avoid the use of alcohol when taking nicotinic acid." 3. "Clay-colored stools are a common side effect and should not be of concern." 4. "Ibuprofen taken 30 minutes before the nicotinic acid may decrease the flushing."

"Ibuprofen taken 30 minutes before the nicotinic acid may decrease the flushing."

The nurse is caring for a client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. Which activity will assist with preventing dislodgement of the pacing catheter? 1. Limiting both movement and abduction of the left arm 2.Limiting both movement and abduction of the right arm 3.Assisting the client to get out of bed and ambulate with a walker 4.Having the physical therapist do active range-of-motion exercises to the right arm

Limiting both movement and abduction of the right arm

A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats/minute range. The client is also complaining of nausea. Which cranial nerve damage should the nurse expect that the client is experiencing? 1.Vagus (CN X) 2.Hypoglossal (CN XII) 3.Spinal accessory (CN XI) 4.Glossopharyngeal (CN IX)

Vagus (CN X)

The nurse is assessing a client newly diagnosed with mild hypertension. Which assessment finding should the nurse expect? 1.Asymptomatic 2.Shortness of breath 3.Visual disturbances 4.Frequent nosebleeds

asymptomatic

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? 1. Call a code. 2. Check the client's status. 3. Call the primary health care provider. 4. Document the lack of complexes.

check the client's status

A client with rapid-rate atrial fibrillation asks the nurse why the cardiologist is going to perform carotid sinus massage. The nurse educates the client about the treatment. Which statement by the client indicates that the teaching has been effective? 1. "The vagus nerve slows the heart rate." 2."The diaphragmatic nerve slows the heart rate." 3."The diaphragmatic nerve overdrives the rhythm." 4."The vagus nerve increases the heart rate, overdriving the rhythm."

the vagus nerve slows the Heart Rate

A client is brought into the emergency department in ventricular fibrillation (VF). The nurse prepares to defibrillate by placing defibrillation pads on which part of the chest? 1. The upper and lower halves of the sternum 2.Parallel between the umbilicus and the right nipple 3.The right shoulder and the back of the left shoulder 4.To the right of the sternum and to the left of the precordium

to the right of the sternum and to the left of the precordium

The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority? 1.Ensure that the client has been intubated. 2.Set the defibrillator to the "synchronize" mode. 3.Administer an amiodarone bolus intravenously. 4. Confirm that the rhythm is actually ventricular fibrillation

Confirm that the rhythm is actually ventricular fibrillation

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food? 1. Apples 2.Bananas 3.Smoked salami 4.Steamed vegetables

smoked salami

The nurse has provided self-care activity instructions to a client after insertion of an implanted cardioverter-defibrillator (ICD). The nurse determines that further instruction is needed if the client makes which statement? 1. "I need to avoid doing anything that could involve rough contact with the ICD insertion site." 2. "I can perform activities such as swimming, driving, or operating heavy equipment as I need to." 3. "I should try to avoid doing strenuous things that would make my heart rate go up to or above the rate cutoff on the ICD." 4. "I should keep away from electromagnetic sources such as transformers, large electrical generators, and metal detectors, and I shouldn't lean over running motors."

"I can perform activities such as swimming, driving, or operating heavy equipment as I need to."

An ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which statement indicates that the client needs additional education? 1."It is important that I limit protein intake." 2."I need to maintain a regular exercise program." 3."I understand that I need to avoid adding salt to foods." 4."It is important that I begin reducing and then maintaining weight."

"It is important that I limit protein intake."

The nurse should evaluate that defibrillation of a client was most successful if which observation was made? 1. Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg 2. Nonarousable, sinus rhythm, BP 88/60 mm Hg 3. Arousable, marked bradycardia, BP 86/54 mm Hg 4. Nonarousable, supraventricular tachycardia, BP 122/60 mm Hg

Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg

A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? 1. Causative factors, such as caffeine 2. Sensation of fluttering or palpitations 3. Blood pressure and oxygen saturation 4. Precipitating factors, such as infection

Blood pressure and oxygen saturation

A client with valvular heart disease who has a clot in the right atrium is receiving a heparin sodium infusion at 1000 units/hr and warfarin sodium 7.5 mg at 5:00 p.m. daily. The morning laboratory results are as follows: activated partial thromboplastin time (aPTT), 32 seconds; international normalized ratio (INR), 1.3. The nurse should take which action based on the client's laboratory results? 1. Collaborate with the primary health care provider (PHCP) to discontinue the heparin infusion and administer the warfarin sodium as prescribed. 2.Collaborate with the PHCP to obtain a prescription to increase the heparin infusion and continue the warfarin sodium as prescribed. 3.Collaborate with the PHCP to withhold the warfarin sodium since the client is receiving a heparin infusion and the aPTT is within the therapeutic range. 4.Collaborate with the PHCP to continue the heparin infusion at the same rate and to discuss use of dabigatran etexilate in place of warfarin sodium.

Collaborate with the PHCP to obtain a prescription to increase the heparin infusion and continue the warfarin sodium as prescribed.

The nurse provides discharge instructions to a client with atrial fibrillation who is taking warfarin sodium. Which statement, by the client, reflects the need for further teaching? "I will avoid alcohol consumption." 2."I will take my pills every day at the same time." 3."I have already called my family to pick up a MedicAlert bracelet." 4."I will take coated aspirin for my headaches because it will coat my stomach."

I will take a coated aspirin for my headaches because it will coat my stomach

A client develops atrial fibrillation with a ventricular rate of 140 beats/minute and signs of decreased cardiac output. Which medication should the nurse anticipate administering first? 1.Warfarin 2.Lidocaine 3.Metoprolol 4.Atropine sulfate

Metoprolol

A client is diagnosed with an ST segment elevation myocardial infarction (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? 1. Monitor for kidney failure. 2.Monitor psychosocial status. 3.Monitor for signs of bleeding. 4.Have heparin sodium available.

Monitor for signs of bleeding

A client has frequent runs of ventricular tachycardia. The primary health care provider has prescribed flecainide. What is the best nursing action related to the effects of this medication while the client is hospitalized? 1.Monitor the client's urinary output. 2.Assess the client for neurological changes. 3.Keep the call bell within the client's reach. 4.Monitor vital signs and cardiac rhythm frequently.

Monitor vital signs and cardiac rhythm frequently.

Cardiac monitoring leads are placed on a client who is at risk for premature ventricular contractions (PVCs). Which heart rhythm will the nurse anticipate in this client if PVCs are occurring? 1. A P wave preceding every QRS complex 2. QRS complexes that are short and narrow 3. Inverted P waves before the QRS complexes 4. Premature beats followed by a compensatory pause

Premature beats followed by a compensatory pause

The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse interpret this rhythm? 1. Asystole 2.Atrial fibrillation 3.Ventricular fibrillation 4.Ventricular tachycardia

Ventricular Fibrillation

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? 1. Lub-dub sounds 2.Scratchy, leathery heart noise 3.A blowing or swooshing noise 4.Abrupt, high-pitched snapping noise

a blowing or swooshing noise

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? 1. A pregnant woman who exclaims, "My baby is not moving." 2.A woman who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" 3.A young child standing next to an adult family member who is screaming, "I want my mommy!" 4.An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

a woman who is complaining, "my leg is bleeding so bad, I am afraid it is going to fall off"

Endovenous laser treatment (EVLT) is done on a client with varicose veins. Which interventions should the nurse include in the postprocedure plan of care? Inform the client that the EVLT procedure ensures closure of the treated vein. 2. Assess color and temperature of the affected limb to determine vascular status. 3. Teach the client the importance of using graduated compression stockings (GCSs) during the day. 4. Inform the client that circulation impairment and nerve damage is expected to occur following the procedure.

assess color and temperature of the affected limb to determine vascular status

A client has a history of heart failure and is suspected of having pulmonary edema. The nurse should plan to take which actions? Select all that apply. 1.Assess lung sounds. 2.Apply supplemental oxygen. 3.Palpate peripheral and central pulses. 4.Administer furosemide as prescribed and insert a Foley catheter. 5.Place the client in high-fowlers, with legs in a dependent position.

assess lung sounds apply supplimental oxygen administer furosemide as prescribed and insert a foley catheter, place the client in high-fowlers, with legs in a dependent position

Which is the priority assessment in the care of a client who is newly admitted to the hospital for acute arterial insufficiency of the left leg and moderate chronic arterial insufficiency of the right leg? 1.Monitor oxygen saturation with pulse oximetry. 2.Assess activity tolerance before and after exercise. 3.Observe the client's cardiac rhythm with telemetry. 4.Assess peripheral pulses with an ultrasonic Doppler device.

assess peripheral pulses with an ultrasonic Doppler device

A client is being treated with procainamide for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. What intervention should the nurse take first? 1. Obtain a 12-lead electrocardiogram. 2. Check the client's fingerstick blood glucose level. 3. Auscultate the client's apical pulse and blood pressure. 4. Measure the QRS interval duration on the rhythm strip.

auscultate the client's apical pulse and BP

A man has developed atrial fibrillation and has been placed on warfarin. The nurse is doing discharge dietary teaching with the client and determines that the client needs additional education if he states that he would choose which food while taking this medication? 1.Cherries 2.Potatoes 3.Broccoli 4.Spaghetti

broccoli

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/ hr, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client's blood urea nitrogen level is 35 mg/dL (12.6 mmol/L), and the serum creati¬nine level is 1.8 mg/dL (159 mcmol/L), measured this morning. Which nursing action is the priority? 1. Check the serum albumin level. 2. Check the urine specific gravity. 3. Continue monitoring urine output. 4. Call the primary health care provider (PHCP).

call health care provider

A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal. The nurse should alert the primary health care provider because the vital sign changes and client assessment are most consistent with which complication? chart info 11 am pulse 92; RR 24; bp 140/80 11:15 am pulse 96; RR 26; bp 128/82 11:30 am pulse 104; RR 28; bp 104/68 11:45 am pulse 118; RR 32; bp 88/58 1. Cardiogenic shock 2. Cardiac tamponade 3. Pulmonary embolism 4. Dissecting thoracic aortic aneurysm

cardiogenic shock

A chaotic small, irregular, disorganized cardiac pattern suddenly appears on a client's cardiac monitor. Which is the nurse's first action? 1.Call the cardiologist. 2.Check the blood pressure. 3.Check the client and the chest leads. 4.Initiate cardiopulmonary resuscitation (CPR).

check the client and the chest leads

A client is brought to the emergency department complaining of substernal chest pain. To distinguish between angina and myocardial infarction, the nurse assesses for which characteristics of angina? Select all that apply. 1.Chest pain that resolves with rest 2.Chest pain requiring an opioid for relief 3.Chest pain that is relieved by nitroglycerin 4.Chest pain that lasts longer than 30 minutes 5.Chest pain that is usually precipitated by exertion

chest pain that resolves with rest chest pain that is relieved by nitroglycerin chest pain that is usually precipitated by exertion

The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pads on the client's chest and before discharging the device, which intervention is a priority? 1. Ensure that the client has been intubated. 2.Set the defibrillator to the "synchronize" mode. 3.Administer an amiodarone bolus intravenously. 4.Confirm that the rhythm is ventricular fibrillation.

confirm that the rhythm is ventricular fibrillation

The nurse is monitoring a client with hypertension who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication? 1. Report of infrequent insomnia 2.Development of expiratory wheezes 3.A baseline blood pressure of 150/80 mm Hg after 2 doses of the medication 4.A baseline resting heart rate of 88 beats per minute followed by a resting heart rate of 72 beats per minute after 2 doses of the medication

development of expiratory wheezes

The nurse is monitoring a client with heart failure who is taking digoxin. Which findings are characteristic of digoxin toxicity? Select all that apply. 1. Tremors 2.Diarrhea 3.Irritability 4.Blurred vision 5.Nausea and vomiting

diarrhea, blurred vision, n/v

The primary health care provider prescribes limited activity (bed rest and bathroom only) for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. 1. Encourage coughing with deep breathing. 2. Place in high-Fowler's position for eating. 3. Encourage increased oral intake of water daily. 4. Place thigh-length elastic stockings on the client. 5. Place sequential compression boots on the client. 6. Encourage the intake of dark green, leafy vegetables.

encourage coughing with deep breathing encourage increased oral intake of water daily place thigh-length elastic stockings on the client

The nurse is assessing a client with an abdominal aortic aneurysm. Which assessment finding by the nurse is unrelated to the aneurysm? 1.Pulsatile abdominal mass 2.Hyperactive bowel sounds in the area 3.Systolic bruit over the area of the mass 4.Subjective sensation of "heart beating" in the abdomen

hyperactive bowel sounds in the area

The nurse is reviewing the record of a client who arrives at the health care clinic. The nurse notes that irbesartan has been prescribed for the client. The nurse should suspect that the client has which condition? 1.Hypertension 2.Hypothyroidism 3.Diabetes mellitus 4.Renal transplant rejection

hypertension

The primary health care provider (PHCP) writes a prescription for lisinopril for a hospitalized client with hypertension. The nurse caring for the client determines that the medication has been prescribed to treat which disorder? 1.Hypertension 2.Immune disorder 3.Venous insufficiency 4.Gastroesophageal reflux disorder

hypertension

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? 1. It can develop into ventricular fibrillation at any time. 2.It is almost impossible to convert to a normal rhythm. 3.It is uncomfortable for the client, giving a sense of impending doom. 4.It produces a high cardiac output with cerebral and myocardial ischemia.

it can develop into ventricular fibrillation at any time

The nurse determines that a client requires further teaching after permanent pacemaker insertion if which statement is made? 1."I'll need to call my cardiologist if I feel tired or dizzy." 2."My pulse rate should be less than what my pacemaker is set at." 3."I'll have to avoid carrying the grocery bags into the house for the next 6 weeks." 4."It's safe to use my microwave as long it is properly grounded and well shielded."

my pulse rate should be less than what my pacemaker is set at

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse should assess the client for which manifestation that differentiates pericarditis from other cardiopulmonary problems? 1. Anterior chest pain 2. Pericardial friction rub 3. Weakness and irritability 4. Chest pain that worsens on inspiration

pericardial friction rub

A client with pulmonary edema has been receiving diuretic therapy. The client has a prescription for additional furosemide in the amount of 40 mg intravenous push. Knowing that the client will also be started on digoxin, which laboratory result should the nurse review as the priority? 1. Sodium level 2.Digoxin level 3.Creatinine level 4.Potassium level

potassium level

The nurse is preparing to ambulate a client on the third day after cardiac surgery. What should the nurse plan to do to enable the client to best tolerate the ambulation? 1.Remove telemetry equipment. 2.Provide the client with a walker. 3.Premedicate the client with an analgesic. 4.Encourage the client to cough and breathe deeply.

premedicate the client with an analgesic

A client is admitted to a hospital with acute myocardial infarction and is started on tissue plasminogen activator (tPA) by infusion. Which parameter should the nurse determine requires the least frequent assessment to detect complications of therapy with tPA? 1.Neurological signs 2.Blood pressure and pulse 3.Presence of bowel sounds 4.Complaints of abdominal and back pain

presence of bowel sounds

Prior to administering a client's daily dose of digoxin to treat heart failure, the nurse reviews the client's laboratory data and notes the following results: serum calcium, 9.8 mg/dL (2.45 mmol/L); serum magnesium, 1.0 mEq/L (0.4 mmol/L); serum potassium, 4.1 mEq/L (4.1 mmol/L); serum creatinine, 0.9 mg/dL (79.5 mcmol/L). Which result should alert the nurse that the client is at risk for digoxin toxicity? 1. Serum calcium level 2.Serum potassium level 3.Serum creatinine level 4.Serum magnesium level

serum magnesium level

The nurse is evaluating a client's cardiac rhythm strip to determine if there is proper function of the VVI mode pacemaker. Which denotes proper functioning? 1.Spikes precede all P waves and QRS complexes. 2.There are consistent spikes before each P wave. 3.Spikes occur before QRS complexes when intrinsic ventricular beats do not occur. 4.Spikes occur before all QRS complexes regardless of intrinsic ventricular activity.

spikes occur before QRS complexes when intrinsic ventricular beats do not occur

A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and reports itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which interventions are a priority? Select all that apply. 1. Stop the infusion. 2.Raise the head of the bed. 3.Administer protamine sulfate. 4.Administer diphenhydramine. 5.Call for the Rapid Response Team (RRT).

stop the infusion, administer diphenhydramine, call for the Rapid Response Team

The nurse is monitoring a client for adverse effects of medications. Which findings are characteristic of adverse effects of hydrochlorothiazide? Select all that apply. 1. Sulfa allergy 2.Osteoporosis 3.Hypokalemia 4.Hypouricemia 5.Hyperglycemia 6.Hypercalcemia

sulfa allergy, hypokalemia, hyperglycemia, hypercalcemia

A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? 1. Tomato soup 2.Boiled shrimp 3.Instant oatmeal 4.Summer squash

summer squash

Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply. 1. Urine output 50 mL/hr 2. Hypoactive bowel sounds 3. Temperature of 102° F (38.9° C) 4. Heart rate of 96 beats per minute 5. Mean arterial pressure 65 mm Hg 6. Systolic blood pressure 110 mm Hg

temp of 102, HR 96 bpm, Mean arterial pressure 65 mm Hg

The registered nurse (RN) is listening to a lecture on pulmonary edema. Which statement by the RN indicates that the teaching has been effective? 1. "The client may have mild anxiety." 2. "The client will not experience anxiety." 3. "The client will experience extreme anxiety." 4. "The client will only experience anxiety in a stressful environment."

the client will experience extreme anxiety

The nurse is caring for a client just admitted to the critical care unit with a diagnosis of myocardial infarction (MI). In the early period after an MI, why are nutrition interventions and education so important? Select all that apply. 1.To reduce angina 2.To cut down on cardiac workload 3.To decrease the risk of dysrhythmias 4.To cause weight loss in obese clients 5.To cut down on the cost of a hospital stay 6.To eliminate further deterioration of kidney function

to reduce angina, to cut down on cardiac workload, to decrease the risk of dysrhythmias

The nurse is educating the client about variant angina. Which statement by the client indicates that the teaching has been effective? 1."Variant angina is induced by exercise." 2."Variant angina occurs at the same time each day." 3."Variant angina occurs at lower levels of activity." 4."Variant angina is less predictable and a precursor of myocardial infarction."

variant angina occurs at the same time each day

A client with heart failure who has a serum potassium (K+) level of 2.9 mEq/L (2.9 mmol/L) tells the nurse that he does not feel like eating lunch. The nurse checks his serum digoxin level from that morning and notes that it is 1.0 ng/mL (1.2 nmol/L). What should the nurse determine about this digoxin level? 1.Low 2.Extremely toxic 3.Within the therapeutic range 4.Just above the high end of the therapeutic range

within the therapeutic range

A client with a history of heart failure who is receiving digoxin daily has a serum potassium level of 3 mEq/L (3 mmol/L) and is complaining of anorexia. The primary health care provider prescribes a serum digoxin level to be done. The nurse checks the results and should expect to note which level that is outside of the therapeutic range? 1.0.3 ng/mL 2.0.5 ng/mL 3.0.8 ng/mL 4.1.0 ng/mL

1.0 ng/mL

The nurse is reviewing the laboratory results for a client who arrives at the health care clinic for follow-up assessment after being diagnosed with atrial fibrillation. The international normalized ratio (INR) is analyzed because the client has been taking warfarin sodium since discharge from the hospital. The nurse determines that the INR range is at an appropriate level if what value is noted on the laboratory report? 1.0.6 2.0.75 3.1.0 4.2.3

2.3

A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? 3.2 mEq/L (3.2 mmol/L) 2.3.8 mEq/L (3.8 mmol/L) 3.4.2 mEq/L (4.2 mmol/L) 4.4.8 mEq/L (4.8 mmol/L)

3.2 mEq/L (3.2 mmol/L)

A client in ventricular fibrillation is about to be defibrillated. To convert this rhythm effectively, the monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery? 1) 50 J 2) 120 J 3) 200 J 4)360 J

360 J

A hypertensive client has been prescribed clonidine hydrochloride, a transdermal patch. The nurse provides written instructions to the client on the use of the patch. Which statement by the client indicates the need for further instruction? 1."I need to change the patch every 24 hours." 2."I need to apply the patch to a hairless body site." 3."I need to apply the patch to skin areas that are not broken." 4."I need to apply the patch to the skin on the upper arm or body."

I need to change the patch every 24 hours

A client in shock develops a central venous pressure (CVP) of 2 mm Hg. Which prescribed intervention should the nurse implement first? 1. Increase the rate of O2 flow 2. Obtain arterial blood gas results 3. Insert an indwelling urinary catheter 4. Increase the rate of intravenous (IV) fluids

Increase the rate of the IV fluids

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication? 1.Warmth, redness, and pain in the left hand 2.Ecchymosis and audible bruit over the fistula 3.Edema and reddish discoloration of the left arm 4.Pallor, diminished pulse, and pain in the left hand

Pallor, diminished pulse, and pain in the left hand

Intravenous heparin therapy is prescribed for a client with atrial fibrillation. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit? 1. Vitamin K 2. Protamine sulfate 3. Potassium chloride 4. Aminocaproic acid

Protamine sulfate

A client is admitted to the hospital for an acute episode of angina pectoris. Which parameter is the priority for the nurse to monitor? 1.Pulse and blood pressure 2.Temperature and respirations 3.Food tolerance and urinary output 4.Right upper quadrant pain and fatigue

Pulse and blood pressure

The nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade, knowing that which signs are associated with this complication of pericarditis? Select all that apply. 1.Bradycardia 2.Pulsus paradoxus 3.Distant heart sounds 4.Falling blood pressure (BP) 5.Distended jugular veins

Pulsus paradoxus, distand heart sounds, falling BP, distended Jugular veins

A client is having a follow-up primary health care provider (PHCP) office visit after vein ligation and stripping. The client describes a sensation of "pins and needles" in the affected leg. Which would be an appropriate action by the nurse based on evaluation of the client's comment? 1. Report the complaint to the PHCP. 2. Instruct the client to apply warm packs. 3. Reassure the client that this is only temporary. 4. Advise the client to take acetaminophen until it is gone.

Report the complaint to the PHCP

The nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client's laboratory results and determines that which result would be consistent with the observation? 1.Serum chloride level of 98 mEq/L (98 mmol/L) 2.Serum sodium level of 145 mEq/L (145 mmol/L) 3.Serum calcium level of 10.5 mg/dL (2.75 mmol/L) 4.Serum potassium level of 2.8 mEq/L (2.8 mmol/L)

Serum potassium level of 2.8 mEq/L (2.8 mmol/L)

The client has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. The nurse should assess the client for which associated signs and/or symptoms? Select all that apply. 1. Syncope 2.Dizziness 3.Palpitations 4.Hypertension 5.Flat neck veins

Syncope, dizziness, palpitations

An adult client has been unsuccessfully defibrillated for ventricular fibrillation, and cardiopulmonary resuscitation (CPR) is resumed. The nurse confirms that CPR is being administered effectively by noting which action? 1.The ratio of compressions to ventilations is 30:2. 2.The carotid pulse is palpable with each compression. 3.Respirations are given at a rate of 10 breaths per minute. 4.The chest compressions are given at a depth of 1.5 to 2 inches (2.5 to 5 cm).

The carotid pulse is palpable with each compression.

A client is seen in the emergency department for complaints of chest pain that began 3 hours ago. The nurse should suspect myocardial injury or infarction if which laboratory value comes back elevated? 1. Troponin 2.Myoglobin 3.C-reactive protein 4.Creatine kinase (CK)

Troponin

A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hr. The nurse determines that the client is receiving the therapeutic effect based on which results? 1. Prothrombin time of 12.5 seconds 2. Activated partial thromboplastin time of 28 seconds 3. Activated partial thromboplastin time of 60 seconds 4. Activated partial thromboplastin time longer than 120 seconds

activated partial thromboplastin time of 60 seconds

The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse knows that which intervention is the priority for this client? 1. Administration of digoxin 2. Administration of whole blood 3. Administration of intravenous fluids 4. Administration of packed red blood cells

administer digoxin

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement which priority interventions? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low-Fowler's side-lying position

administer oxygen, insert a foley catheter, administer furosemide, administer morphine sulfate IV

The nurse has completed medication administration that included a nitroglycerin. Within minutes, the client is complaining of a headache. Which is the priority nursing action at this time? 1.Evaluate pupil response. 2.Place the client on the left side. 3.Administer the prescribed analgesic. 4.Notify the primary health care provider (PHCP) immediately.

administer the prescribed analgesic

A client is at risk for vasovagal attacks that cause bradydysrhythmias. The nurse would tell the client to avoid which actions to prevent this occurrence? Select all that apply. 1. Applying pressure on the eyes 2. Raising the arms above the head 3. Taking stool softeners on a daily basis 4. Bearing down during a bowel movement 5. Simulating a gag reflex when brushing the teeth

applying pressure on the eyes, raising the arms above the head, bearing down during a bowel movement, simulating a gag reflex when brushing the teeth

A client with a history of hypertension has been prescribed triamterene. The nurse determines that the client understands the effect of this medication on the diet if the client states to avoid which fruit? 1. Pears 2.Apples 3.Bananas 4.Cranberries

bananas

The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1. Out-of-bed activities as desired 2. Bed rest with the affected extremity kept flat 3. Bed rest with elevation of the affected extremity 4. Bed rest with the affected extremity in a dependent position

bed rest with elevation of the affected extremity

A client has been admitted with left-sided heart failure. When planning care for the client, interventions should be focused on reduction of which specific problem associated with this type of heart failure? 1.Ascites 2.Pedal edema 3.Bilateral lung crackles 4.Jugular vein distention

bilateral lung crackles

The nurse is providing postoperative care for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse should be most concerned about monitoring for which potential complications? 1.Bleeding and infection 2.Thrombosis and infection 3.Bleeding and wound dehiscence 4.Wound dehiscence and evisceration

bleeding and infection

A client with the recent diagnosis of myocardial infarction and impaired renal function is recuperating on the cardiac step-down unit. The client's blood pressure has been borderline low, and intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular vein for approximately 24 hours to increase renal output and maintain the blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that the client is most likely experiencing which complication of IV therapy? 1.Hematoma 2.Air embolism 3.Systemic infection 4.Circulatory overload

circulatory overload

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? 1. Stridor 2.Crackles 3.Scattered rhonchi 4.Diminished breath sounds

crackles

The nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply. 1. Emotional stress 2.Atrial fibrillation 3.Nutritional anemia 4.Peptic ulcer disease 5.Recent upper respiratory infection

emotional distress, atrial fibrillation, nutritional anemia, recent upper respiratory infection

A client experiencing "skipped heartbeats" is diagnosed with benign premature ventricular contractions and is placed on metoprolol tartrate. The client returns to the primary health care provider's (PHCP's) office 1 month later for a checkup. The nurse should implement which type of database when performing an assessment? 1.Follow-up database 2.Emergency database 3.Complete health database 4.Problem-centered database

follow-up database

A client with a history of atrial fibrillation is receiving oral anticoagulant therapy with warfarin. The result of a newly drawn prothrombin time (PT) is 40 seconds. The nurse should anticipate which prescription to be prescribed for this client? 1.Hold the next dose of warfarin. 2.Increase the next dose of warfarin. 3.Administer the next dose of warfarin. 4.Stop the warfarin, and administer heparin.

hold the next dose of warfarin

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription? 1. Adding a dose of heparin sodium 2. Holding the next dose of warfarin 3. Increasing the next dose of warfarin 4. Administering the next dose of warfarin

hold the next dose of warfarin

A client is admitted to the hospital with a diagnosis of myocardial infarction (MI) and is going to have an intravenous (IV) nitroglycerin infusion started. Noting that the client does not have an intra-arterial monitoring line in place, what piece of equipment should the nurse obtain for use at the bedside? 1.Defibrillator 2.Pulse oximeter 3.Noninvasive blood pressure monitor 4.Central venous pressure (CVP) insertion tray

noninvasive blood pressure monitor

The nurse is providing care to a client admitted for coronary artery disease (CAD) and a history of tobacco use. What is the most important element of the nurse's focused assessment of the client's smoking history? 1.Number of pack-years 2.Desire to quit smoking 3.Brand of cigarettes used 4.Number of past attempts to quit smoking

number of pack-years

The nurse is performing an admission assessment on a client with a diagnosis of Raynaud's disease. How should the nurse assess for this disease? 1. Checking for a rash on the digits 2. Observing for softening of the nails or nail beds 3. Palpating for a rapid or irregular peripheral pulse 4. Palpating for diminished or absent peripheral pulses

palpating for diminished or absent peripheral pulses

Spironolactone is prescribed for a client with heart failure. In providing dietary instructions to the client, the nurse identifies the need to avoid foods that are high in which electrolyte? 1.Calcium 2.Potassium 3.Magnesium 4.Phosphorus

potassium

A client is scheduled for a cardiac catheterization using an iodine agent. Which assessment is most critical before the procedure? 1.Intake and output 2.Height and weight 3.Baseline peripheral pulse rates 4.Previous allergy to contrast agents

previous allergy to contrast agents

The nurse notes bilateral 2+ edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. Based on this observation, what should the nurse plan to do first? 1.Review intake and output records for the last 2 days. 2.Prescribe daily weights starting on the following morning. 3.Request a sodium restriction of 1 g/day from the cardiologist. 4.Change the time of diuretic administration from morning to evening.

review the intake and output records for the last 2 days

A client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. Urinary output has decreased and the blood pressure is 92/68 mm Hg. The nurse minimally suspects which stage of shock based on this data? 1. Stage 1 2.Stage 2 3.Stage 3 4.Stage 4

stage 2

A client is taking amiloride 10 mg orally daily for hypertension. What medication instruction should the nurse provide to the client? 1.Take the dose without food. 2.Eat foods with extra sodium. 3.Take the dose in the morning. 4.Withhold the dose if the blood pressure is high.

take dose in the morning

The nurse administered intravenous bumetanide to a client being treated for heart failure. Which outcome indicates that the medication has achieved the expected effect? 1. Cough becomes productive of frothy pink sputum. 2.Urine output increases from 10 mL hourly. 3.The serum potassium level changes from 3.8 to 3.1 mEq/L (3.8 to 3.1 mmol/L). 4.B-type natriuretic peptide (BNP) factor increases from 200 to 262 ng/mL (200 to 262 mcg/L).

urine output increases from 10 mL hourly

The nurse is developing a plan of care for a client recovering from pulmonary edema. The nurse establishes a goal to have the client participate in activities that reduce cardiac workload. The nurse should identify which client action as contributing to this goal? 1. Using a bedside commode 2. Sleeping in the supine position 3. Elevating the legs when in bed 4. Using seasonings to improve the taste of food

using a bedside commode

A client with myocardial infarction is developing cardiogenic shock. What condition should the nurse carefully assess the client for? 1. Pulsus paradoxus 2.Ventricular dysrhythmias 3.Rising diastolic blood pressure 4.Falling central venous pressure

ventricular dysrhythmias

The nurse is watching the cardiac monitor and notices that a client's rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats per minute. The nurse determines that the client is experiencing which dysrhythmia? 1. Sinus tachycardia 2.Ventricular fibrillation 3.Ventricular tachycardia 4.Premature ventricular contractions

ventricular tachycardia

A client in sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/60 mm Hg, reports dizziness. Which intervention should the nurse anticipate will be prescribed? 1. Administer digoxin. 2.Defibrillate the client. 3.Continue to monitor the client. 4.Prepare for transcutaneous pacing.

prepare for transcutaneous pacing

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? 1. Muffled heart sounds 2.Client reports dyspnea 3.A rise in blood pressure 4.Jugular venous distention

rise in blood pressure

A client is admitted to the emergency department with a diagnosis of myocardial infarction (MI). The primary health care provider (PHCP) prescribes the administration of alteplase. The registered nurse (RN) preceptor is orienting a new RN in the use of this medication. Which statement by the new RN indicates that teaching has been effective? 1."Administer the medication within 4 to 6 hours after onset of chest pain." 2."Administer the medication concurrently with the administration of heparin." 3."Administer the medication with the administration solution set protected from light." 4."Administer the medication after the results of all laboratory tests have been received."

"Administer the medication within 4 to 6 hours after onset of chest pain."

The home health care nurse is visiting a client with coronary artery disease with elevated triglyceride levels and a serum cholesterol level of 398 mmol/L). The client is taking cholestyramine, and the nurse teaches the client about the medication. Which statement by the client indicates the need for further teaching? 1. "Constipation and bloating might be a problem." 2. "I'll continue to watch my diet and reduce my fats." 3. "Walking a mile each day will help the whole process." 4. "I'll continue my nicotinic acid from the health food store."

"I'll continue my nicotinic acid from the health food store."

Serum medication level assay for a newly admitted client with a history of heart failure taking digoxin 0.125 mg orally daily. Which value would indicate a therapeutic level? 1.0.1 ng/mL (0.13 nmol/L) 2.0.6 ng/mL (0.76 nmol/L) 3.2.4 ng/mL (2.30 nmol/L) 4.2.8 ng/mL (3.07 nmol/L)

0.6 ng/mL (0.76 nmol/L)

A client with hypertension has a new prescription for a medication called moexipril. The nurse plans to provide written directions that tell the client to take the medication at which time? 1.At bedtime 2.With meals 3.1 hour before meals 4.With a snack in late afternoon

1 hour before meals

A hospitalized client with coronary artery disease complains of substernal chest pain. After assessing the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg sublingually. After 5 minutes the client states, "My chest still hurts." Which actions should the nurse take? Select all that apply. 1.Call a Code Blue. 2.Contact the client's family. 3.Assess the client's pain level. 4.Check the client's blood pressure. 5.Contact the primary health care provider (PHCP). 6.Administer a second nitroglycerin, 0.4 mg sublingually.

3.Assess the client's pain level. 4.Check the client's blood pressure.

The nurse employed in a cardiac unit determines that which client is the least likely to have an implanted cardioverter-defibrillator (ICD) inserted? 1. A client with syncopal episodes related to ventricular tachycardia 2.A client with ventricular dysrhythmias despite medication therapy 3.A client with an episode of cardiac arrest related to myocardial infarction 4.A client with 3 episodes of cardiac arrest unrelated to myocardial infarction

A client with an episode of cardiac arrest related to myocardial infarction

The nurse is caring for a postpartum client with a diagnosis of deep vein thrombosis who is receiving a continuous intravenous infusion of heparin sodium. Review of which laboratory result is the most important by the nurse? 1.Platelet count 2.Prothrombin time (PT) 3.International normalized ratio (INR) 4.Activated partial thromboplastin time (aPTT)

Activated partial thromboplastin time (aPTT)

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1.Weight loss and dry skin 2.Flat neck and hand veins and decreased urinary output 3.An increase in blood pressure and increased respirations 4.Weakness and decreased central venous pressure (CVP)

An increase in blood pressure and increased respirations

A client's electrocardiogram shows that the ventricular rhythm is irregular and there are no discernible P waves. The nurse recognizes that this pattern is associated with which condition? 1.Atrial flutter 2.Atrial fibrillation 3.Third-degree atrioventricular (AV) block 4.First-degree AV block

Atrial Fibrillation

The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse interpret the client's heart rhythm? 1. Atrial fibrillation 2.Sinus tachycardia 3.Ventricular fibrillation 4.Ventricular tachycardia

Atrial Fibrillation

A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition? 1.Heparin overdose 2.Vitamin K deficiency 3.Factor VIII deficiency 4.Disseminated intravascular coagulopathy (DIC)

Disseminated intravascular coagulopathy (DIC)

The nurse is caring for a child with heart failure (HF). The nurse provides instructions to the mother regarding the procedure for administration of the prescribed digoxin. Which statement by the mother indicates a need for further teaching? 1."I will make sure to mix the medication with food." 2."I need to take my child's pulse before administering the medication." 3."If more than 1 dose is missed, I need to call the primary health care provider." 4."If my child vomits after being given the medication, I should not repeat the dose."

I will make sure to mix the medication with food

The nurse assesses the sternotomy incision of a client on the third day after cardiac surgery. The incision shows some slight puffiness along the edges and is non-reddened, with no apparent drainage. The client's temperature is 99º F (37.2º C) orally. The white blood cell count is 7500 mm3 (7.5 × 109/L). How should the nurse interpret these findings? 1.Incision is slightly edematous but shows no active signs of infection. 2.Incision shows early signs of infection, although the temperature is nearly normal. 3.Incision shows no sign of infection, although the white blood cell count is elevated. 4.Incision shows early signs of infection, supported by an elevated white blood cell count.

Incision is slightly edematous but shows no active signs of infection

A client is being treated for moderate hypertension and has been taking diltiazem for several months. The client schedules an appointment with the primary health care provider because of episodes of chest pain, and Prinzmetal's angina is diagnosed. The client asks the nurse which therapeutic effects the medication will provide, and the nurse provides education. Which statement by the client indicates that the teaching has been effective? 1."It increases the force of contraction of heart tissues." 2."It increases oxygen demands within the myocardium." 3."It prevents an influx of calcium ions in the smooth muscle." 4."It leads to an increase in calcium absorption in the smooth muscle."

It prevents an influx of calcium ions in the smooth muscle."

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed? 1. Discontinuing the heparin infusion 2. Increasing the rate of the heparin infusion 3. Decreasing the rate of the heparin infusion 4. Leaving the rate of the heparin infusion as is

Leave the rate of the heparin infusion as is

The nurse is giving discharge instructions to a client who has just undergone vein ligation and stripping. The nurse evaluates that the client understands activity and positioning limitations if the client states that which action is appropriate to do? 1. Walk for as long as possible each day. 2. Cross the legs at the ankle only, not at the knee. 3. Sit in a chair 3 times a day for 3 hours at a time. 4. Lie down with the legs elevated and avoid sitting.

Lie down with the legs elevated and avoid sitting.

A client with a history of type 2 diabetes is admitted to the hospital with chest pain. The client is scheduled for a cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1. Glipizide 2.Metformin 3.Repaglinide 4.Regular insulin

Metformin

The nurse is caring for a client who suddenly starts complaining of palpitations, restlessness, and anxiety. The nurse obtains a stat electrocardiogram (ECG) which shows this rhythm. Refer to figure. The nurse should perform which actions in anticipation of appropriate medication therapy with amiodarone? 1.Obtain an infusion pump and prepare to administer 150 mg over 1 hour followed by a maintenance dose. 2.Obtain an infusion pump and prepare to administer 150 mg over 10 minutes followed by a maintenance dose. 3.Obtain a syringe and administer 150 mg over 1 minute via intravenous push followed by a maintenance dose. 4.Obtain a syringe and administer 360 mg over 2 minutes via intravenous push followed by a maintenance dose.

Obtain an infusion pump and prepare to administer 150 mg over 10 minutes followed by a maintenance dose.

A client receiving total parenteral nutrition (TPN) has a history of heart failure. The primary health care provider (PHCP) has prescribed furosemide 40 mg by mouth daily to prevent fluid overload. Which laboratory value should the nurse monitor to identify the presence of an adverse effect of this medication? 1.Sodium 2.Glucose 3.Potassium 4.Magnesium

Potassium

1 obtain an intravenous (IV) infusion pump 2 monitor urine output during administration 4 monitor the IV site for signs of infiltration or phlebitis 5 ensure that the medication is diluted in the appropriate volume of fluid 6 ensure the bag is labeled so that it reads the volume of potassium in the solution

Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. 1. Obtain an intravenous (IV) infusion pump. 2. Monitor urine output during administration. 3. Prepare the medication for bolus administration. 4. Monitor the IV site for signs of infiltration or phlebitis. 5. Ensure that the medication is diluted in the appropriate volume of fluid. 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

Which readings obtained from a client's pulmonary artery catheter suggest that the client is in left-sided heart failure? 1.Cardiac output of 5 L/min 2.Right atrial pressure of 9 mm Hg 3.Pulmonary capillary wedge pressure (PCWP) of 20 mm Hg 4.Pulmonary artery systolic/diastolic pressures of 24/10 mm Hg

Pulmonary capillary wedge pressure (PCWP) of 20 mm Hg