NCLEX Challenge 5

A nurse is reviewing discharge instructions with a client who has Raynaud's disease. Which of the following client statements indicates an understanding of the teaching?

"I am going to take a stress management class."

A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?

"Heparin does not dissolve clots. It stops new clots from forming."

A nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching?

"Diuretics are the first type of medication to control hypertension."

A nurse is admitting a client who has a history of heart failure. Select the 5 findings that require immediate follow-up.

Vital signs, Respiratory assessment, Renal function, BNP, and ECG

A nurse is admitting a client who has a history of heart failure. Check the 5 findings that require immediate follow up.

Vital signs, Respiratory assessment, Renal function, BNP, and ECG

A nurse is caring for a client who is on warfarin therapy for atrial fibrillation. The client's INR is 5.2. Which of the following medications should the nurse prepare to administer?

Vitamin K

A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet?

"I eat two eggs for breakfast each morning."

A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication?

"I feel nauseated and have no appetite."

A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?

"I plan to slow down if I am tired the day after exercising."

A nurse is providing teaching to a client who has a new prescription for lisinopril. Which of the following statements by the nurse indicates an understanding of the teaching?

"I should report a cough to my provider."

A nurse is providing teaching about the Mediterranean diet to a client newly who has a new diagnosis of hypertension. Which of the following statements by the client indicates a need for further teaching?

"I will limit my intake of red meat to twice weekly."

A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include?

"Use elastic stockings."

A nurse is assessing a client who is taking lisinopril to treat hypertension. Which of the following findings is a priority to report?

Swelling of the tongue

A nurse is assessing a client who has mitral valve stenosis. Which of the following findings should the nurse expect?

A heart murmur

A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose?

4 mL

A nurse is caring for a client who has a new diagnoses of essential hypertension. The nurse should monitor the client for which of the following findings that is consistent with this diagnosis?

Vertigo

A nurse is caring for an adolescent following a cardiac catheterization. Which of the following assessment findings should the nurse report to the provider? Select the 4 findings that the nurse should report to the provider.

Pressure dressing is correct. Blood pressure is correct. Right lower extremity color and warmth is correct Apical pulse is correct

A nurse is preparing to care for an 84-year-old male client who is being admitted to a medical unit from a provider's office. The nurse reviews the client's medical records to prepare the client's plan of care.

Actions to take: elevate the head of the bed and encourage an intake of low sodium diet Condition: Heart failure parameters to monitor: urinary output and blood pressure

A nurse is caring for a 45-year old client in the emergency department: complete the diagram

Actions to take: obtain an echocardiogram and obtain a prescription for an NSAID Condition: pericarditis parameters to monitor: pain level, and pulsus paradoxus

Complete the diagram: the client present to the ED stating that they had a sudden on set of dyspnea while taking a shower

Actions to take: obtain venous access and place the client in high-Fowlers position Condition: pulmonary embolism parameters to monitor: aPTT values and cardiac dysrhythmias

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?

Adjust the thermostat so that the environment is warm.

A nurse caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions?

Asthma

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects?

Protamine Sulfate

A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium?

Bananas

A nurse is reviewing the assessment finding for the client on day 4. Which of the following findings requires further action?

Breath sounds are correct. Weight is correct. Oxygen saturation is correct. Blood pressure is correct

A nurse in a clinic is caring for a client who has recently begun taking warfarin. The nurse is reviewing potential drug and food interaction risks and should instruct the client to avoid which of the following?

Cabbage

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?

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

A nurse is providing teaching to a client who has hypertension and a new prescription for captopril. Which of the following instructions should the nurse provide?

Do not use salt substitutes while taking this medication.

A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for?

Dyspnea

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?

Edema

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Elevated central venous pressure

A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

Ensure the client has been taking their prescribed diuretic

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?

Exercise at least three times per week.

A nurse is providing discharge instructions to a client who developed DVT postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include?

Flexing her knees and feet frequently

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following beverages should the nurse tell the client to avoid while taking this medication?

Grapefruit juice

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Hacking cough

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions?

Heart Failure

A nurse is reviewing the clients medical record. Which of the following findings places the client at risk for heart disease?

History of hypertension, history of smoking, cholesterol level,

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.)

Hypercholesterolemia is correct. Hypertension is correct. Obesity is correct Smoking is correct.

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?

Impaired tissue perfusion

A nurse is caring for a client who has peripheral arterial disease. Which of the following symptoms should the nurse expect to find in the early stage of the disease?

Intermittent claudication

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?

LDL 172 mg/dL

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

Metformin

A nurse is assessing a client who has hypercholesterolemia and is receiving simvastatin. Which of the following findings should the nurse recognize as a potential adverse effect?

Muscle weakness

The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action?

Notify the provider of the clients allergy.

A nurse is caring for an adolescent in an emergency department. The nurse reports the 2400 assessment findings to the provider. Which of the following should the nurse anticipate the provider will prescribe? For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Obtain blood cultures x 3 is anticipated Obtain an echocardiogram is anticipated Restrict dental hygiene is contraindicated. Administer antibiotic therapy is anticipated Perform strenuous exercise regimen twice daily is contraindicated

A nurse is giving a presentation about preventing DVT. Which of the following should the nurse include as a risk factor for this disorder (select all that apply.)

Oral contraceptive use, and immobility

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?

PT

A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for the client?

Peripherally inserted central catheter

A nurse is reviewing the laboratory data on a client who has a new prescription for heparin for treatment of a pulmonary embolism. Which of the following data should the nurse report to the provider?

Platelets 74,000/mm3

A nurse is planning to administer digoxin to a client who has heart failure. Which of the following laboratory results is the priority for the nurse to review prior to administering the medication?

Potassium

A nurse is reviewing the serum laboratory findings for a client who has hypertension and is prescribed hydrochlorothiazide. Which of the following findings should the nurse report to the provider?

Potassium 2.3 mEq/L

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding?

Potassium 2.9 mEq/L

A nurse is teaching a newly licensed nurse about heart sounds. Which of the following sounds is heard when the aortic and pulmonic valves close?

S2

For each assessment finding, click to specify if the assessment finding is consistent with an arterial ulcer, a venous ulcer, or a diabetic ulcer. Each finding may support more than one disease process.

Skin cool to touch of the affected extremity is consistent with arterial and diabetic ulcers. When there is arterial narrowing there is decreased perfusion, resulting in diminished blood flow. Both arterial and diabetic pathologies cause vessel narrowing resulting in hypoxia to surrounding tissues. +1 posterior tibial pulse is consistent with arterial ulcers. Vasoconstriction of the oxygen rich arterial blood flow makes peripheral pulses increasingly difficult to find. Hair loss is consistent with arterial ulcers. The decreased perfusion causes cellular death to the hair follicles. Pale wound bed is consistent with arterial and diabetic ulcers. Decreased perfusion to the wound bed results in decreased pigmentation or pale discoloration. Both types of ulcers have this as an underlying pathology. Pain at ulcer site is consistent with arterial ulcers and venous ulcers. A comorbidity associated with diabetes is peripheral neuropathy which causes sensory deterioration to the peripheral nervous system, which innervates the foot. Defined edge is consistent with arterial and diabetic ulcers. The decreased perfusion to the wound margins causes skin breakdown from the center outward. History of hypertension is consistent with arterial, venous, and diabetic ulcers. Hypertension causes venous constriction which results in decreased tissue perfusion. The resulting hypoxia and lack of sufficient nutrients to sustain cellular function causes cellular injury.

A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia?

Spironolactone

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include?

The client will walk for 30 min 5 days a week.

A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.)

The date of the incident is correct The name of the provider who prescribed the medication is incorrect. The potential adverse effects of the medication is incorrect. The time the client was to receive the medication is correct. The client's vital signs is correct.

A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

The most distal pulse refers to the pulse that is at the farthest point on the affected extremity. The dorsalis pedis pulse on the anterior foot is the most distal pulse below the femoral artery. Because the client had left-sided angiography, the correct answer will be the left pedal pulse.

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

The nurse should auscultate the client's apical pulse on the left side of the chest, not the right.

A nurse is caring for a 50-year-old client in the emergency department. The nurse is reviewing the client's data to initiate a plan of care. 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.

The nurse should obtain blood cultures and request an antibiotic because the client is most likely experiencing infective endocarditis due to their previous abscessed tooth. The client is experiencing fever, chills, night sweats, fatigue, Janeway lesions, and heart murmur. These are manifestations of infective endocarditis. The nurse should monitor the client's temperature and neurological status. An elevated temperature can indicate that a change in the antibiotic or surgical intervention is needed. In addition, the nurses should monitor the client's neurological status. A complication of endocarditis is an arterial embolization in which clots break off and travel through the body. This can affect the major organs, such as the brain and heart.

A nurse is assessing a client who is postoperative following a vaginal hysterectomy. Which of the following findings is a manifestation of DVT

Unilateral leg edema

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?

Use an electric razor while on this medication.

The nurse is reviewing the client's assessment findings. Which of the following findings indicates that the client's condition has improved or has not changed since their two-week follow-up appointment? Click to specify the client findings that have improved or have not changed since their last visit.

When generating solutions for the client who has congestive heart failure, the nurse should anticipate revising the client's plan of care to assist the client dyspnea. Although the client reports they feel better than two weeks ago, they continue to report shortness of breath and the nurse observes the client with dyspnea and their oxygen saturation remains 95%; therefore, these findings have not changed. The client has lost 2.7 kg (6 lb) which is significant, but the client is still considered obese. The nurse should report these findings to the provider and collaborate with the provider and dietician to help the client improve their diet and lose weight. The nurse should recognize that the client's blood pressure, jugular venous distention, clear lung sounds, decreased potassium level, and weight loss have all improved and may be attributed to the prescription of carvedilol, isosorbide dinitrate, and furosemide and with the education of limiting fluid intake and restricting sodium. The client should weigh themselves each day at the same time and on the same scale to monitor for fluid gain.

The nurse is preparing the client for the cardiac catheterization. Which of the following actions should the nurse take?

Witness the client's signature on the informed consent form is correct Obtain the client's vital signs is correct Confirm the client's allergies is correct.

The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications?

carvedilol

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

check the clients vitals signs

A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication?

decreased blood pressure

A nurse is planning care for a client who has deep-vein thrombosis (DVT) and is receiving anticoagulation therapy. Which of the following interventions should the nurse include in the plan of care?

encourage the client to walk

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

massaging her legs