NCLEX-RN Concepts

A client, with new onset of atrial fibrillation, is receiving warfarin to help prevent thromboembolism. The client will be discharged when the warfarin reaches therapeutic levels, and when the international normalized ratio (INR) ranges from

2 to 3 INR

A client reports left calf pain after undergoing a renal arteriogram through the left femoral artery. What intervention will the nurse perform first?

Assess peripheral pulses in the left leg.

A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown. At 1030, the client has sharp mid-chest pain after having a bowel movement. What should the nurse do first?

Assess the client's vital signs

A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions for avoiding future crises would the nurse provide to the child and family? Select all that apply.

Drink plenty of fluids. Report a sore throat to an adult immediately. Wash hands before meals and after playing.

A client is talking with the nurse about unsightly varicose veins and their discomfort. What information should the nurse provide to the client?

Keep the legs elevated when sitting or lying down.

A woman who gave birth to a healthy baby 6 hours ago is having cramps in her legs. Upon further assessment, the nurse identifies leg pain on dorsiflexion. What action should the nurse take?

Notify the health care provider (HCP).

A client recovering from surgery to repair a fracture of the tibia and fibula of the left leg is reporting increased pain at the site. What sign must the nurse be alert to that would indicate compromised circulation to the leg?

increased edema in the toes of the affected leg

The nurse is assessing a client with an A-V fistula. Which finding should the nurse report to the healthcare provider?

skin discoloration distal to the fistula

The nurse is caring for an older adult man who walks 2 miles every morning. The nurse notes that during his morning walk, he called his child and stated that he thought that he was having a heart attack. Which symptom, identified by the client, is the most common and consistent with that of a heart attack (myocardial infarction)?

substernal pain

A client is receiving furosemide as part of the treatment for heart failure. Which assessment finding indicates that the medication is attaining a therapeutic effect?

trace peripheral edema, previously +2

As an initial step in treating a client with angina, the health care provider (HCP) prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by:

vasodilation of peripheral vasculature.

A primigravid client in a preparation for parenting class asks how much blood is lost during an uncomplicated vaginal birth. What should the nurse should tell the client?

"The maximum blood loss considered within normal limits is 500 ml."

What is the highest nursing priority in the plan of care for a client with peripheral vascular problems?

Promote arterial and venous circulation.

A client with sepsis begins having labored breathing, confusion, and lethargy. What complication should the nurse assess for in this client?

Acute respiratory distress syndrome (ARDS)

The nurse is caring for a client in the medical unit. The nurse receives a health care provider's order for hydrocortisone 100 mg intravenously at a rate of 10 mL/hour for a client in acute adrenal crisis. The nurse understands that this treatment is common in clients with which disease process?

Addison's

When performing the square wave test on the arterial line, the nurse notes an underdamped square wave. What is the priority action by the nurse?

Remove air bubbles from the system.

The nurse is caring for a client in skeletal traction. Which should the nurse assess to monitor the client's circulatory status? Select all that apply.

capillary refill calf tenderness peripheral pulses temperature of the toes

The nurse is caring for a child with hemophilia who is actively bleeding from the leg. What should the nurse apply to the site?

direct pressure to the injured area continuously for 10 minutes

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise the client to:

divide daily food intake into five or six meals.

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan?

elevating the stump for the first 24 hours