NSG 420 medsurg 2 test one
The nurse should give which discharge instructions about thermal injury to a client with peripheral vascular disease? Select all that apply.
"Avoid sunburn during the summer." "Wear extra socks in the winter." "Choose loose, soft, cotton socks."
Which client statement should the nurse evaluate as indicating the client's correct understanding of the causes of coronary artery disease (CAD)?
"The leading cause of CAD is atherosclerosis."
A home care nurse is visiting a left-handed client who has an implantable cardioverter-defibrillator (ICD) implanted in their left chest. The client tells the nurse how excited they are because the client's planning to go rifle hunting with a grandson. How should the nurse respond?
"You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site."
When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial BP of 147/82 and an ankle pressure of 112/74. The nurse calculates the patients ankle-brachial index (ABI) as ________ (round up to the nearest hundredth
0.76 The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP.
After receiving report, which patient admitted to the emergency department should the nurse assess first?
50-year-old who is complaining of sudden sharp and worst ever upper back pain
After receiving change-of-shift report about the following four patients, which patient should the nurse assess first ?
59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI
A client is receiving cilostazol for intermittent claudication. What should the nurse ask the client to determine the effectiveness of the drug?
"Do you have less pain in the legs?"
A client had a below-the-knee amputation secondary to arterial occlusive disease. The nurse is instructing the client about residual limb care. Which statement by the client indicates that the client understands how to implement the plan of care?
"I should rewrap the stump as often as needed."
A client who requested a do-not-resuscitate (DNR) order upon admission to the hospital now states a desire for the medical team to do everything possible to help the client get better. The client is concerned about the DNR order. Which response by the nurse is best?
"It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away."
When the nurse is screening patients for possible peripheral arterial disease, indicate where the posterior tibial artery will be palpated.
3
After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first ?
A patient who is cool and clammy, with new-onset confusion and restlessness
The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first ?
A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due
A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. Based on these findings, which nursing diagnosis would be most appropriate?
Activity intolerance related to arthralgia
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)
It teaching a patient about coronary disease, the nurse explains that changes that occur in this disorder include
Abnormal levels of cholesterol especially LDL, accumulation of lipid and fibrous tissue within the coronary arteries Development of angina due to decreased blood supply to heart muscle
The nurse is admitting a client who takes digoxin daily, reported seeing green halos around the lights, and has not wanted to eat breakfast. The laboratory report shows that serum sodium = 135 mEq/L, potassium = 3.2 mEq/L, magnesium = 2.5 mg/dL, and calcium = 10.2 mg/dL. Which nursing action is appropriate?
Administer a potassium supplement
Which topic should the nurse include in patient teaching for a patient with a venous stasis ulcer on the left lower leg?
Application of elastic compression stockings
The nurse is caring for a client with peripheral arterial occlusive disease (PAD). What nursing intervention is most appropriate to reduce platelet aggregation and promote circulation?
Administer clopidogrel.
A 20-year-old has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54, and the student denies any health problems. What action by the nurse is most appropriate?
Allow the student to participate on the soccer team
A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock
Apical heart rate 45 beats/min.
Which actions could the nurse delegate to unlicensed assistive personnel (UAP) who are providing care for a patient who is at risk for venous thromboembolism?
Apply sequential compression device whenever the patient is in bed
A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which actions should the nurse take next ?
Apply the transcutaneous pacemaker (TCP) pad
When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is a priority for the nurse to include?
Arrange for placement of a long-term IV catheter
When titrating IV nitroglycerin (Tridil) for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication?
Ask about chest pain
A 19-year-old student comes to the student health center at the end of the semester complaining that, My heart is skipping beats. An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take next ?
Ask the patient about current stress level and caffeine use
Which action by the nurse will determine if the therapies ordered for a patient with chronic constrictive pericarditis are effective?
Assess for the presence of jugular venous distention (JVD).
A client is admitted to the telemetry unit following a ST segment-elevation myocardial infarction (STEMI). The electrocardiogram (EKG) tracing shows a run of sustained ventricular tachycardia. What is the first action that the nurse should take?
Assess the client's airway, breathing, pulses, and level of conciseness.
When admitting a patient with a nonST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first ?
Attach the cardiac monitor.
A patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next ?
Auscultate for a pericardial friction rub.
A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse do first ?
Auscultate the breath sounds
Two days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with a deep breath. Which action will the nurse take first ?
Auscultate the heart sounds
A patient has a severe blockage in his right coronary artery. Which heart structure are most likely to be affected by this blockage (Select all that apply)
Av node , left Ventricle , Right ventricle
A 46-year-old is diagnosed with thromboangiitis obliterans (Buergers disease). When the nurse is developing a discharge teaching plan for the patient, which outcome has the highest priority for this patient?
Cessation of all tobacco use
The unlicensed assistive personnel (UAP) reports to the registered nurse that a client admitted with pneumonia is very diaphoretic. The nurse reviews the following vital signs in the medical record obtained by the UAP. What should the nurse do? Select all that apply.
Check the urine output. Ask the client to drink more fluids. Notify the health care provider (HCP). Administer acetaminophen as prescribed.
When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To document more information about the murmur, which action will the nurse take next ?
Determine the timing of the murmur.
A patient who has chest pain is admitted to the emergency department (ED) and all of the following are ordered. Which one should the nurse arrange to be completed first ?
Electrocardiogram (ECG)
Heparin is ordered for a patient with a nonST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin?
Heparin prevents the development of new clots in the coronary arteries.
Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?
Instruct the patient to call for assistance before getting out of bed.
Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse?
New onset shortness of breath
A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which of the following actions should the nurse take next ?
Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol
Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure?
B-type natriuretic peptide
To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory result will the nurse plan to review?
B-type natriuretic peptide (BNP)
When a person's blood pressure rise, the homeostatic mechanism to compensate for elevation involves
Baroreceptors that inhibit the sympathetic nervous system causing vasodilation
Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 33%?
Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitor
The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider?
Bilateral crackles are auscultated in the mid-lower lobes.
An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider
Blood pressure (BP) of 88/42 mm Hg
While listening at the mitral area, the nurse notes abnormal heart sounds at the patients fifth intercostal space, midclavicular line. After listening to the audio clip, describe how the nurse will document the assessment finding.
Systolic murmur noted at mitral area
When developing a community health program to decrease the incidence of rheumatic fever, which action would be most important for the community health nurse to include
Teach community members to seek treatment for streptococcal pharyngitis
When reviewing the 12-lead electrocardiograph (ECG) for a healthy 79-year-old patient who is having an annual physical examination, what will be of most concern to the nurse?
The heart rate (HR) is 42 beats/minute.
Which intervention by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more education about care of patients with ICDs?
The nurse assists the patient to do active range of motion exercises for all extremities.
During the assessment of a 25-year-old patient with infective endocarditis (IE), the nurse would expect to find
a new regurgitant murmur
IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops
a systolic BP <90 mm Hg.
Which nursing responsibilities are priorities when caring for a patient returning from a cardiac catheterization (select all that apply)
a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses
A client is critically ill with sepsis. The nurse expects what assessment finding related to compensatory mechanisms attempting to maintain normal pH?
increased respiratory rate
When assessing a client for early sepsis, which assessment finding would most concern the nurse?
mean arterial pressure less than 70 mmHg
A patient with diabetes mellitus and chronic stable angina has a new order for captopril (Capoten). The nurse should teach the patient that the primary purpose of captopril is to
prevent changes in heart muscle.
When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for
shortness of breath on exertion.
Which nursing assessment finding in an elderly client with sepsis requires immediate intervention?
urine output of 90 mL over the past 6 hours
When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, I will
use a heating pad on my feet at night to increase the circulation and warmth in my feet
The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patients cardiac rhythm a
ventricular tachycardia
The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include
when cardiac rehabilitation will begin.
A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/minute. The label on the infusion bag states: dobutamine 250 mg in 250 mL normal saline. When setting the infusion pump, the nurse will set the infusion rate at how many mL per hour?
27 In order to administer the dobutamine at the prescribed rate of 5 mcg/kg/minute from a concentration of 250 mg in 250 mL, the nurse will need to infuse 27 mL/hour.
A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of _____ beats/minute
40 to 60
When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular heart rhythm, the nurse counts 30 small blocks from one R wave to the next. The nurse calculates the patients heart rate as ___
50 There are 1500 small blocks in a minute, and the nurse will divide 1500 by 3
A client with sepsis and hypotension is being treated with dopamine. The nurse asks a colleague to double-check the dosage that the client is receiving. There are 400 mg of dopamine in 250 ml, the infusion pump is running at 23 mL/hour, and the client weighs 79.5 kg. How many micrograms per kilogram per minute is the client receiving? Record your answer using two decimal places.
7.71
When preparing to defibrillate a patient. In which order will the nurse perform the following steps? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the paddles on the patients chest. e. Check the location of other staff and call out all clea
A, C, D, E, B
A patients cardiac monitor shows sinus rhythm, rate 64. The P-R interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next ?
Call the health care provider before giving the next dose of metoprolol (Lopressor).
A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had an AMI?
Cardiac-specific troponin
A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving
Carvedilol (Coreg) 3.125 mg
A patient is being evaluated for post-thrombotic syndrome. Which assessment will the nurse perform?
Check for presence of lipodermatosclerosis
To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?
Check stools for occult blood
Which action could the nurse delegate to unlicensed assistive personnel (UAP) trained as electrocardiogram (ECG) technicians working on the cardiac unit?
Check the heart monitor for changes in rhythm while a patient who had a valve replacement ambulates.
When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse?
Chest pain level 7 on a 0 to 10 point scale
When teaching a patient about rest pain with PAD what should the nurse explain has caused the pain?
Decrease blood flow to the nerves of the feet
To improve the physical activity level for a mildly obese 71-year-old patient, which action should the nurse plan to take?
Determine what kind of physical activities the patient usually enjoys.
While doing the admission assessment for a thin 76-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take?
Document the finding in the patient chart
The nurse is caring for a client 1 day after having a colectomy. The client is lethargic and difficult to arouse; the temperature is 101.5°F (38.6°C), blood pressure is 92/36 mm Hg (MAP 55 mm Hg), and heart rate is 114 bpm with SpO2 of 88% on oxygen at 2 L/min per nasal cannula (previously 94%). A saline lock has been established and is patent. Which prescription should the nurse implement first?
Draw blood cultures.
The health care provider orders the following interventions for a 67-kg patient who has septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90% on room air. In which order will the nurse implement the actions? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Obtain blood and urine cultures. b. Give vancomycin (Vancocin) 1 g IV. c. Start norepinephrine (Levophed) 0.5 mcg/min. d. Infuse normal saline 2000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation >95%
E, D, C, A, B
A 46-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions should the nurse provide to the patient before discharge
Elastic compression stockings should be applied before getting out of bed
The part of the vascular system responsible for hemostasis is the
Endothelial layer of arteries
A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The nurse will anticipate an order for which medication?
Furosemide (Lasix) IV
A patient who has recently started taking pravastatin (Pravachol) and niacin (Nicobid) reports the following symptoms to the nurse. Which is most important to communicate to the health care provider?
Generalized muscle aches and pains
A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question
Give PRN furosemide (Lasix) 40 mg IV.
Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg?
Give a sedative before cardioversion is implemented
The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first?
Give epinephrine (Adrenalin
A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104 F, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?
Give normal saline IV at 500 mL/hr
A patient who is on the progressive care unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first ?
Give supplemental O2 at 2 to 3 L/min via nasal cannula.
A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is most appropriate when giving the medication?
Give the patients other medications 2 hours after the colesevelam
When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?
Give the scheduled aspirin and lipid-lowering medication.
The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history will be most pertinent to ask?
Have you had a recent sore throat?
The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate?
Have you had dental work done recently
the nurse is caring for a patient with acute decompensated heart failure who is receiving IV dobutamine. Why is would this drug be prescribed?
Heart contractility will improve Dobutamine is a selective B-agonist
Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patients response to the activity, which assessment data would indicate that the exercise level should be decreased?
Heart rate increases from 66 to 92 beats/minute.
Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes?
Help the patient modify favorite high-fat recipes by using monosaturated oils when possible.
which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
Help the patient to use a pillow to splint while coughing
A 67-year-old patient is admitted to the hospital with a diagnosis of venous insufficiency. Which patient statement is most supportive of the diagnosis?
I cant get my shoes on at the end of the day
The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says which of the following?
I should reduce the amount of green, leafy vegetables that I eat.
The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of knowledge regarding long-term management of rheumatic fever when a 30-year-old recovering from rheumatic fever without carditis says which of the following?
I will be immune to further episodes of rheumatic fever after this infection.
After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective?
I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart.
When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following?
I will have small incisions in my leg where they will remove the vein.
Which statement made by a patient with coronary artery disease after the nurse has completed teaching about therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed?
I will miss being able to eat peanut butter sandwiches
In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective?
I will stop what I am doing and sit down before I put the nitroglycerin under my tongue.
After providing a patient with discharge instructions on the management of a new permanent pacemaker, the nurse knows that teaching has been effective when the patient states
I wont lift the arm on the pacemaker side up very high until I see the doctor
A patient has ST segment changes that support an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient?
II
After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective
Increase in the patients heart rate
An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate doing next?
Increase the rate for the sodium nitroprusside (Nipride) infusion
Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, I am too nervous to take care of myself. Based on this information, which nursing diagnosis is appropriate?
Ineffective coping related to anxiety
Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias
Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia
A client is to start chemotherapy to treat lung cancer. A venous access device has been placed to permit administration of chemotherapeutic medications. Three days later at the scheduled appointment to receive chemotherapy, the nurse assesses that the client is dyspneic and the skin is warm and pale. The vital signs are blood pressure 80/30 mm Hg, pulse 132 bpm, respirations 28 breaths/min, temperature 103°F (39.4°C), and oxygen saturation 84%. The central line insertion site is inflamed. After the nurse calls the rapid response team, what should the nurse do next?
Insert a peripheral intravenous fluid line and infuse normal saline.
The nurse is assessing a patient with myocarditis before administering the scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider?
Irregular pulse
After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective?
It is important not to suddenly stop taking the carvedilol.
When developing a teaching plan for a 76-year-old patient newly diagnosed with peripheral artery disease (PAD), which instructions should the nurse include?
It is very important that you stop smoking cigarettes
Which assessment finding obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider?
Jugular venous distention (JVD) to jaw leve
A 21-year-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient?
Lifelong anticoagulant therapy will be needed after mechanical valve replacement
When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider?
Loose, bloody stools
A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is most appropriate?
Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots.
When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education?
Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock
Which action should the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)?
Monitor blood pressure frequently
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?
Monitor breath sounds frequently
Which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm?
Monitor fluid intake and urine output
A patient with chronic heart failure and atrial fibrillation is treated with low dose digitalis and loop diuretic what does the nurse need to do to prevent complication with this drug combination? Select all that apply
Monitor serum potassium levels teach patient how to take pulse rate
A patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?
Monitor the patients blood pressure and heart rate every hour
While working in the outpatient clinic, the nurse notes that a patient has a history of intermittent claudication. Which statement by the patient would support this information?
My legs cramp whenever I walk more than a block
During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider?
New onset of confusion
When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse?
Newly inverted T waves on the electrocardiogram
Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider?
No change in the patients chest pain
A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy. Which information will the nurse plan to teach the patient about managing this disorder?
Notify the doctor about any symptoms of heart failure such as shortness of breath
A nurse is caring for a client receiving radiation for Hodgkin's lymphoma who begins to exhibit confusion. Upon further assessment, the nurse notes that the client has warm, flushed, dry skin; a heart rate of 110 beats per minute; and a temperature of 101.8° F (38.8° C). Which is the nurse's next best action?
Notify the healthcare provider.
The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first?
Notify the surgeon and anesthesiologist
Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as a telemetry technician on the cardiac care unit?
Observe cardiac rhythms for multiple patients who have telemetry monitoring.
While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Which action should the nurse take next ?
Observe for JVD with the patient upright at 45 degree
An 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take first?
Obtain the blood pressure
A patient who is complaining of a racing heart and feeling anxious comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next ?
Obtain the patients vital signs including oxygen saturation.
The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first?
Obtain vital signs.
The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism. Which action by the nurse to elevate the patients feet is best?
One pillow is placed under the thighs and two pillows are placed under the lower leg
A patient recovering from heart surgery develops pericarditis and complains of level 6 (0 to 10 scale) chest pain with deep breathing. Which ordered PRN medication will be the most appropriate for the nurse to give?
Oral ibuprofen (Motrin) 600 mg
A patient is admitted to the ICU with a diagnosis NSTEMI which drugs would nurse expect patient to receive
Oral statin therapy Anti-platelet therapy Intravenous nitroglycerin
Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement?
Order blood cultures drawn from two sites
Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective?
Oxygen saturation
Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse?
Oxygen saturation of 88%
To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the patients
P wave.
Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider?
Pallor and weakness of the right hand
After receiving the following information about four patients during change-of-shift report, which patient should the nurse assess first?
Patient who has just returned to the unit after balloon valvuloplasty
After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first ?
Patient who is taking digoxin and has a potassium level of 3.1 mEq/L
The nurse who works in the vascular clinic has several patients with venous insufficiency scheduled today. Which patient should the nurse assign to an experienced licensed practical/vocational nurse (LPN/LVN)?
Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg
After receiving report on the following patients, which patient should the nurse assess first ?
Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg
The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which patient laboratory result is most important to communicate as soon as possible to the health care provider?
Patient with increase in troponin T and troponin I level
Which patient at the cardiovascular clinic requires the most immediate action by the nurse?
Patient with stable angina whose chest pain has recently increased in frequency
After change-of-shift report in the progressive care unit, who should the nurse care for first?
Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics
A patients cardiac monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first ?
Perform immediate defibrillation.
A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first ?
Place the patient on NPO status
The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP?
Placing electrodes in the correct position for a patient who is to receive ECG monitoring
A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first ?
Provide oxygen at 100% per non-rebreather mask
When analyzing the rhythm of a patients electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n
QRS interval of 0.14 second
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective?
Reduced dyspnea with the head of bed at 30 degree
A patient had a nonST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?
Reinforcement of teaching about the purpose of prescribed medication
A patient with a tricuspid valve disorder will have impaired blood flow between the
Right atrium and right ventricle
A P wave on ECG represents an impulse arising at the
SA node and depolarizing the atria
Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain?
ST-segment elevation
Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider?
Serum potassium 2.9 mEq/L
A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider?
Serum potassium level 3.0 mEq/L after 1 week of therapy
A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best ?
Sexual activity uses about as much energy as climbing two flights of stairs.
A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of medications to the nurse. Which medication has the most immediate implications for the patients care?
Sildenafil (Viagra)
The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?
Skin cool and clammy
Which subjective data related to the cardiovascular system should be obtained from the patient (select all that apply)? a. Annual income b. Smoking history c. Religious preference d. Number of pillows used to sleep e. Blood for basic laboratory studies
Smoking history, Religious preference, number of pillows used to sleep
A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action that the nurse should take
Start cardiopulmonary resuscitation (CPR)
A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which group of medications will the nurse plan to include when providing patient teaching about PAD management?
Statins
A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123. Based on this information,which nursing diagnosis is a priority for the patient?
Stress overload related to acute change in health
Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider?
Sudden onset right flank pain
The nurse hears a murmur between the S1 and S2 heart sounds at the patients left fifth intercostal space and midclavicular line. How will the nurse record this information?
Systolic murmur heard at mitral area
Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan?
Teach the patient about the procedure.
A patient who is 2 days post-femoral-popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/LVN) caring for the patient requires the registered nurse (RN) to intervene?
The LPN/LVN has the patient sit in a chair for 90 minutes
A 53-year-old patient with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most appropriate?
The choice of a patient for a heart transplant depends on many different factor
Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE) indicates that more education about the drug is needed?
The nurse ejects the air bubble in the syringe before giving the drug.
Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)?
The pain has lasted longer than 30 minutes.
The nurse is caring for a 78-year-old patient with aortic stenosis. Which assessment data obtained by the nurse would be most important to report to the health care provider?
The patient complains of chest pressure when ambulating
After teaching a patient with newly diagnosed Raynauds phenomenon about how to manage the condition, which action by the patient demonstrates that the teaching has been effective?
The patient exercises indoors during the winter months
Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be most important to report to the health care provider before the MRI?
The patient has a permanent ventricular pacemaker.
The nurse is caring for a 64-year-old patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately ?
The patient has bilateral crackles.
When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is most important for the nurse to communicate to the health care provider?
The patient is allergic to shellfish
Which finding about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the health care provider?
The patient is complaining of chest pain
Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis?
The patient states that the pain goes away with one sublingual nitroglycerin table
The nurse is obtaining a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC). Which information obtained by the nurse is most important?
The patients 29-year-old brother died from a sudden cardiac arrest
The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action?
The patients IV infusion site is cool and pale
Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine?
The patients central venous pressure is 3 mm Hg
Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)?
The patients serum creatinine level is elevated.
Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter?
The procedure will use electrical energy to destroy areas of the conduction system
When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge teaching on which patient risk factor?
Uncontrolled hypertension
which statements accurately describe heart failure with preserved ejection fraction HFpEF? (select all that apply)
Uncontrolled hypertension is primary cause Left ventricular ejection fraction maybe be within normal limits The pathophysiology involves ventricular relaxation and filling Therapies focus on symptom to control and treatment of underlying conditions
Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective?
Urine output is 60 mL over the last hour
The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)?
Urine output less than 30 mL/hr
The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use?
Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10
The nurse notes that a patients cardiac monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm?
Ventricular bigeminy
A nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock. Which finding indicates that the medication is effective?
Warm, pink, and dry skin
A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, I just had a little chest pain. As soon as I get out of here, Im going for my vacation as planned. Which reply would be most appropriate for the nurse to make?
What do you think caused your chest pain?
A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy?
What time did your chest pain begin?
The nurse is teaching a group of women about risk for varicose veins. Which client is at risk for varicose veins?
a client who has had thrombophlebitis
Which client is most at risk for developing disseminated intravascular coagulation (DIC)?
a client with an amniotic fluid embolism
During the administration of the thrombolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences
a decrease in level of consciousness.
A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that
a flushed feeling may be noted when the contrast dye is injected
Based on the Joint Commission Core Measures for patients with heart failure, which topics should the nurse include in the discharge teaching plan for a patient who has been hospitalized with chronic heart failure (select all that apply)?
a. How to take and record daily weight c. Date and time of follow-up appointment d. Symptoms indicating worsening heart failure e. Actions and side effects of prescribed medication
A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)?
a. Prepare to administer atropine IV. b. Obtain baseline body temperature. d. Provide high-flow oxygen (100%) by non-rebreather mask. e. Prepare for emergent intubation and mechanical ventilation
Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)?
a. Use aseptic technique when caring for invasive lines or devices. b. Ambulate postoperative patients as soon as possible after surgery. c. Remove indwelling urinary catheters as soon as possible after surgery. e. Administer prescribed antibiotics within 1 hour for patients with possible seps
During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of feeling too tired to get out of bed. Based on these data, the best nursing diagnosis for the patient is
activity intolerance related to fatigue
When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that
additional diagnostic testing will be required.
A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to
administer oxygen.
The nurse is caring for a 70-year-old male client after a colectomy. The client has received chemotherapy prior to surgery and has hypertension and diabetes mellitus. Which factors put this client at risk for sepsis? Select all that apply.
age abdominal surgery diabetes mellitus
A charge nurse is completing day-shift client care assignments on the genitourinary floor. A new graduate is present for their first day on the unit. An agency nurse and an experienced nurse are also present on the unit. The charge nurse should assign the new graduate to the care of
an elderly client with bladder cancer awaiting surgery, an elderly client who had a prostatectomy and bladder irrigation 2 days ago, and an elderly client with renal insufficiency
Following an acute myocardial infarction, a previously healthy 63-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about
angiotensin-converting enzyme (ACE) inhibitors
A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about
anticoagulant therapy
A patient at the clinic says, I have always taken a walk after dinner, but lately my leg cramps and hurts after just a few minutes of starting. The pain goes away after I stop walking, though. The nurse should
assess for the presence of the dorsalis pedis and posterior tibial pulse
A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurses priority action will be to
assess the patient for clinical manifestations of acute heart failure
During a physical examination of a 74-year-old patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The most appropriate action for the nurse to take next will be to
assess the patient for symptoms of left ventricular hypertrophy.
To assess the patient with pericarditis for evidence of a pericardial friction rub, the nurse should
auscultate by placing the diaphragm of the stethoscope on the lower left sternal border
A 23-year-old patient tells the health care provider about experiencing cold, numb fingers when running during the winter and Raynauds phenomenon is suspected. The nurse will anticipate teaching the patient about tests for
autoimmune disorders
The health care provider prescribes an infusion of heparin (Hep-Lock) and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to
avoid giving any IM medications to prevent localized bleeding
While caring for a 23-year-old patient with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient states that it will be necessary to
avoid use of over-the-counter (OTC) medications that contain stimulant drug
To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the
bell of the stethoscope with the patient in the left lateral position
A client is returning from the operating room after inguinal hernia repair. The nurse notes that the client has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure?
bibasilar crackles
A client has been diagnosed with septic shock. The nurse would anticipate implementing which order?
blood chemistry of serum lactate
The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider?
blood pressure 137/88 mm Hg
The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if the
blood pressure is 90/54 mm Hg.
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?
blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute
Several hours after an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 40 mL. The nurse notifies the health care provider and anticipates an order for a(n)
blood urea nitrogen (BUN) level
When auscultating over the patients abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a
bruit.
For which client(s) does the nurse anticipate the healthcare provider's orders for pneumatic compression devices? Select all that apply.
client in the intensive care unit on a ventilator with sepsis client with four vessel coronary artery bypass graft with bilateral chest tubes client who had extended low anterior resection for colonic mass
Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetals (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will
decrease spasm of the coronary arteries.
A client with heart failure is taking furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. What other sign should the nurse assess next?
digoxin toxicity.
A client is prescribed lisinopril for the treatment of hypertension. The client asks a nurse about possible adverse effects. Which common adverse effects of angiotensin-converting enzyme (ACE) inhibitors would the nurse include in the teaching? Select all that apply
dizziness hypotension headache
A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines that the P-R interval is 0.24 seconds. The most appropriate intervention by the nurse would be to
document the finding and continue to monitor the patient
When assessing a pt you note a pulse deficit of 23 beats. This finding may be caused by
dysrhythmias
A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to teach the patient about the purpose of
echocardiography
After noting a pulse deficit when assessing a 74-year-old patient who has just arrived in the emergency department, the nurse will anticipate that the patient may require
electrocardiographic (ECG) monitoring
When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the
elevation of the patients low-density lipoprotein (LDL) level.
A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the patient. The nurses priority action will be to
give IV morphine sulfate 4 mg
A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective?
i will call for help when I need to get up to use the bathroom
A client is admitted with a suspected bacterial infection. What laboratory finding does the nurse apply as the best indication that the infection is in the acute phase?
immature neutrophils 12% on white blood cell differential
The nurse is caring for a client in the coronary care unit when the cardiac monitor reveals ventricular fibrillation and the client becomes unresponsive. The nurse should anticipate which intervention?
immediate defibrillation
An older adult has developed a urinary tract infection, and is at risk for urosepsis. Which signs or symptoms should the nurse monitor? Select all that apply.
increased heart rate decreased urinary output increased respiratory rate change in level of consciousness
While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patients bed elevated 45 degrees. The nurse knows this finding indicate
increased right atrial pressure
A patient is at risk for which complications in the first year after heart transplant? select all that apply
infection rejection sudden cardiac death
A nurse is caring for a patient with shock of unknown etiology whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which collaborative intervention ordered by the health care provider should the nurse question
infuse normal saline at 250 mL/h
The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to
keep a diary of daily activities while the monitor is worn.
A 73-year-old patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. The nurse should notify the health care provider and immediately
keep the patient in bed in the supine position
Which clinical findings should the nurse expect in a patient with acute lower extremity VTE? S(elect all that apply)
mild to moderate calf pain and tenderness Unilateral edema and induration of the thigh
When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include
milk, yogurt, and other milk products
An expected finding in the assessment of an 81-year-old patient is
narrowed pulse pressure
During discharge teaching with a 68-year-old patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient on the
need for frequent laboratory blood testing
After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for
norepinephrine (Levophed).
The nurse suspects cardiac tamponade in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should
note when Korotkoff sounds are auscultated during both inspiration and expiration
The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include
notify the health care provider if nausea develops
A client with Stevens-Johnson syndrome exhibits the following clinical manifestations. Which assessment finding requires priority action by the nurse?
oral temperature of 102.2°F (39°C)
A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse
palpates both carotid arteries simultaneously to compare pulse quality.
A patient who has chronic heart failure tells the nurse, I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating! The nurse will document this assessment finding
paroxysmal nocturnal dyspnea
The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. The priority intervention by the nurse for this problem is to
place the patient in Fowlers position, leaning forward on the overbed table
The standard policy on the cardiac unit states, Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg. The nurse will need to call the health care provider about the
postoperative patient with a BP of 116/42.
The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find
prolonged capillary refill in all the toes
While caring for a patient with aortic stenosis, the nurse identifies a nursing diagnosis of acute pain related to decreased coronary blood flow. A priority nursing intervention for this patient would be
promote rest to decrease myocardial oxygen demand
A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?
protamine sulfate
While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the water pill with the heart pill. When planning for the patients discharge the nurse will facilitate a
referral to a home health care agency
Which clinical manifestation can the nurse expect to see in both patients with buerger's disease and a patient with Raynaud's phenomenon (select all the apply)
sensitivity to cold temperatures gangrenous ulcers under the fingertips color changes of fingers and toes
the nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that
she will call the clinic if her weight goes from 124 to 128 pounds in a wee
When caring for a patient with infective endocarditis of the tricuspid valve, the nurse should monitor the patient for the development oF
shortness of breath.
Which treatment should the nurse anticipate for an otherwise healthy person with an initial VTE?
subcutaneous unfractionated Heparin as outpatient
The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with most recent temperature 98.6°F (37°C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16 breaths/minute, and heart rate (HR) 78 bpm, but these signs are now changing. Which set of vital signs indicates that the nurse should contact the health care provider (HCP)?
temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24 breaths/min
The nurse receives shift hand-off on an assigned client who had a surgical procedure. What objective assessment suggests that the client may be developing sepsis and is at risk for septic shock? Select all that apply.
temperature increase blood pressure decrease 32 mL of urine in 2 hours tachypnea
Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for
the ability to do daily activities without chest pain
A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. The client's cholesterol profile is as follows: total cholesterol 265 mg/dl (6.845 mmol/L), low-density lipoprotein (LDL) 139 mg/dl (3.603 mmol/L), and high-density lipoprotein (HDL) 32 mg/dl (0.829 mmol/L). The client asks the nurse how to lower their cholesterol. The nurse should tell the client that
the nurse will ask the dietitian to talk with the client about modifying their diet.
A patient reports dizziness and shortness of breath for several days. During cardiac monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this heart rhythm as
third-degree atrioventricular (AV) block
the nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be
troponins T and I.
A patient has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining an admission history from the patient, it will be most important for the nurse to ask about
trouble swallowing.
The emergency department (ED) nurse receives report that a patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 1 minute. In preparation for the patients arrival, the nurse will obtain
two 14-gauge IV catheters
Which statement by a patient with restrictive cardiomyopathy indicates that the nurses discharge teaching about self-management has been most effective?
will take antibiotics when my teeth are cleaned at the dental office
