NSG 4520 EXAM 3: Perfusion & Protection ATI Quiz
A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant's apical heart rate is less than what rate?
90/min
A nurse is teaching a client who has a new prescription for bumetanide. Which of the following instructions should the nurse include in the teaching? A) "Report changes in hearing." B) "Avoid foods high in potassium." C) "Take the prescribed second dose at nighttime." D) "Limit your fluid intake to no more than 1.5 L a day."
A) "Report changes in hearing."
While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following? A) A systolic murmur B) A third heart sound (S3) C) An expected heart sound D) A fourth heart sound (S4)
A) A systolic murmur
A nurse is teaching a client who has rheumatoid arthritis (RA) about increasing physical rest as part of her treatment plan. Which of the following outcomes of this intervention should the nurse document as a goal for this client? A) Reduced joint stress B) Maintenance of joint function C) Suppression of the inflammatory process D) Decreased stiffness
A) Reduced joint stress
A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function? A) Serum creatinine B) Blood urea nitrogen (BUN) C) Serum sodium D) Urine-specific gravity
A) Serum creatinine
A nurse is performing discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include? A) "Avoid using moisturizing lotions on your skin." B) "Wash your hair with a mild protein shampoo." C) "Apply powder liberally to sensitive skin areas." D) "Use a sun-blocking agent with a sun protection factor of at least 15."
B) "Wash your hair with a mild protein shampoo."
A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity? A) "I am gaining weight." B) "I am constipated." C) "My vision seems yellow." D) "My tongue is red and beefy."
C) "My vision seems yellow."
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? A) Asthma B) Aortic valve regurgitation C) Heart failure D) Aortic stenosis
C) Heart failure
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? A) "I can walk a mile a day." B) "I've had a backache for several days." C) "I am urinating more frequently." D) "I feel nauseated and have no appetite."
D) "I feel nauseated and have no appetite."
A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity? A) Anorexia B) Ataxia C) Photosensitivity D) Jaundice
A) Anorexia
A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe? A) Troponin I B) Lipase C) B-type natriuretic peptide (BNP) D) Aspartate aminotransferase (AST)
A) Troponin I
A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? A) A grey colored, non-purpuric papular rash B) A dry, red rash across the bridge of the nose and on the cheeks C) Pitting edema of the hands and fingers D) Subcutaneous nodules on the ulnar side of the arm
B) A dry, red rash across the bridge of the nose and on the cheeks
A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority? A) The client's ECG tracing shows irregular heart rate without P waves B) The client has an aPTT of 80 seconds C) The client experiences sudden weakness of one arm and leg D) The client's urine output is cloudy and odorous
C) The client experiences sudden weakness of one arm and leg
A nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission? A) Auscultating the rate and characteristics of the child's heart sounds B) Using a pain-rating tool to determine the severity of the joint pain C) Identifying the degree of parental anxiety related to the diagnosis D) Assessing the client's erythematosus rash
A) Auscultating the rate and characteristics of the child's heart sounds
A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following instructions should the nurse include? (SATA) A) Expect to feel the medication's effects immediately B) Do not drink alcoholic beverages while taking this medication C) Report unexplained bruising to the provider D) Avoid people who has infection E) Take NSAIDS to help minimize the adverse effects of the medication
B) Do not drink alcoholic beverages while taking this medication C) Report unexplained bruising to the provider D) Avoid people who has infection
A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions? A) Defibrillation B) Elective cardioversion C) CPR D) Radiofrequency catheter ablation
B) Elective cardioversion
A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? (SATA) A) Dyspnea B) Gastrointestinal bloating C) Jugular vein distention D) Confusion E) Hypotension
A) Dyspnea C) Jugular vein distention D) Confusion
A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take? A) Obtain an EKG B) Administer enteric-coated acetaminophen C) Administer ibuprofen D) Maintain oxygen saturations greater than or equal to 92%
A) Obtain an EKG
A nurse is reviewing laboratory results of a client who has atrial fibrillation and is taking warfarin. For which of the following results should the nurse notify the provider? A) PT 45 seconds B) Hgb 16 g/dL C) Hct 44% D) Platelets 190,000/mm3
A) PT 45 seconds
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? A) Potassium B) Hemoglobin C) Creatinine D) Blood urea nitrogen (BUN)
A) Potassium
A nurse is teaching a client who has rheumatoid arthritis (RA) about self-care strategies for managing the disease. Which of the following activities should the nurse include in the teaching? A) Press water from a sponge rather than wringing it B) Turn doorknobs using a clockwise motion C) Finish weekly household tasks within 1 or 2 days D) Engage in repetitive tasks, even when joints are inflamed, to keep the joints mobile
A) Press water from a sponge rather than wringing it
A nurse at a provider's office receives a phone call from a client who reports nausea and unrelieved chest pain after taking nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse? A) Tell the client to take an antacid B) Instruct the client to call 911 C) Tell the client to take another nitroglycerin D) Advise the client to come to office
B) Instruct the client to call 911
A nurse in a provider's office is assessing a client who has AIDS. The nurse notes that the client has multiple and widespread raised, purplish-brown skin lesions. The nurse should recognize that these findings indicate which of the following conditions? A) Actinic keratosis B) Kaposi's sarcoma C) Toxic epidermal necrosis D) Basal cell carcinoma
B) Kaposi's sarcoma
A nurse in a provider's office is assessing a client who has rheumatoid arthritis (RA). Which of the following findings is a late manifestation of this condition? A) Anorexia B) Knuckle deformity C) Low-grade fever D) Weight loss
B) Knuckle deformity
A nurse is caring for a client who received an injection of penicillin G procaine. The client begins to experience dyspnea and tongue swelling. Which of the following actions should the nurse perform first? A) Obtain intravenous fluids for administration B) Record the observed data in medical record C) Deliver a dose of aminophylline by inhalation D) Administer epinephrine subcutaneously
D) Administer epinephrine subcutaneously
A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication? A) White blood cell (WBC) count B) Rheumatoid factor (RF) C) Antinuclear antibody (ANA) D) Erythrocyte sedimentation rate (ESR)
D) Erythrocyte sedimentation rate (ESR)
A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE? A) Sunlight B) Pregnancy C) Infection D) Exercise
D) Exercise
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A) Jugular venous distention B) Abdominal distention C) Dependent edema D) Hacking cough
D) Hacking cough
A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response? A) "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." B) "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." C) "Exercise is good for you and good for your heart." D) "Your doctor is the expert here, and I'm sure he would only recommend what is best for you."
A) "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely."
A nurse is teaching the partner of a client who has an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? A) "These tests help determine the degree of damage to the heart tissues." B) "Cardiac enzymes will identify the location of the MI." C) "These tests will enable the provider to determine the heart structure and mobility of the heart valves." D) "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion."
A) "These tests help determine the degree of damage to the heart tissues."
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? A) Check the client's vital signs B) Request a dietician consult C) Suggest that the client rests before eating a meal D) Request an order for an antiemetic
A) Check the client's vital signs
A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority? A) Defibrillation B) Airway management C) Epinephrine administration D) Amiodarone administration
A) Defibrillation
A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect? A) Frothy sputum B) Dependent edema C) Nocturnal polyuria D) Jugular distention
A) Frothy sputum
A nurse is caring for a client who has heart failure and a potassium level of 3.4 mEq/L. The nurse should identify which of the following medications as the cause of the client's low potassium level? A) Furosemide B) Nitroglycerin C) Metoprolol D) Spironolactone
A) Furosemide
A nurse is assessing a client prior to administering atenolol. Which of the following findings should prompt the nurse to withhold the medication? A) Heart rate 46/min B) Oxygen saturation 95% C) Respiratory rate 18/min D) Blood pressure 160/94 mmHg
A) Heart rate 46/min
A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2 mg/min. When the client asks the nurse why he is receiving that medication, the nurse should explain that is has which of the following actions? A) Prevents dysrhythmias B) Slows intestinal permeability C) Dissolves blood clots D) Relieves pain
A) Prevents dysrhythmias
A nurse is assessing a client who is to have IV urography. Which of the following data should indicate to the nurse that this procedure is contraindicated for this client? A) Presence of a metal rod in her tibia B) Allergy to shellfish C) History of claustrophobia D) Prescribed rosiglitazone
B) Allergy to shellfish
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority? A) Positive Western blot test B) CD4-T-cell count 180 cells/mm3 C) Platelets 150,000/mm3 D) WBC 5,000/mm3
B) CD4-T-cell count 180 cells/mm3
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? A) Decreased brain natriuretic peptide (BNP) B) Elevated central venous pressure (CVP) C) Increased pulmonary artery wedge pressure (PAWP) D) Decreased specific gravity
B) Elevated central venous pressure (CVP)
A nurse is assessing a client for early manifestations of rheumatoid arthritis (RA). Which of the following changes is an early manifestation of RA? A) Morning stiffness B) Fatigue C) Temporomandibular joint pain D) Baker's cysts
B) Fatigue
A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect? A) Dry, hacking cough B) Hepatomegaly C) Dizziness D) Crackles in the lungs
B) Hepatomegaly
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? A) "I will read food labels and limit my sodium to 4 grams per day." B) "I should use naproxen to manage discomfort." C) "I plan to slow down if I am tired the day after exercising." D) "I will take my diuretic before sleep and drink fluids during the day."
C) "I plan to slow down if I am tired the day after exercising."
A nurse is caring for a client who is prescribed diphenhydramine to relieve pruritus. The client asks the nurse how he can minimize the daytime sedation he is experiencing. Which of the following responses should the nurse give? A) "Gradually decrease the dose once tolerance to the effect is reached." B) "Distribute the doses evenly throughout the day." C) "Take most of the daily dose at bedtime." D) "Take the medication with meals."
C) "Take most of the daily dose at bedtime."
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia? A) Epinephrine B) Magnesium C) Atropine D) Sodium bicarbonate
C) Atropine
A nurse in a provider's office is assessing a client who reports occasional atypical chest pain, palpitations, and exercise intolerance. On auscultation, the nurse notes a systolic click. The nurse should recognize this finding as a manifestation of which of the following conditions? A) Aortic regurgitation B) Mitral stenosis C) Aortic stenosis D) Mitral valve prolapse
D) Mitral valve prolapse
A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety? A) Nitroglycerin B) Aspirin C) Oxygen D) Morphine
D) Morphine
A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect? A) Weight loss B) Increased urine output C) Bradycardia D) Orthopnea
D) Orthopnea
A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions? A) Febrile B) Hemolytic C) Allergic D) Bacterial
B) Hemolytic
A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective? A) Increased heart rate B) Increased urine output C) Decreased blood pressure D) Decreased blood glucose level
B) Increased urine output
A nurse is collecting a medication history from a client who has 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? A) Atorvastatin B) Metformin C) Nitroglycerin D) Carvedilol
B) Metformin
A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include? A) The client cannot travel by air due to the security screening B) The client should hold his cell phone on the side opposite the ICD C) The client should avoid the use of small electric devices D) The client can carry his ICD in a small pocket
B) The client should hold his cell phone on the side opposite the ICD
A nurse is talking with a client who has come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme-linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis? A) CD4+ T-cell count B) Western blot analysis C) Quantitative RNA assay D) Viral load test
B) Western blot analysis
A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification? A) Morphine sulfate 2 mg IV bolus every 2 hr PRN pain B) Laboratory testing of serum potassium upon admission C) 0.9% normal saline IV at 50 mL/hr continuous D) Bumetanide 1 mg IV bolus every 12 hr
C) 0.9% normal saline IV at 50 mL/hr continuous
A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first? A) Attach the leads for a 12-lead ECG B) Obtain a blood sample C) Initiate oxygen therapy D) Insert the IV catheter
C) Initiate oxygen therapy
A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? A) Slow B) Not palpable C) Irregular D) Bounding
C) Irregular
A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (SATA) A) Orthopnea B) Headache C) Nausea D) Tachycardia E) Diaphoresis
C) Nausea D) Tachycardia E) Diaphoresis
A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider? A) Client report of feelings of depression B) Dry, raised rash on the face C) Presence of peripheral edema D) Joint pain in hands and knees
C) Presence of peripheral edema
A nurse is caring for a client who has a delayed hypersensitivity reaction. The nurse should expect which of the following manifestation? A) Bronchospasm B) Serum sickness C) Tissue damage at the site D) Excessive mucus secretion
C) Tissue damage at the site
A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provider the client? A) Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues B) Troponin is a lipid whose levels reflect the risk for coronary artery disease C) Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart D) Troponin is a protein that helps transport oxygen throughout the body
C) Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart
