Perfusion 1

which diagnosis increases the risk for development of a pulmonary embolism? 1. atrial fibrillation 2. forearm laceration 3. migraine headache 4. respiratory infection

1

which medication is indicated to prevent progression of a myocardial infarction for ac client admitted to the emergency department with crushing chest pain? 1. aspirin 2. atropine 3. gabapentin 4. epinephrine

1

which manifestation in a client with heart failure indicates digoxin toxicity? select all that apply 1. nausea 2. yellow vision 3. irregular pulse 4. increased urine output 5. heart rate of 64 bpm

1, 2, 3

when assessing a client with right ventricular heart failure, the nurse would expect which finding? select all that apply 1. dependent edema 2. swollen hands and fingers 3. collapsed neck veins 4. right upper quadrant discomfort 5. oliguria

1, 2, 4

which action will the nurse take for a client with a suspected pulmonary embolus? select all that apply 1. administer oxygen at high flow rates 2. notify the rapid response team 3. lower the head of the client's bed 4. place the client on a cardiac monitor 5. anticipate rapid administration of warfarin

1, 2, 4

which topic(s) would the nurse include while teaching a client diagnosed with microvascular angina? select all that apply 1. use of daily aspirin 2. tobacco cessation techniques 3. benefits of coronary artery bypass graft surgery 4. management of usual daily activities to avoid symptoms 5. use of nitroglycerin to prevent and treat anginal symptoms

1, 2, 4, 5

which clinical indicators would the reuse consider evidence of increasing intracranial pressure? select all that apply 1. vomiting 2. irritability 3. hypotension 4. increased respirations 5. decreased level of consciousness

1, 2, 5

which topic will the nurse include when teaching a group of clients about risk factors for heart disease? select all that apply 1. obesity 2. hypertension 3. diabetes insipidus 4. asian-americas ancestry 5. increased high-density lipoprotein (HDL)

1, 2which st

when a client with chronic dyspnea is scheduled for computed tomography (CT) using contrast, which assessment information would the nurse communicate to the health care provider before the procedure? select all that apply 1. metformin taken today 2. hematocrit 38% 3. serum creatinine 2.1 mg/dl 4. coronary artery disease history 5. shellfish allergy 6. respiratory rate 22 breaths per minute

1, 3, 5

which clinical indicator would the nurse monitor to determine if the client's simvastatin is effective? 1. heart rate 2. triglycerides 3. blood pressure 4. international normalized ratio (INR)

2

which information would the nurse include when explaining the cause of transient ischemic attacks (TIAs) to a client? 1. genetic valvular heart disease 2. atherosclerotic plaques within arteries 3. developmental defects in arterial walls 4. emboli ascending from the lower extremities

2

for which clinical manifestation will the nurse monitor for when caring for a client admitted with heart failure? select all that apply 1. weight loss 2. unusual fatigue 3. dependent edema 4. nocturnal dyspnea 5. increased urinary output

2, 3, 4

which instruction will the nurse include in the teaching plan for a client who will be taking simvastatin? select all that apply 1. increase dietary intake of potassium 2. avoid prolonged exposure to the sun 3. schedule regular ophthalmic examinations 4. take the medication at least half an hour before meals 5. contact your health care provider if skin becomes gray-bronze

2, 3, 5

a client who recently experienced a brain attack (cerebrovascular accident (CVA)) and has limited mobility reports constipation. which is most important for the nurse to determine when collecting information about the constipation? 1. presence of distention 2. amount of high-fiber food consumed 3. length of time this problem has existed 4. extent of discomfort when attempting to defecate

3

which antidote would the nurse anticipate administering to a client whose laboratory report establishes a warfarin overdose? 1. physostigmine 2. vitamin K 3. iron dextran 4. protamine sulfate

2

which goal would the nurse include in the plan of care for a client who manifests right-sided hemianopsia as a result of a cerebrovascular accident (CVA)? 1. correct the client's misuse of equipment 2. instruct the client to scan surroundings 3. teach the client to look at the position of the left extremities 4. provide the client with tactile stimulation to the affected extremities

2

which laboratory result will the nurse expect when caring for a client who presents to the emergency department with an ST-segment-elevation myocardial infarction (STEMI)? 1. decreased white blood cell count 2. elevated serum troponin I and T 3. decreased creatine kinase-MB (CK-MB) 4. decreased B-type natriuretic peptide (BNP)

2

which statement by a client who is seen for follow-up in the heart failure clinic is most important for the nurse to communicate to the health care provider? 1. "I am unable to run 1 mile (1.6 km) now" 2. "I wake up at night short of breath" 3. "my spouse says I snore loudly" 4. "my shoes seem larger lately"

2

which therapeutic effect would the nurse expect to identify when mannitol is administered to a client? 1 improved renal blood flow 2. decreased intracranial pressure 3. maintenance of circulatory volume 4. prevention of the development of thrombi

2

which medication is used to treat a client whose cardiac monitor reveals several runs of ventricular tachycardia? 1. atropine 2. epinephrine 3. amiodarone 4. sodium bicarbonate

3

which client would be at an increased risk for coronary artery disease (CAD)? 1. client with total cholesterol 175 and LDL cholesterol 80 2. client with total cholesterol 190 and HDL cholesterol 40 3. client with total cholesterol 200 and HDL cholesterol 45 4. client with total cholesterol 250 and LDL cholesterol 120

4

which health problem history would increase an older adult's risk for experiencing a cerebrovascular accident (CVA)? 1. glaucoma 2. hypothyroidism 3. continuous nervousness, stress 4. transient ischemic attacks (TIAs)

4

the nurse is monitoring a 6 yo child for toxicity precipitated by digoxin. which sign of digoxin toxicity would the nurse monitor for? 1. oliguria 2. vomiting 3. tachypnea 4. splenomegaly

2

which explanation would the nurse include when teaching a client with heart failure about the reason for a low-sodium diet? 1. body weight control 2. decreased fluid retention 3. lowering of blood pressure 4. prevention of hypernatremia

2

which finding for a client who has a diagnosis of paroxysmal atrial fibrillation is most important to report quickly to the health care provider? 1. irregular heartbeat 2. right arm weakness 3. client report of palpitations 4. client report of lightheadedness

2

which action would the nurse anticipate taking when a client develops third degree atrioventricular block with a heart rate of 30 bpm? 1. assist with rapid defibrillation 2. prepare for synchronized cardioversion 3. obtain the transcutaneous pacemaker 4. initiate cardiopulmonary resuscitation

3

which assessment is the nurse's priority before beginning an infusion of tissue plasminogen activator (t-PA) to a client in the emergency department? 1. vital signs 2. electrocardiogram (ECG) monitoring 3. signs of bleeding 4. level of chest pain

3

which behavior would the nurse include when teaching a family what to expect from a client who experienced a stroke not he left side of the brain? select all that apply 1. impaired judgement 2. spatial-perceptual deficits 3. slow performance and caution 4. impaired speech/language aphasias 5. tendency to deny or minimize problems 6. awareness of deficits with depression and anxiety

3, 4, 6

which term would the nurse use to document the rhythm when a client's cardiac rhythm strip shows more P waves than QRS complexes and there is not relationship between the atria and the ventricles? 1. first degree atrioventricular (AV) block 2. second degree AV block Mobitz I (Wenckebach) 3. second degree AV block Mobitz II 4. third degree AV block (complete heart block)

4

in which order will the nurse perform these prescribed actions for a client who is in the emergency department with sudden onset of dyspnea and possible pulmonary embolism? 1. administer unfractionated heparin 2. administer oxygen to keep saturation higher than 93% 3. place client on cardiac monitor 4. check oxygen saturation using pulse oximetry 5. obtain blood for coagulation studies

4, 2, 3, 5, 1

which action would the nurse implement to assist a client's development of independence, after experiencing a cerebrovascular accident (CVA) 2 weeks ago? 1. establish long-range goals for the client 2. reinforce success in tasks accomplished 3. point out errors in performance on which to focus 4. explain ways the client can regain independence in activities

2

which collaborative intervention will the nurse anticipate to treat the dysrhythmia when a client has supraventricular tachycardia that has persisted despite treatment with vagal maneuvers and medications? 1. defibrillation 2. pacemaker placement 3. synchronized cardioversion 4. cardiac resynchronization therapy

3

which condition unrelated to cardiac disease is the major cause of right ventricular failure? 1. hypovolemic shock 2. chronic kidney disease 3. chronic obstructive pulmonary disease (COPD) 4. systemic inflammatory response syndrome (SIRS)

3

which prescribed action has the highest priority when a client comes to the emergency department with moderate substernal chest pain that is unrelieved by rest and nitroglycerin? 1. administer morphine sulfate 2. transfer to the coronary care unit 3. obtain a 12-lead electrocardiogram (ECG) 4. have a blood specimen drawn for troponin studies

3

after the nurse teaches a client with hyperlipidemia about dietary changes, which client statement indicates that the teaching has been effective? 1. "I guess I will need to cut out all fat or cholesterol in my diet" 2. "I love fried foods, but I will plan to use hydrogenated oil for frying" 3. "the main important dietary change will be to avoid eating any eggs" 4. "I like steak, but will plan to broil it and have a salad along with the meat"

4

when a client suddenly develops a second-degree heart block, type I, with a rate of 48 bpm, which action would the nurse take first? 1. obtain a temporary pacemaker 2. Give the prescribed PRN atropine 3. notify the health care provider 4. take the client's blood pressure

4

the nurse is caring for a variety of clients. in which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? 1. a 59 yo who had a know replacement 2. a 60 yo who has bacterial pneumonia 3. a 68 yo who had emergency dental surgery 4. a 76 yo who has a history of thrombocytopenia

1

three days after admission to the hospital for a brain attack (cerebrovascular accident (CVA)), a client has a nasogastric tube inserted and is receiving continuous tube feedings. which action would the nurse take to evaluate whether the feeding is being absorbed? 1. aspirate for a residual volume 2. evaluate the intake in relation to the output 3. instill air into the client's stomach while auscultating 4. compare the client's body weight with the baseline data

1

which action would the nurse take next when a client with a history of heart failure on daily weights has a 4 pound weight gain since the previous day? 1. perform a head-to-toe assessment 2. place the client on restricted fluid intake 3. discuss a restricted sodium diet with the client 4. document the findings in the health care record

1

which action would the nurse take when a client with coronary artery disease and a recent diagnosis of venous thrombosis calls the outpatient clinic to report sudden onset of shortness of breath? 1. suggest that the client call 911 2. have the client take slow, deep breaths 3. schedule the client to be seen in the clinic in 1 hour 4. have the client take a low dose aspirin tablet immediately

1

which clinical finding is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block? 1. syncope 2. headache 3. tachycardia 4. hemiparesis

1

which drug action will the nurse include when describing the purpose of heparin in a client who develops thrombophlebitis in the right calf and is prescribed bed rest and initiated on an intravenous (IV) infusion of heparin? 1. it prevents extension of the clot 2. it reduces the size of the thrombus 3. it dissolves the blood clot in the vein 4. it facilitates absorption of red blood cells

1

which explanation would the nurse provide to a client about transient ischemic attacks (TIAs)? 1. temporary episodes of neurological dysfunction 2. intermittent attacks caused by multiple small clots 3. ischemic attacks that result in progressive neurological deterioration 4. exacerbations of neurological dysfunction alternating with remissions

1

which finding will the nurse expect when analyzing the cardiac rhythm for a client with first degree atrioventricular (AV) block? 1. every P wave is conducted to the ventricles 2. some P waves are conducted to the ventricles 3. there are no P waves visible on the rhythm strip 4. none of the P waves are conducted to the ventricles

1

which finding would be of most concern when the nurse is assessing a client with pulmonary embolism diagnosis who is receiving intravenous heparin? 1. client reports stools are black 2. oxygen saturation is 93% 3. respiratory rate is 25 breaths per minute 4. client has an ecchymosis on the ankle

1

which symptom would the nurse include when teaching a group of female clients about clinical manifestations of coronary artery disease that are more common in women? select all that apply 1. dyspnea 2. indigestion 3. unusual fatigue 4. left chest pain 5. substernal pressure

1, 2, 3

which modifiable risk factor would the nurse include in a community presentation on cardiovascular risk factors? select all that apply 1. weight 2 inactivity 3. cholesterol 4. tobacco use 5. homocysteine

1, 2, 3, 4, 5

which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? select all that apply 1. providing oxygen 2. assessing vital signs 3. obtaining a 12-lead EKG 4. drawing blood for cardiac enzymes 5. auscultating heart sounds 6. administering nitroglycerin

1, 2, 3, 4, 5, 6

which clinical indicator will the nurse monitor to evaluate the effectiveness of treatment for a client with exacerbation of left ventricular failure? select all that apply 1. lung sounds 2. heart sounds 3. heart rate 4. peripheral edema 5. dyspnea on exertion 6. jugular vein distention

1, 2, 3, 5

which topic would be included when teaching a client with heart failure who will be discharged with a new prescription for digoxin? select all that apply 1. take your radial pulse daily and write it down 2. avoid foods that are high in potassium such as bananas and potatoes 3. notify the health care provider if you develop any vision changes 4. call the health care provider if your pulse Is irregular or less than 60 bpm 5. eat at least 1 serving of green leafy vegetables daily

1, 3, 4

a postpartum client receiving a continuous heparin infusion for a deep vein thrombosis has an activated partial thromboplastin time (aPTT) of 128 seconds. which action would the nurses take in response to this situation? 1. increase the IV rate of heparin 2. interrupt the infusion and notify the primary health care provider of the aPTT result 3. document the result on the medical record and recheck the aPTT in 4 hours 4. call the primary health care provider to obtain a prescription for a low-molecular-weight heparin

2

which statement indicates that the teaching has been effective after the nurse has finished teaching a 50 yo female client about symptoms of coronary artery disease in women? 1. "I don't need to worry about symptoms like chest pain or pressure" 2. "I will call my health care provider about any unusual fatigue" 3. "women has less risk of death from heart disease than men" 4. "bad cholesterol levels are usually higher in women than in men"

2

how would the nurse interpret the rhythm when a client's rhythm strip shows that the P and QRS waves are consistent, with a P wave preceding every QRS complex and a PR interval of 0.26 seconds? 1. complete heart block 2. normal sinus rhythm 3. first degree atrioventricular (AV) block 4. second degree AV block

3

when taking the health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report? 1. losing weight over the past week 2. tingling in the upper extremities 3. using several pillows at night to sleep 4. wheezing when exposed to dust or pollen

3

which assessment is the priority when a client with heart filature reports a 9 pound weight gain in the past 2 weeks? 1. palpate the abdomen 2. check for ankle edema 3. auscultate breath sounds 4. ask about dietary salt intake

3

which care plan would the nurse implement for an infant admitted to the pediatric unit with the diagnosis of heart failure? 1. increase the infant's fluid intake 2. position the infant flat on the back 3. offer the infant small, frequent feedings 4. measure the infant's head circumference

3

which explanation about the need to be on bed rest post-procedure would the nurse give when teaching a client who is scheduled for a coronary arteriogram? 1. to reduce fatigue 2. to avoid severe headache 3. to decrease bleeding risk 4. to prevent orthostatic hypotension

3

which finding about a client's angina is most important for the nurse to communicate to the health care provider? 1. causes mild perspiration 2. occurs after moderate exercise 3. continues after rest and nitroglycerin 4. precipitates discomfort in the arms and jaw

3

which finding in a client who has just been admitted indicates that the nurse will anticipate assisting with insertion of a temporary pacemaker? 1. shortness of breath 2. substernal discomfort 3. third-degree heart block 4. premature ventricular contrations

3

which finding in a client with right calf venous thrombosis is most important to communicate to the health care provider? 1. severe right calf pain 2. right calf redness and swelling 3. oxygen saturation 89% 4. heart rate of 136 bpm

3

which information would the nurse include in the discharge teaching plan for a client who sustained a cerebrovascular accident (CVA) with residual hemiparesis and hemianopsia? 1. necessity for bed rest at home 2. use of oxygen (O2) therapy at home 3. significance of a safe environment 4. need for decreased protein in the diet

3

which rationale would the nurse include to address the client's concern about why both warfarin and intravenous (IV) heparin are needed at the same time for a partial occlusion if the left common carotid artery? 1. this permits the administration of smaller doses of each medication 2. giving both medications allows clot dissolution while preventing new clot formation 3. heparin provides anticoagulant effects until warfarin reaches therapeutic levels 4. administration of heparin with warfarin provides immediate and maximum protection against clot formation

3

which action would the nurse implement to prevent the development of plantar flexion when providing care for a client who sustained a cerebrovascular accident (CVA) 2 days ago? 1. place a pillow under the thighs 2. elevate the knee patch of the bed 3. encourage active range of motion 4. maintain the feet at right angles to the legs

4

which clinical finding enables the nurse to conclude that the heparin therapy is effective in a client who has atrial fibrillation with rapid ventricular response and is started on a continuous heparin infusion? 1. atrial fibrillation converts to a sinus rhythm 2. the heart rate is stabilized at 70 to 90 bpm 3. the international normalized ratio (INR) is within normal range 4. an activated partial thromboplastin time (aPTT) is twice the usual value

4

which finding is a client seen in the emergency department with chest pain is most important to communicate to the health care provider? 1. severe nausea and vomiting 2. substernal pain level 9 (0 to 10 scale) 3. blood glucose 230 4. ST segment elevation on electrocardiogram

4

which information about a client who has heart failure would the nurse communicate to the health care provider before administration of the prescribed digoxin? 1. apical pulse rate 96 bpm 2. bilateral foot and ankle pitting edema 3. crackles heart at the base of both lungs 4. potassium level of 2.3

4

which intervention and rationale would the nurse plan for a client admitted to the hospital with a right-sided cerebrovascular accident (CVA)? 1. apply elastic stockings to prevent flaccid leg muscles 2. use a bed cradle to prevent dorsiflexion of the feet 3. implement passive range-of-motion (ROM) exercises to prevent muscle atrophy 4. use a hand roll and support the left arm on a pillow to prevent contractures

4

which intervention would the nurse implement after determining that a client, who sustained a cerebrovascular accident (CVA), needs assistance with eating for optimum nutrition? 1. request that the clients food be pureed 2. feed the client to conserve the client's energy 3. have a family member assist the client with each meal 4. encourage the client to participate in the feeding process

4

which medication would the nurse conclude is the cause of a decreased heart rate in a client receiving a cardiac glycoside, a diuretic, an angiotensin-converting enzyme (ACE) inhibitor, and a vasodilator? 1. diuretic 2. vasodilator 3. ACE inhibitor 4. cardiac glycoside

4

which response would the nurse give to a client whose total cholesterol level is found to be 210 at a screening session at a health fair and asks the nurse what to do in light of this result? 1. "your cholesterol is high, and you may need medication" 2. "this is within the acceptable range, and no action is required" 3. "your level is low; you should eat more foods that contain cholesterol" 4. "your cholesterol is elevated slightly. a diet low in saturated fats should be followed"

4

which statement by a client is consistent with a diagnosis of heart failure? 1. "I see spots before my eyes" 2. "I am tired at the end of the day" 3. "I feel bloated when I eat a large meal" 4. "I have trouble breathing when I climb a flight of stairs"

4

which statement by the client would the nurse expect when assessing a client with a diagnosis of left ventricular failure? 1. "my ankles are swollen" 2. "my appetite is not very good" 3. "when I eat a large meal, I feel bloated" 4. "I have trouble breathing when I walk rapidly"

4