PRACTICE EAQs Integumentary & Cardiovascular, Blood & Lymphatic

A client with midsternal pain presents to the emergency department. Vital signs are stable. Which form of nitroglycerin does the nurse anticipate giving initially?

spray

The nurse provides medication discharge instructions to a client who received a prescription for digoxin (Lanoxin) following the client's myocardial infarction. The nurse concludes that the teaching was effective when the client says what?

"I should check my radial pulse rate daily."

The health care provider prescribes isosorbide dinitrate (Isordil) 10 mg as needed three times a day and a nitroglycerin transdermal disk once a day for a client with chronic angina pectoris. The client asks the nurse why the isosorbide dinitrate is prescribed. What is the nurse's best response?

"The isosorbide dinitrate allows more oxygen to get to heart tissue."

While classifying a client with heart failure in accordance with New York Heart Association guidelines, the nurse finds that per

3

What is the most important information the nurse and the rapid response team must keep in mind when caring for a client who had a cardiac arrest?

How long the client was anoxic

A client with heart failure is receiving digoxin and hydrochlorothiazide. The nurse will assess for which signs and symptoms that indicate digoxin toxicity? Select all that apply.

Nausea Yellow vision Irregular pulse

A client with pharyngitis, carditis, polyarthritis, and erythematous circles and wavy lines on the trunk reports fatigue and severe chest pain. Which medication treatment will be most beneficial to this client?

Penicillin

A client with severe varicose veins has surgery that involves ligation, dissection, and removal of incompetent vessels. In which position should the nurse place the client after surgery

Supine with the legs elevated at a 15-degree angle

A nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next?

Verify the pulse by using a Doppler

A nurse is caring for a client who is receiving radiation therapy. Which information about skin care should the nurse include in the teaching plan?

"Avoid applying lotions and powders over the area."

A client is admitted to the hospital with multiple signs and symptoms associated with a cardiac problem. What clinical finding alerts the nurse that the health care provider probably will insert a pacemaker?

Heart block

A client is taking administering warfarin (Coumadin). The nurse recalls that the antidote for this medication is what?

Vitamin K

A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor. What does the nurse conclude that these complexes are a sign of?

Cardiac irritability

A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). What recommendations are essential for the nurse to include? Select all that apply.

Eat foods high in vitamin C. Take your temperature daily Balance periods of rest and activity.

A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned?

Methyldopa Methyldopa is associated with acquired hemolytic anemia and should be discontinued to prevent progression and complications. Famotidine will not cause these symptoms; it decreases gastric acid secretion, which will decrease the risk of gastrointestinal bleeding. Ferrous sulfate is an iron supplement to correct, not cause, symptoms of anemia. Levothyroxine is not associated with red blood cell destruction.

A client with a history of heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally.

Raise the client to high-Fowler position

A client just had a total hip replacement and is experiencing restlessness and changes in mentation. Which complication does the nurse consider the client may be experiencing based on these responses?

Hypovolemic shock

A nurse is assessing a group of clients. Which client is considered at the highest risk for a dissecting aneurysm?

The highest incidence of dissecting aneurysm is in people in their sixth and seventh decades of life; it is seen 2 to 5 times more frequently in men than in women. It occurs most often in older clients with hypertension. The 40-year-old female is not at as great a risk as a male. The 70-year-old male with peripheral vascular disease and the 42-year-old female with peripheral vascular disease are not at as high a risk as a male with uncontrolled hypertension.

To manage heart failure a client has been taking several medications, including furosemide 40 mg by mouth twice a day. The client develops severe muscle cramps and fatigue, and laboratory tests confirm the presence of hypokalemia. Potassium chloride intravenously (IV) and ECG monitoring have been prescribed. Which ECG change associated with hypokalemia should the nurse expect to observe?

flattened T waves

A client with burns is to receive the exposure method of treatment with application of mafenide twice a day. With this type of treatment the nurse plans to do what?

Administer prescribed pain medication

A health care provider prescribes ophthalmic drops for a client. What should a nurse include in the instructions for a client learning to self-administer eye drops?

Apply pressure to the nasolacrimal duct after instillation.

Within the first 2 hours after a radical neck dissection, 40 mL of medium red, bloody fluid is collected in the portable wound drainage system. What should the nurse do first?

Obtaining vital signs is important because 40 mL of drainage in 2 hours is excessive; 80 to 120 mL of drainage is expected within the first 24 postoperative hours. The client's status should be assessed first, then the health care provider should be notified. Charting the amount on the I&O record should be done eventually, but it is not the priority at this time. It is unsafe to continue to monitor the amount for another 2 hours without checking vital signs first is unsafe; the client is bleeding excessively.

A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching?

Using a back-and-forth motion while cleaning the wound