Test 2 Adult Health 2

The nurse is teaching a client who is being discharged about care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education? "The PICC line can stay in for months." "I have less chance of getting an infection because the line is not in my hand." "I can continue my 20-mile (32-km) running schedule as I have in the past." "I can still go about my normal activities of daily living."

"I can continue my 20-mile (32-km) running schedule as I have in the past." The statement by the client stating that his or her normal running schedule can continue indicates a need for further education. Excessive physical activity can dislodge the PICC or lead to catheter occlusion and should be avoided.Clients with PICCs should be able to perform normal activities of daily living. PICCs have lower complication rates because the insertion site is in the upper extremity. The dry skin of the arm has fewer types and numbers of microorganisms, leading to lower rates of infection. PICC lines can be used long term (months).

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which client statement indicates the need for further teaching? "I won't put the salt shaker on the table anymore." "I need to avoid eating hamburgers." "I need to avoid lunchmeats but may cook my own turkey." "I must cut out bacon and canned foods."

"I need to avoid eating hamburgers." Further teaching about restricting sodium in the diet for a client with heart failure is needed when the client says, "I need to avoid eating hamburgers." Cutting out beef or hamburgers made at home is not necessary, but fast-food hamburgers are to be avoided owing to higher sodium content.Bacon, canned foods, lunchmeats, and processed foods are high in sodium, which promotes fluid retention, and must be avoided. The client correctly understands that adding salt to food must be avoided.

Which nursing statement reflects appropriate cardiac physical assessment technique? "I will auscultate the aortic valve in the second intercostal space at the right sternal border." "I will palpate the apical pulse over the third intercostal space in the midclavicular line." "I will assess for orthostatic hypotension by moving the client from a standing to a reclining position." "I will assess for carotid bruit by auscultating over the anterior neck."

"I will auscultate the aortic valve in the second intercostal space at the right sternal border."

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which client statement indicates understanding of the teaching? "I should expect occasional chest pain." "I will try walking for 1 hour each day." "I will report to the provider weight loss of 2 to 3 lb (0.9 to 1.4 kg) in a day." "I will call the provider if I have a cough lasting 3 or more days."

"I will call the provider if I have a cough lasting 3 or more days." The client understands the discharge teaching about when to seek medical attention when the client says: "I will call the provider if I have a cough lasting 3 or more days." Cough, a symptom of heart failure, is indicative of intra-alveolar edema; it is important to notify the provider if this occurs.The client would call the provider for weight gain of 3 lb (1.4 kg) in a week or 1-2 lb (0.45 to 0.9 kg) overnight. The client would begin by walking 200 to 400 feet (61 to 123 m) per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure. The provider must be notified if this occurs.

The nurse is caring a college athlete who collapsed during soccer practice. The client has been diagnosed with hypertrophic cardiomyopathy and states, "This can't be. I am in great shape. I eat right and exercise." Which nursing response is appropriate? "How does this make you feel?" "This can be caused by taking performance-enhancing drugs." "It could be worse if you weren't in good shape." "This may be caused by a genetic trait."

"This may be caused by a genetic trait." The appropriate nursing response is that this may be caused by a genetic trait. Hypertrophic cardiomyopathy is often transmitted as a single gene autosomal dominant trait.Exploring the client's feelings is important, but does not address the client's question. Hypertrophic cardiomyopathy is not caused by performance-enhancing drugs. Reminding the client that he or she is in good shape is not at all therapeutic and does not address the client's question.

Potassium level

3.5-5 (K+)

About how many mL will the nurse record as having been replaced for a client with dehydration initially weighed 142 lb (64.5 kg) and now weighs 156 lb (70.9 kg) after 2 days of rehydration therapy? 3000 6300 9300 7000

6300 1 kg = 2.2 lb. 1 kg of water = 1 L (1000 mL) of water. 14 lb divided by 2.2 = 6300 g (6300 mL).

Which client arterial blood pH value indicates to the nurse the lowest concentration of free hydrogen ions? 7.45 7.42 7.36 7.29

7.45 The concentration of hydrogen ions is inversely (negatively) related to the pH. Thus the lower the pH, the higher the concentration of hydrogen ions and the higher the pH, the lower the concentration of free hydrogen ions. The pH of 7.29 represents the greatest concentration of free hydrogen ions in this list and the pH of 7.45 represents the lowest concentration of free hydrogen ions

Which client will the nurse observe frequently for indications of hyperkalemia? A 72 year old receiving total parenteral nutrition A 65 year old taking furosemide for chronic heart failure A 38 year old being managed for diabetic ketoacidosis A 30 year old who has anxiety-induced hyperventilation

A 38 year old being managed for diabetic ketoacidosis Hyperkalemia occurs as compensation for any type of acidosis, including diabetic ketoacidosis, by having cells take up excess hydrogen ions (from the acidosis) in exchange for releasing intracellular potassium to maintain electroneutrality in both fluid compartments. The client receiving TPN is at risk for metabolic alkalosis due to an increase in base components. Hyperventilation leads to respiratory alkalosis, which causes hypokalemia. Furosemide increases potassium loss, leading to hypokalemia

After receiving change-of-shift report about these four clients, which client would the nurse assess first? A 79 year old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min. A 55 year old admitted with pulmonary edema who received furosemideand whose current O2 saturation is 94%. A 46 year old with aortic stenosis who takes digoxin and has new-onset frequent premature ventricular contractions. A 68 year old with pericarditis who is reporting sharp chest pain with inspiration.

A 46 year old with aortic stenosis who takes digoxin and has new-onset frequent premature ventricular contractions. The nurse would first assess the 46 year old with aortic stenosis on digoxin and now has new-onset frequent PVCs. The PVCs may be indicative of digoxin toxicity. Further assessment for clinical signs and symptoms of digoxin toxicity must be done and the primary health care provider notified about the dysrhythmia.The 55 year old is stable and can be assessed after the client with aortic stenosis. The 68 year old may be assessed after the client with aortic stenosis. This type of pain is expected in pericarditis. Tachycardia is expected in the 79 year old because rejection will cause signs of decreased cardiac output, including tachycardia. This client may be seen after the client with aortic stenosis.

After receiving the change-of-shift report, which client does the nurse assess first? A 67 year old with nausea and vomiting who reports abdominal cramps. A 77 year old with normal saline infusing at 150 mL/hr with an average hourly urine output of 75 mL. A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg. A 45 year old with a nasogastric (NG) tube who has dry oral mucosa and reports feeling very thirsty.

A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg. The nurse must first assess the client receiving IV diuretics whose blood pressure is 88/52 mm Hg. This client with hypotension may have developed hypoperfusion caused by hypovolemia and may require immediate action. All other clients listed have less urgent problems and do not require immediate assessment

Which client will the nurse recognize as having the greatest risk for development of hypocalcemia? A 26 year old with hyperparathyroidism A 70 year old who has alcoholism and malnutrition A 40 year old taking tetracycline for an infection A 35 year old athlete taking NSAIDs for joint pain

A 70 year old who has alcoholism and malnutrition Calcium is absorbed from the gastrointestinal tract under the influence of vitamin D. When a client is malnourished, not only is the dietary intake of calcium usually low, but the client is also vitamin deficient. Hyperparthyroidism would increase serum calcium levels. Neither NSAIDs nor tetracycline increase the risk for hypocalcemia

Which client will the nurse consider to be at greatest risk for dehydration?? A 75-year-old woman with chronic back pain A 25-year-old woman taking oral contraceptives A 75-year-old man who has a vitamin deficiency A 25-year-old man who has frequent esophageal reflux

A 75-year-old woman with chronic back pain Women at any age have a higher risk for dehydration because women have more body fat than men, and fat cells contain practically no water. Men have a higher percentage of total body water at any age because they have more muscle mass than women and muscle cells contain a high concentration of water. The risk for dehydration increases with age. As adults age, their total body water volume decreases because both older men and older women loss muscle mass with aging.

The nurse is conducting an admission assessment on a male client. Which assessment data is a risk factor for cardiovascular disease? Select all that apply. A. BMI of 26 B. BP of 120/66 C. Triglycerides 140 mg/dL D. Moderate exercise for 20-30 minutes weekly E. Exposure to secondhand cigarette smoke F. History of repeated streptococcal tonsillitis G. Family history of cardiovascular disease

A. BMI of 26 D. Moderate exercise for 20-30 minutes weekly E. Exposure to secondhand cigarette smoke F. History of repeated streptococcal tonsillitis G. Family history of cardiovascular disease

Which acid-base problem does the nurse expect when the ventilator of a client being mechanically ventilated is set at too high a rate of breaths per minute for 6 hours? Acid-deficit alkalosis Acid excess acidosis Base excess alkalosis Base-deficit acidosis

Acid-deficit alkalosis A ventilator set at either too high a ventilation rate and/or at too great a tidal volume will cause the client to lose too much carbon dioxide, leading to an acid-deficit respiratory alkalosis.

For which signs and symptoms will the nurse assess in a client who has acute respiratory acidosis with a PaCO2 level of 88 mm Hg? (Select all that apply.) Hyperactive deep tendon reflexes Acute confusion Lethargy Hypotension pH 7.49 Tall T-waves

Acute confusion Lethargy Hypotension Tall T-waves When caring for a client with acute respiratory failure and respiratory acidosis, the nurse would assess for lethargy, hypotension, and fatigue. Clients with acidosis have problems associated with decreased excitable tissues, including hypotension and decreased perfusion, impaired memory and cognition, increased risk for falls, and reduced neuromuscular responses (not hyperactive deep tendon reflexes). The pH will be below 7.35, which is a characteristic of acidosis. Acute confusion occurs because of reduced gas exchange and reduced cognition

Which problem does the nurse expect resulted in a client's acid-base imbalance during an illness that causes vomiting for 2 days? Alkalosis from overelimination of hydrogen ions Acidosis from overproduction of of hydrogen ions Alkalosis from overproduction of bicarbonate ions Acidosis from underelimination of bicarbonate ions

Alkalosis from overelimination of hydrogen ions Prolonged or excessive vomiting results in alkalosis from overelimination of hydrogen ions when stomach

The nurse is teaching a class on diagnostic cardiovascular testing. Which teaching will the nurse include? The left side of the heart is catheterized first and may be the only side examined. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. Holter monitoring allows periodic recording of cardiac activity during an extended period of time. Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism.

An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography

What is the relationship between free hydrogen ions and carbon dioxide? An increase in free hydrogen ions always lowers carbon dioxide levels. Carbon dioxide can bind free hydrogen ions to increase the pH. Carbon dioxide can bind free hydrogen ions to decrease the pH. An increase in free hydrogen ions always increases carbon dioxide levels.

An increase in free hydrogen ions always increases carbon dioxide levels. In human physiology and homeostasis, free hydrogen ions and carbon dioxide levels are directly related. Any condition that changes the concentration of one always causes a corresponding change in the concentration of the other in the same direction. Carbon dioxide is not a buffer and does not directly bind free hydrogen ions.

Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN? An older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours. A client receiving blood products after excessive blood loss during surgery. A client admitted for hyperglycemia who has an IV insulin drip and needs frequent glucose checks. A client who has a diltiazem IV infusion being titrated to maintain a heart rate between 60 and 80 beats/min.

An older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours. The older client admitted for confusion with a heparin lock is the most stable and requires basic monitoring of the IV site for common complications such as phlebitis and local infection, which would be familiar to an LPN/LVN.The client with a diltiazem IV infusion, the client with an IV insulin drip, and the client receiving blood products all are not stable and will require ongoing assessments and adjustments in IV therapy that should be performed by an RN.

The nurse caring for a client with heart failure who is taking digoxin. What assessment data requires that nurse notify the health care provider? (Select all that apply.) Select all that apply. Anorexia Blurred vision Fatigue Heart rate 110/beats/min Serum digoxin level of 1.5 ng/mL (1.92 nmol/L)

Anorexia Blurred vision Fatigue The signs and symptoms of digoxin toxicity that the nurse notifies the provider include: blurred vision, fatigue, and anorexia. Changes in mental status, especially in older adults, may also occur.Sinus bradycardia and not tachycardia is a sign of digoxin toxicity. A serum digoxin level between 0.8 and 2.0 (1.02 and 2.56 nmol/L) is considered normal and is not a symptom.

The nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement requires further nursing education? A. "I may need to take this drug every other day according to lab values." B. "I need to take potassium supplements with this medication." C. "I will try my best not to use table salt on my food." D. "This medication will cause me to urinate more often."

Answer: B Spironolactone is a potassium sparing diuretic. This drug can cause hyperkalemia and as such the client would not take potassium supplements with this drug. The statement, "I need to take potassium supplements with this medication" requires additional nursing education.

The nurse is caring for a hospitalized client with infective endocarditis who has been receiving antibiotics for 2 days. The client is now experiencing flank pain with hematuria. What condition will the nursing suspect? A.​Pulmonary embolus B.​Renal infarction C.​Transient ischemic attack D.​Splenic infarction

Answer: B The classic clinical signs of renal infarction, associated with embolization from infective endocarditis, are flank pain, hematuria, and pyuria.

A client who recently had a heart valve replacement is preparing for discharge. What statement by the client indicates that the nurse will need to do additional health teaching? A. "I need to brush my teeth at least twice daily and rinse with water." B. "I will eat foods that are low in vitamin K, such as potatoes and iceberg lettuce." C. "I need to take a full course of antibiotics prior to my colonoscopy." D. "I will take my blood pressure every day and call if it is too high or low."

Answer: C Rationale: Antibiotics are only required prior to dental procedures. Good oral hygiene is the best prevention for endocarditis. The statement in option A is correct and shows the patient understands the need for oral hygiene. The patient with a mechanical valve will be on warfarin thus, foods high in Vitamin K should be avoided. This statement in option B is correct and shows the patient understands foods that are LOW in Vitamin K. This statement in option D is also correct and shows that the patient understands

A client is diagnosed with left-sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply. A.​ Peripheral edema B.​ Crackles in both lungs C.​Tachycardia D.​ Ascites E.​ Tachypnea

Answers: B, C, E, F Rationale: For a client with left sided heart failure the nurse will anticipate assessment findings of crackles in both lungs, tachypnea, tachycardia, and a third heart sound, usually an S3 gallop. Peripheral edema and ascites are associated with right sided heart failure

Which action does the nurse expect is most likely to help restore acid-base balance in a client whose arterial blood pH is 7.17 immediately after a grand mal seizure? Administering bicarbonate orally or intravenously Providing hydration with IV normal saline Administering insulin Applying oxygen

Applying oxygen The severe acidosis seen immediately following a grand mal seizure is both respiratory and metabolic in origin (a combined acidosis). The client does not breathe during the actual seizure, which causes a huge retention of carbon dioxide (respiratory acidosis). The carbon dioxide level is very high because the seizing muscles are working hard under anaerobic conditions creating lots of lactic acid and hydrogen ions (metabolic acidosis), which are then converted to carbon dioxide through the carbonic anhydrase reaction. If the client stops having seizure activity, he or she will return to acid-base balance without intervention. This return occurs earlier when oxygen is applied. Bicarbonate is not lost during a seizure and most definitely should not be replaced. Hydration and insulin do nothing to restore acid-base balance in this situation.

The nurse is assessing a client with right-sided heart failure. What assessment findings will the nurse anticipate? (Select all that apply.) Select all that apply. Oliguria Ascites Pulmonary congestion Peripheral edema Shortness of breath Third heart sound

Ascites Peripheral edema Right-sided heart failure is associated with increased systemic venous pressure and congestion; producing signs such as peripheral edema, ascites, liver enlargement, and neck vein distension. Left-sided heart failure is associated with pulmonary congestion and can produce shortness of breath, weakness, fatigue, oliguria, and a third heart sound (S3 gallop).

The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What will the nurse do first? Check connections. Check the infusion rate. Assess the insertion site. Discontinue the IV and start another.

Assess the insertion site. The initial response by the nurse is to assess the insertion site. The purpose of this action is to check for patency, which is the priority. IV assessments typically begin at the insertion site and move "up" the line from the insertion site to the tubing, to the tubing's connection to the bag.Checking the IV connection is important, but is not the priority in this situation. Checking the infusion rate is not the priority. Discontinuing the IV to start another may be required, but it may be possible to "save" the IV, and the problem may be positional or involve a loose connection.

Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply.) Testing skin turgor Asking about any abdominal pain Assessing cognition Checking deep tendon reflexes Monitoring urine output Checking for the presence of fever

Assessing cognition Monitoring urine output The serum sodium is extremely low, which makes depolarization slower and cell membranes less excitable. It also can cause cerebral edema to form, leading to confusion and seizure activity. When sodium levels become very low, coma and death may occur. Assessing cognition and checking deep tendon reflexes are the most important assessment data to obtain. Monitoring urine output needs to be done but is not the priority action in this situation. Assessing skin turgor, presence of abdominal pain, and fever are not an urgent assessment to prevent immediate harm.

Which assessment is most important for the nurse to perform on a client who is receiving IV magnesium sulfate? Monitoring 24-hour urine output Monitoring the serum calcium levels Assessing the blood pressure hourly Asking the client whether a headache is present

Assessing the blood pressure hourly Assessing hourly blood pressures is critical when caring for a client receiving IV magnesium sulfate because hypotension is a sign/symptom of hypermagnesemia that could occur when too much has infused. Most clients who have fluid and electrolyte problems will be monitored for intake and output; however, changes will not immediately indicate problems with magnesium overdose. Headaches are not associated with hypermagnesemia. Although administration of magnesium sulfate can cause a drop in calcium levels, this occurs over a period of time and would not be the best way to assess magnesium toxicity

The home health nurse visits a client with heart failure who has gained 5 lb (2.3 kg) in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? Auscultate the client's posterior breath sounds. Notify the health care provider about the client's weight gain. Remind the client about dietary sodium restrictions. Assess the client for peripheral edema.

Auscultate the client's posterior breath sounds. The action the home care nurse takes first is to auscultate the heart failure client's posterior breath sounds. Because the client is at risk for pulmonary edema and hypoxemia, the breath sounds must be assessed.Assessment of edema may be delayed until after breath sounds are assessed. After a full assessment, the nurse must notify the health care provider. After physiologic stability is attained, then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.

The nurse is assessing a client with heart failure. Which assessment data is the best indicator of fluid balance? A. Blood pressure 144/79 B. Urine output 200 mL in the last 4 hours C. Weight increase of 9 pounds in the past week D.Generalized edema in the lower extremities

C. Weight increase of 9 pounds in the past week

Which body system will the nurse assess first to prevent harm for a client who has severe metabolic acidosis? Gastrointestinal system Respiratory system Cardiovascular system Autonomic nervous system

Cardiovascular system During acidosis, the body attempts to bring the pH closer to normal by moving free hydrogen ions into cells in exchange for potassium ions. This exchange can cause hyperkalemia, which alters all excitable membranes. In the heart, hyperkalemia can block electrical conduction through the heart and cause severe bradycardia and even cardiac arrest. Although all body systems are affected to some degree, the cardiovascular system must be assessed first to institute actions to prevent death.

The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters will the nurse choose most often? Cephalic vein of the forearm Palmer side of the wrist Back of the hand Subclavian vein

Cephalic vein of the forearm The cephalic vein of the forearm is the insertion site chosen most often. For same-day surgery, the cephalic or basilic vein allows insertion of a larger IV catheter while allowing movement of the arm without impairing intravenous flow.Peripheral venous catheters should never be inserted into the back of the hand in an older adult because the veins are brittle. Peripheral venous catheters are not inserted into the palmar side of the wrist because the median nerve is located close to this area. Catheters are typically inserted into the subclavian vein by the health care provider, not by the nurse

A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened 20 hours ago. What action will the nurse take? Change the set in about 4 hours. Nothing; the set is for long-term use. Change the set immediately. Change the set in the next 12 to 24 hours

Change the set in about 4 hours. Because both ends of the set are being manipulated with each dose, standards of practice dictate that the set should be changed every 24 hours, so the set should be changed in about 4 hours.It is not necessary to change out the set immediately, but it must be changed before the next 12 to 24 hours.

The nurse is administering a drug to a client through an implanted port. Before giving the medication, what will the nurse do to ensure safety? Check for blood return Administer 5 mL of a heparinized solution. Flush the port with 10 mL of normal saline. Palpate the port for stability.

Check for blood return. To ensure safety, before a drug is given through an implanted port, the nurse must first check for blood return. If no blood return is observed, the drug should be held until patency is reestablished.If no blood return is observed, the drug should be held until patency is re-established. Ports are flushed with heparin or saline after, rather than before, use. The port is palpated for stability, but this action alone does not ensure the client's safety.

Which assessment is most importantfor the nurse to perform on a client whose serum potassium level is 2.0 mEq/L (mmol/L)? Checking pulse oximetry Measuring blood pressure Listening to bowel sounds in all four quadrants Observing the ECG for flat T-waves

Checking pulse oximetry Although all assessment actions listed are important, the most critical one to perform is assessing respiratory function effectiveness. Skeletal muscle weakness can make respiratory movements ineffective, leading to respiratory failure and death. Although cardiac changes can occur.

Which assessment data will the nurse associate with suspected pericarditis? (Select all that apply.) Sudden-onset chest pain relieved by anti-inflammatory agents. Chest and abdominal pain relieved by antacids. Chest pain relieved by sitting upright. Squeezing, vise-like chest pain. Pain in the chest described as sharp or stabbing

Chest pain relieved by sitting upright Sudden-onset chest pain relieved by anti-inflammatory agents Pain in the chest described as sharp or stabbing. The chest pain of pericarditis is relieved when sitting upright or forward, may appear abruptly, and is relieved by anti-inflammatory agents. The inflammatory pain of pericarditis tends to be sharp, stabbing, and related to breathing.Squeezing, vise-like chest pain is characteristic of myocardial infarction. Chest and abdominal pain relieved by antacids is characteristic of peptic ulcer.

The client asks the nurse about modifiable risk factors for heart disease. What nursing response is appropriate? (Select all that apply.) . Cigarette smoking is one of the most significant modifiable risk factors. Your personal health over the past 10 years a modifiable risk. Your overall body mass index is nonmodifiable. Increasing physical exercise is a method to modify your risk. Diabetes mellitus is a modifiable risk factor.

Cigarette smoking is one of the most significant modifiable risk factors. Increasing physical exercise is a method to modify your risk

The nurse is caring for a client with heart failure in a cardiac clinic. What assessment data indicates that the client has demonstrated a positive outcome related to the addition of metoprolol to the medication regimen? Client states, "I can sleep on one pillow." Current ejection fraction is 25%. Client reports feeling like her heart beats very fast at times. Records indicate five episodes of pulmonary edema last year

Client states, "I can sleep on one pillow." A client with heart failure has had a positive outcome to metoprolol when she states that she is able to sleep on one pillow. Improvement in activity tolerance, less orthopnea, and improved symptoms represents a positive response to beta blockers such as metoprolol.An ejection fraction of 25% is well below the normal of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest. This is not a positive outcome.

Which client is best to assign to an LPN/LVN working on the telemetry unit? Client with pericarditis who has a paradoxical pulse and distended jugular veins. Client with heart failure who is receiving dobutamine. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. Client with rheumatic fever who has a new systolic murmur.

Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. The best client to assign to the LPN/LVN working on the telemetry unit is the client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. This client is the most stable. Administration of oxygen to a stable client is within the scope of LPN/LVN practice.The client with heart failure is receiving an intravenous inotropic agent, which requires monitoring by the RN. The client with pericarditis is displaying signs of cardiac tamponade and requires immediate lifesaving intervention. The client with a new-onset murmur requires assessment and notification of the primary health care provider, which is within the scope of practice of the RN.

For which client does the nurse remain alert for the possibility of respiratory acidosis? Client with increased urinary output Client who is anxious and is breathing rapidly Client with multiple rib fractures Client receiving IV NS

Client with multiple rib fractures A client with multiple rib fractures may have poor gas exchange from shallow breathing because of pain and because the rib fractures may inhibit adequate chest expansion. A client who is anxious and breathing rapidly is at risk for respiratory alkalosis, not acidosis. A normal saline bolus does not result in respiratory acidosis. An increased urinary output would not be a stimulus for a respiratory acid-base imbalance.

Which assessment on an older client with some degree of dehydration will the nurse perform to determine whether the client is safe for independent ambulation? Ensuring that the most recent serum potassium level is above 3.5 mEq/L (mmol/L) Assessing for furrows on the tongue to determine dryness of oral mucous membranes Comparing blood pressure measurements in the lying, sitting, and standing positions Ensuring that the pulse rate obtained radially is within 2 beats/min of that obtained apically

Comparing blood pressure measurements in the lying, sitting, and standing positions When caring for an older adult admitted for dehydration, the nurse determines if the client is safe for independent ambulation by assessing for orthostatic blood pressure changes. Comparisons of blood pressures obtained with the client lying, then sitting, and finally standing can detect postural changes. If the standing blood pressure is significantly lower than that obtained while the client was in the lying or sitting positions, insufficient blood flow to the brain may cause hypotension with light-headedness and dizziness, which increase the risk for falls.Comparing apical to radial pulse rates does not provide information to detect degree of dehydration. Although assessment of oral mucous membranes can detect symptoms of dehydration, it does not provide information for falls risk. Dehydration usually results in an elevated serum potassium level, not a decreased level.

The nurse is checking an IV fluid order and questions accuracy. What nursing action is appropriate? Ask the charge nurse about the order. Start the fluid as ordered. Contact the pharmacy for clarification. Contact the prescribing health care provider.

Contact the prescribing health care provider. First, the nurse will contact the health care provider who ordered the fluids. The nurse is legally and professionally responsible for accuracy and has the duty to verify the order with the health care provider who ordered it.The nurse can consult the charge nurse, but this is not the definitive action that the nurse should take. Contacting the pharmacy is not the best action that the nurse should take. Giving (or starting) the fluid when the order is questionable is not appropriate and could possibly harm the client.

The nurse is admitting an 84-year-old client with heart failure to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data is most concerning? A. Digoxin therapy daily. B. Daily metoprolol. C. Furosemide twice daily. D. Currently taking an antacid for upset stomach.

Correct Answer: A Confusion, blurry vision, and upset stomach are symptoms of Digoxin toxicity, which is common in older adults and requires immediate treatment. The other answers are important assessment data but do not indicate immediate connection to the client's presentation.

The nurse is caring for a client with heart failure who is on oxygen at 2L per nasal cannula with an oxygen saturation of 90%. The client states, "I feel short of breath." Which action will the nurse take first? A.​Contact respiratory therapy. B.​Increase the oxygen to 4L. C.​Place the client in a high Fowler's position. D.​Draw arterial blood for arterial blood gas analysis

Correct Answer: C The first action of the nurse is to place the client in high Fowler's position. This position allows for maximal lung expansion. The nurse can also place pillows under each arm to maximize chest expansion. Repositioning the client with heart failure can improve overall gas exchange. If dyspnea continues the nurse may contact respiratory therapy for a breathing treatment, assess arterial blood gases (as prescribed) or increase oxygen if warranted by ABG results.

The nurse is teaching a client with heart failure about a newly prescribed medication, ivabradine. What teaching will the nurse include? Select all that apply. A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your healthcare provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the healthcare provider if elevated."

Correct answers: A, B, C, D, E (Yes, they are all correct- new NCLEX format) Rationale: Ivabradine is an HCN channel blocker that slows the heart rate. Side effects include: bradycardia, hypertension, atrial fibrillation, and luminous phenomena (visual brightness) The nurse will teach the client that visual changes are expected initially. The nurse will advise to take this medication with meals and teach the client how to check radial pulse and to report low heart rate or irregularity to the health care provider. The nurse will also teach clients that visual changes are associated with light and clients should use caution when driving or using machines in situations where light intensity may change abruptly.

A client with heart failure reports a 7.6-lb (3.4 kg) weight gain in the past week. What intervention does the nurse anticipate from the primary health care provider? Sodium restriction Daily weight monitoring Restricted activity Dietary consult

Daily weight monitoring

Hypokalemia effects on body systems:

Decreased GI motility Decreased Resp. Drive Decreased Cardiac function

What response does the nurse expect to see in the blood volume and blood osmolarity of a client whose secretion of aldosterone is abnormally low? Decreased blood volume; increased blood osmolarity Increased blood volume; decreased blood osmolarity Decreased blood volume; decreased blood osmolarity Increased blood volume; increased blood osmolarity

Decreased blood volume; decreased blood osmolarity The action of aldosterone, known as the water- and sodium-saving hormone, increases the kidney reabsorption of both water and sodium to maintain blood volume and osmolarity. Clients who have low levels of aldosterone secretion lose large amounts of sodium and water in the urine, which results in low blood volume and low blood osmolarity.

What is the nurse's best first action when a client's hand goes into flexion contractures during blood pressure measurement with an external cuff? Deflating the blood pressure cuff and giving the client oxygen Documenting the finding as the only action Initiating the Rapid Response Team Placing the client in the high-Fowler position and increasing the IV flow rate

Deflating the blood pressure cuff and giving the client oxygen Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. This effect of hypocalcemia is enhanced in the presence of tissue hypoxia. The flexion contractions occurring during blood pressure measurement are indicative of hypocalcemia and referred to as a positive Trousseau sign. Initiating the Rapid Response Team is a good second action. Placing the client in high-Fowler position will not help the hypocalcemia.

What is the best action for a nurse to take on finding a client's serum chloride level is 101 mEq/L? Urge the client to drink more water. Notify the primary health care provider. Assess the client's deep tendon reflexes. Document the finding as the only action.

Document the finding as the only action. The normal range for serum chloride levels is between 98 and 106 mEq/L. No action beyond confirming documentation is needed.

The nurse is teaching a class on risk factors for cardiovascular disease. Which risk factors will the nurse include? (Select all that apply.) Smoking history Elevated high-density lipoprotein (HDL) level Decreased bone density Low blood pressure Family history of heart disease Fiber-rich diet Elevated C-reactive protein levels Diabetes Mellitus

Elevated C-reactive protein levels Smoking history Family history of heart disease Diabetes Mellitus

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload? Checking for presence of dependent edema Assessing blood pressure Measuring intake and output Elevating the head of the bed

Elevating the head of the bed Pulmonary edema with difficulty breathing can develop quickly in clients with fluid overload. Although assessing whether other signs and symptoms of fluid overload is important, the priority is to ensure adequate gas exchange before taking any other action. Raising the head of the bed takes little time and can help improve gas exchange even when pulmonary edema is present.

A client who is suffering from dyspnea on exertion and heart failure (HF) will most likely report which symptom during the health history? Brown discoloration of lower extremities Swelling of one leg Fatigue Slow heart rate

Fatigue

Which action will the nurse delegate to experienced assistive personnel (AP) working in the cardiac catheterization laboratory? Educate the client about the need to remain on bedrest after the procedure. Obtain client vital signs and a resting electrocardiogram (ECG). Have the client sign the consent form before the procedure is performed. Assess preprocedure medications the client took that day.

Obtain client vital signs and a resting electrocardiogram (ECG)

The nurse is caring for a client with heart failure. What assessment data will the nurse anticipate? (Select all that apply.) Select all that apply. Fatigue Sleeping on back without a pillow Chest discomfort or pain Tachycardia Expectorating thick, yellow sputu

Fatigue Chest discomfort or pain Tachycardia When caring for a client with heart failure, the nurse needs to assess for chest discomfort or pain, tachycardia, and fatigue. Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure.Presence of a cough or dyspnea results as pulmonary venous congestion ensues. Clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Thick, yellow sputum is indicative of infection. Position for sleeping isn't a symptom. Clients usually find it difficult to lie flat because of dyspnea symptoms.

Where do free hydrogen ions normally come from in the human body? (Select all that apply.) Free hydrogen ions are produced by-products of carbohydrate and protein metabolism. Heavy exercise and muscle work produce hydrogen ions in the form of lactic acid. Ingestion of spicy food increases the concentration of uncontrolled free hydrogen ions. The kidney produces hydrogen ions when a urinary tract infection is present. Humans breathe in free hydrogen ions in the atmosphere from the buildup of greenhouse gases. Hydrochloric acid is produced in the stomach and is a normal source of free hydrogen ions.

Free hydrogen ions are produced by-products of carbohydrate and protein metabolism. Heavy exercise and muscle work produce hydrogen ions in the form of lactic acid Hydrochloric acid is produced in the stomach and is a normal source of free hydrogen ions. Normal metabolic functions such as metabolism of carbohydrates, proteins, and fats for fuel all result in products that contribute to the free hydrogen ion concentration. Hydrochloric acid in the stomach is broken down into free hydrogen ions and chloride ions. Exercising muscles produce some lactic acid, which also contributes to normal hydrogen ion production. The hydrogen ions present in the urine during a urinary tract infection are produced by the bacteria, not the kidney. Greenhouse gases are not a normal source of free hydrogen ions and neither is the ingestion of spicy foods.

Which laboratory value indicates to the nurse that a client's hyponatremia may be related to a fluid volume excess? Serum chloride level is 100 mEq/L (mmol/L) Blood urea nitrogen (BUN) is elevated Arterial blood pH is 7.37 Hematocrit is 29% (0.29 volume fraction)

Hematocrit is 29% (0.29 volume fraction) When hyponatremia is caused by fluid volume excess, other blood/serum values are low as a result of dilution. The hematocrit level is low, which may be related to hyponatremia. The chloride level is normal. Elevated levels are associated with dehydration and reduced kidney function. The arterial pH is normal.

The nurse is preparing to administer digoxin as prescribed to a client with heart failure and notes: Temperature: 99.8° F (37.7° C), Pulse: 48 beats/min and irregular, Respirations: 20 breaths/min, Potassium level: 3.2 mEq/L (3.2 mmol/L). What action will the nurse take? Hold the digoxin, and obtain a prescription for an additional dose of furosemide. Hold the digoxin, and obtain a prescription for a potassium supplement. Give the digoxin; document assessment findings in the medical record. Give the digoxin; reassess the heart rate in 30 minutes.

Hold the digoxin, and obtain a prescription for a potassium supplement. The nurse needs to hold the digoxin and gets a prescription for a potassium supplement. Digoxin causes bradycardia and hypokalemia potentiates digoxin toxicity.Furosemide decreases circulating blood volume and depletes potassium. There is no indication suggesting that the client has fluid volume excess at this time.

Which assessment finding indicates to the nurse that the older client's therapy for dehydration is successful? Pulse pressure has decreased. Client reports feeling hungry. Hematocrit is 58% (0.58 volume fraction). Hourly urine output is greater than 15 mL.

Hourly urine output is greater than 15 mL. The most sensitive indicator of an adequate fluid volume is increasing urine output. The fact that a client who is dehydrated now has an hourly urine output of more than 15 mL is a positive indicator that the therapy is effective. Decreasing pulse pressure and a hematocrit above normal are indicators of on-going dehydration. Appetite is not a true indicator of hydration status

The nurse is caring for a client who experienced a recent cardiac event. Which client statement indicates maladaptive denial? "I don't need to change. It hasn't killed me yet." "I don't think it is as bad as the doctors say." "I don't know how I am going to change my lifestyle." "I will have to change my diet and exercise more."

I don't need to change. It hasn't killed me yet.

What effect does the nurse expect that an infusion of 200 mL of albumin will have immediately on a client's plasma osmotic and hydrostatic pressures? Decreased osmotic pressure; decreased hydrostatic pressure Decreased osmotic pressure; increased hydrostatic pressure Increased osmotic pressure; increased hydrostatic pressure Increased osmotic pressure; decreased hydrostatic pressure

Increased osmotic pressure; increased hydrostatic pressure The addition of albumin to the plasma would add a colloidal substance that does not move into the interstitial space. Thus, the osmotic pressure would immediately increase. Not only does the additional 200 mL add to the plasma hydrostatic pressure, but also the increased osmotic pressure would draw water from the interstitial space, increasing the plasma volume and ultimately leading to an increased hydrostatic pressure in the plasma volume

Which action will the nurse perform first for the client who has a serum potassium level of 6.9 mEq/L (mmol/L)? Teaching the client which foods to avoid Administering sodium polystyrene sulfonate orally Collaborating with the registered dietitian nutritionist to provide a potssium-restricted diet Initiating continuous cardiac monitoring

Initiating continuous cardiac monitoring The client has hyperkalemia. The nurse must initiate continuous cardiac monitoring for this client because hyperkalemia can lead to life-threatening bradycardia and other dysrhythmias, including tall, peaked T waves; prolonged PR intervals; flat or absent P waves; wide QRS complexes; and possible ectopic beats. Monitoring allows the nurse to determine whether therapy is effective or if the client's condition is worsening. Administering a potassium-reducing medication, recommending a potassium-restricted diet, and teaching the client about which foods to avoid are appropriate but will not immediately decrease the serum potassium level and do not need to be implemented as quickly as monitoring cardiac rhythm.

A client who is to undergo cardiac catheterization must be taught which essential information by the nurse? "Take your oral hypoglycemic with a sip of water on the morning of the procedure." "Keep your affected leg straight for 2 to 6 hours." "Do not take your blood pressure medications on the day of the procedure." "Monitor the pulses in your feet when you get home."

Keep your affected leg straight for 2 to 6 hours."

Which client has the highest risk for cardiovascular disease? Man who is sedentary and reports four episodes of strep throat. Woman with diabetes whose high-density lipoprotein (HDL) cholesterol is 75 mg/dL (1.94 mmol/L). Man who smokes and whose father died at 49 of myocardial infarction (MI). Woman with abdominal obesity who exercises three times per week.

Man who smokes and whose father died at 49 of myocardial infarction (MI)

Which assessment findings will the nurse consider as possible causes for a client to have a serum potassium level of 6.3 mE/L (mmol/L)? (Select all that apply.) Management of hypertension with an angiotensin converting enzyme inhibitor Presence of chronic kidney disease Vegan diet Excessive use of salt substitute Daily therapy with a potassium-sparing diuretics Past history of hepatitis A

Management of hypertension with an angiotensin converting enzyme inhibitor Presence of chronic kidney disease Excessive use of salt substitute Daily therapy with a potassium-sparing diuretics Potential causes of hyperkalemia include excessive use of salt substitutes (which contain high levels of potassium), chronic kidney disease (which prevents adequate excretion of potassium), daily use of a potassium-sparing diuretic (reduces potassium excretion), and the use of an angiotensin converting enzyme inhibitor. Neither a vegan diet nor previous illness with hepatitis A is associated with development of hyperkalemia.

Which condition does the nurse consider as most likely to have caused a client's arterial blood gas value to show an increased pH? Water retention Partial airway obstruction Nasogastric suction Diabetic ketoacidosis

Nasogastric suction Nasogastric suction results in alkalosis from overelimination of hydrogen ions when stomach hydrochloric acid removed by the continuous suction.

Which assessment finding on a client with hypervolemia indicates to the nurse that the client's condition may be worsening? Nose and ears have a slightly yellow-tinged appearance. Neck veins are now distended in the sitting position. Breath sounds can be heard in the right lower lung lobe. Weight is unchanged from that obtained yesterday.

Neck veins are now distended in the sitting position. Neck veins are normally distended when a client is in the supine position and are flat when a client is sitting or standing. When hypervolemia worsens the neck veins are distended even when the client is upright. Hearing breath sounds in the lower lung lobes is a positive sign, not one that indicates the condition is worsening. An unchanged weight indicates the client's condition is stable, not worsening. The color of the ears and nose is not related to hydration status.

Which nursing action may be delegated to assistive personnel (AP) working on the medical unit? Obtain daily weights for several clients with class IV heart failure. Check for peripheral edema in a client with endocarditis. Monitor the pain level for a client with acute pericarditis. Determine the usual alcohol intake for a client with cardiomyopathy.

Obtain daily weights for several clients with class IV heart failure. The nursing action that can be delegated to a UAP on the medical unit is to obtain daily weights for several clients with class IV heart failure. Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN.The role of the professional nurse is to perform assessments. Determining alcohol intake, monitoring pain level, and assessing for peripheral edema would not be delegated.

Which mechanism will the nurse consider the most likely cause of pure acute respiratory acidosis in a client who has bilateral pneumonia? Underelimination of bicarbonate ions Underproduction of hydrogen ions Overelimination of bicarbonate ions Overelimination of hydrogen ions Overproduction of hydrogen ions Underelimination of hydrogen ions Underproduction of bicarbonate ions Overproduction of bicarbonate ions

Overproduction of hydrogen ions Unlike metabolic acidosis, respiratory acidosis results from only one cause—retention of CO2, causing overproduction of free hydrogen ions. Bicarbonate is not involved as a cause or as a compensatory mechanism. Recall that carbon dioxide and hydrogen ions are directly related in human physiology. An increase in one always causes an increase in the other. Retention of CO2 is the problem, not failure of the body to directly eliminate hydrogen ions

A client recovering from cardiac angiography develops slurred speech. What will the nurse do first? Assess the site of the procedure for bleeding. Call in another nurse for a second opinion. Maintain NPO status until the slurred speech resolves. Perform a neurologic assessment and notify the primary care provider

Perform a neurologic assessment and notify the primary care provider.

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? Place the client in high-Fowler position with the legs down. Reassure the client that distress can be relieved with proper intervention. Ask a family member to remain with the client. Monitor pulse oximetry and cardiac rate and rhythm.

Place the client in high-Fowler position with the legs down. The best intervention to help the client with acute pulmonary edema to reduce anxiety and dyspnea is to place the client in high-Fowler position with the legs down. High-Fowler position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion.Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member's presence may help alleviate anxiety, but dyspnea and anxiety resulting from hypoxemia secondary to intra-alveolar edema must be relieved.

The nurse is caring for a client with heart failure in the coronary care unit. The client is exhibiting signs of air hunger and anxiety. Which nursing intervention will the nurse perform firstfor this client? Monitor and document heart rate, rhythm, and pulses. Encourage alternate rest and activity periods. Position the client to alleviate dyspnea. Determine the client's physical limitations

Position the client to alleviate dyspnea. The nurse's first action is to position the client to alleviate dyspnea. This action will help ease air hunger and anxiety. Administering oxygen therapy is also an important priority action.Determining the client's physical limitations is not a priority in this situation. Encouraging alternate rest and activity periods is not the immediate priority. Monitoring of heart rate, rhythm, and pulses is important, but is not the priority

The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the primary health care provider by the nurse for further instructions? Potassium 3.0 mEq/L (3.0 mmol/L) Magnesium 2.1 mEq/L (1 mmol/L) International normalized ratio (INR) of 1.0 Calcium 8.5 mEq/L (4.25 mmol/L)

Potassium 3.0 mEq/L (3.0 mmol/L)

The nurse is teaching a class about mechanical properties of the heart. What teaching will the nurse include? Body size does not affect overall cardiac output. Cardiac output is the amount of blood ejected by the ventricles during each contraction. Preload is the degree of stretch in the myocardial fibers Stroke volume is the amount of blood pumped out of the heart each minute.

Preload is the degree of stretch in the myocardial fibers

Which serum electrolyte value indicates to the nurse that the client has hypernatremia? Sodium 132 mEq/L (mmol/L) Potassium 3.5 mEq/L (mmol/L) Sodium 148 mEq/L (mmol/L) Potassium 5.3 mEq/L (mmol/L)

Sodium 148 mEq/L (mmol/L) Normal serum sodium ranges between 136 and 145 mEq/L (mmol/L). Hypernatremia is a serum sodium value greater than 145 mEq/L (mmol/L). In option A, the serum potassium is normal. In options C, the serum potassium value is above normal and indicates hyperkalemia. In option B, the serum sodium value is low, reflecting hyponatremia.

Which condition or symptom indicates to the nurse that the client's treatment for hyperkalemia is effective? Chvostek sign is negative. Respiratory rate is 22 breaths/min. Pulse rate is 76 beats/min and regular. Hematocrit is 42%.

Pulse rate is 76 beats/min and regular. Hyperkalemia affects cardiac conduction inducing tall T-waves, widened QRS complexes, absent P waves, prolonged PR intervals, bradycardia, and heart block. A heart rate that is regular and within the client's normal range for rate indicates resolution of the hyperkalemia. The normal respiratory rate does not indicate resolution of the hyperkalemia. Chvostek sign is present with hypocalcemia, not hyperkalemia. The hematocrit is not affected by hyperkalemia or its management.

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach as client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply.) Red meat Cereal Citrus fruit Salt substitutes Eggs Bread

Red meat Citrus fruit Salt substitutes While taking a potassium-sparing diuretic, the client is at risk for developing hyperkalemia and needs to avoid foods and other substances that contain higher concentrations of potassium. These include salt substitutes, meat and fish, and citrus fruit. Foods lowest in potassium include eggs, bread, and cereal grains, as well as most berries.

Which sign or symptom indicates to the nurse that treatment for a client's hypokalemia is effective? Reports having a bowel movement daily. ECG shows an inverted T wave. Fasting blood glucose level is 106 mg/dL. Two lb weight gain during the past week.

Reports having a bowel movement daily. Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who have hypokalemia have reduced or absent bowel sounds and are constipated.Gaining 2 lb in a week does not indicate effective management for hypokalemia. An inverted T-wave is associated with worsening hypokalemia. The fasting blood glucose level is not related to recovery from hypokalemia.

Which client assessment data is mostconsistent with cardiac pain requiring the nurse to notify the primary health care provider? Reports of abdominal pain and belching Reports of pressure in the upper abdomen and sternum and diaphoresis Apparent dyspnea on exertion (DOE) and an inability to sleep flat Reports claudication with ambulation and fatigue

Reports of pressure in the upper abdomen and sternum and diaphoresis

Which acid-base disturbance will the nurse remain alert for when caring for a client who has chest burns with tight eschar banding the chest? Respiratory acidosis Metabolic acidosis Metabolic alkalosis Respiratory alkalosis

Respiratory acidosis The tight eschar on the chest can limit chest movement and make breathing less effective with hypoventilation. This problem results in inadequate oxygenation and retention of carbon dioxide, causing respiratory acidosis. Respiratory alkalosis is caused by hyperventilation, increased rate or depth of breathing, causing carbon dioxide to be eliminated in excess. Metabolic acid-base disturbances are usually caused by nonrespiratory issues.

Which laboratory value will the nurse check immediately to prevent harm for a client with metabolic alkalosis who now has a positive Chvostek sign? Serum calcium Serum magnesium Serum glucose level Serum sodium

Serum calcium A positive Chvostek sign is associated with alkalosis accompanied by a low serum calcium level. The hypocalcemia cause overexcitement of the nervous system with dizziness, agitation, confusion, and hyperreflexia, which may progress to seizures. Tingling or numbness may occur around the mouth and in the toes. If the client has hypocalcemia, the nurse must report the finding immediately to the health care provider

A client with heart failure is prescribed furosemide. Which assessment data concerns the nurse with this new prescription? Serum sodium level of 135 mEq/L (135 mmol/L) Serum magnesium level of 1.9 mEq/L (0.95 mmol/L) Serum creatinine of 1.0 mg/dL (88.4 mcmol/L) Serum potassium level of 2.8 mEq/L (2.8 mmol/L)

Serum potassium level of 2.8 mEq/L (2.8 mmol/L) The nurse is concerned with the serum potassium level of 2.8 mEq/L (2.8 mmol/L) in a heart failure client taking furosemide. Furosemide is a loop diuretic and clients taking this drug must be monitored for potassium deficiency from diuretic therapy.A serum sodium level of 135 mEq/L (135 mmol/L) is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL (88.4 mcmol/L) represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L (0.95 mmol/L) represents a normal value.

Which client electrocardiography (ECG) change from baseline will alert the nurse to possible development of hypercalcemia? Shortened QT-interval Absent P wave Prominent U wave Inverted T waves

Shortened QT-interval Hypercalcemia affects increases myocardial contractility and slows depolarization. Common ECG changes include wide T-waves and shortened QT-intervals. Bradycardia and heart block may follow

The nurse is teaching a course about the special needs of older adults receiving IV therapy. What teaching will the nurse include? To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter improves success with venipuncture. Placement of the catheter on the back of the client's dominant hand is preferred. When the catheter is inserted into the forearm, excess hair should be shaved before insertion. Skin integrity can be compromised easily by the application of tape or dressings.

Skin integrity can be compromised easily by the application of tape or dressings. Skin in older adults tends to be thin. Tape or dressings used with IV therapy can compromise skin integrity.Placement on the back of the dominant hand is contraindicated because hand movement can increase the risk of catheter dislodgement. An angle smaller than 25 degrees is required for venipuncture success in older adults. This technique is less likely to puncture through the older adult client's vein. Clipping, and not shaving, the hair around the insertion site typically is necessary only for younger men

Which body areas are best for the nurse to use when assessing skin indications of hydration status for an older client? (Select all that apply.) Tops of the forearms Skin of the shins Skin of the forehead Skin over the abdomen Skin over the sternum Back of the hand

Skin of the forehead Skin over the sternum Assess skin turgor in an older client by pinching the skin over the sternum or on the forehead, rather than on the back of the hand. With aging the skin loses elasticity and tents on hands and arms even when the client is well hydrated and thus, changes in these areas are not reliable indicators of hydration status.Many older clients have dry flaky skin on the shins regardless of hydration status. The skin of the abdomen is looser in older clients and also is not a reliable skin area to check hydration status.

The nurse is assessing a client with a cardiac infection. Which nursing assessment data causes the nurse to suspect infective endocarditis instead of pericarditis or rheumatic carditis? Thickening of the endocardium Pain aggravated by breathing, coughing, and swallowing Splinter hemorrhages Friction rub auscultated at the left lower sternal border

Splinter hemorrhages Splinter hemorrhages are indicative of infective endocarditis. Petechiae (pinpoint red spots) occur in many clients with endocarditis. Splinter hemorrhages appear as black longitudinal lines or small red streaks along the distal third of the nail bed.Friction rub in the left lower sternal border and pain aggravated by breathing, coughing, and swallowing are signs and symptoms indicative of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis

Which assessment data is mostimportant for the nurse to report to the primary care provider prior to a coronary arteriogram? The client reports intermittent substernal chest pain for 6 months. The client has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate. The client reports that a previous arteriogram was negative for coronary artery disease. The client develops wheezes and dyspnea after eating crab or lobster

The client develops wheezes and dyspnea after eating crab or lobster.

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which nursing assessment data, obtained the day after admission, is the best indicator that the treatment has been effective? The client's weight decreases by 2.5 kg. The client has diuresis of 400 mL in 24 hours. The client's blood pressure is 122/84 mm Hg. The client has an apical pulse of 82 beats/min.

The client's weight decreases by 2.5 kg. The best indicator that treatment is effective on a client with heart failure and problems of hypervolemia is the client's weight decreased by 5.5 lb (2.5 kg) in 1 day. The best indicator of fluid volume gain or loss is daily weight. Because each kilogram represents approximately 1 L, this client has lost approximately 2500 mL of fluid.Diuresis of 400 mL in 24 hours represents oliguria. Although a blood pressure of 122/84 mm Hg is a normal finding alone, it is not significant for relief of hypervolemia. Although an apical pulse of 82 beats/min is a normal finding alone, it is not significant to determine whether hypervolemia is relieved.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? The nurse monitors the client's pulse and blood pressure frequently. The client ambulates around the nursing unit with a walker. The nurse obtains a bedside commode before administering furosemide. The nurse returns the client to bed when the client becomes tachycardia

The nurse obtains a bedside commode before administering furosemide. The nursing intervention that can help the client admitted today with heart failure is to have a bedside commode available to the client before administering furosemide. Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand.Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand. The nurse must prevent this situation

A client begins therapy with lisinopril. What does the nurse consider at the start of therapy with this medication? The client's ability to understand medication teaching The potential for bradycardia Liver function tests The risk for hypotension

The risk for hypotension At the start of therapy with lisinopril, the nurse needs to consider the risk for hypotension. Angiotensin-converting enzyme (ACE) inhibitors like lisinopril are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years.Although desirable, ability to understand teaching is not essential. ACE inhibitors are vasodilators and do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.

The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which teaching will the nurse include? "This is a painless test that is done to assess the structure of your heart using sound waves." "You will receive an injection of dobutamine and will walk on a treadmill to reveal whether you have coronary artery disease." "This is a noninvasive test performed to assess your heart rhythm." "This test evaluates you for potentially fatal cardiac rhythms."

This test evaluates you for potentially fatal cardiac rhythms.

Which laboratory finding is consistent with acute coronary syndrome (ACS)? Triglycerides 400 mg/dL (4.52 mmol/L) C-reactive protein 13 mg/dL (130 mg/L) Troponin 3.2 ng/mL (3.2 mcg/L) Lipoprotein-a 18 mg/dL (0.64 mcmol/L

Troponin 3.2 ng/mL (3.2 mcg/L)

A client has been admitted to the hospital with chest pain radiating down the left arm. Which test result bestconfirms that the client sustained a myocardial infarction (MI)? C-reactive protein of 1 mg/dL (10 mg/L) Homocysteine level of 13 mcmol/L Creatine kinase (CK) of 125 units/L Troponin of 5.2 ng/mL (5.2 mcg/L)

Troponin of 5.2 ng/mL (5.2 mcg/L)

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L) (Select all that apply.) Keeping the client NPO during drug treatment Pushing the drug as a bolus slowly over 5 minutes Using an IV controller to deliver the drug Checking IV access for blood return after the infusion Initiating the IV in a hand vein for rapid access Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution

Using an IV controller to deliver the drug Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution Best practice technique for administering parenteral potassium replacement is to ensure that the concentration is no greater than 1 mEq/10 mL of solution at a rate never to exceed 20 mEq/hr. A pump or controller device must be used to deliver the drug to prevent rapid infusion and complications of hyperkalemia, including cardiac arrest. IV potassium must be infused via a large vein with a high volume of flow, avoiding the hand. Potassium is not to be infused or pushed as a bolus to prevent cardiac. Assessing the IV access for placement and an adequate blood return is performed before administering potassium-containing solutions. It is not necessary or good practice to keep the client NPO during parenteral potassium administration.

The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential? Reassure the client that they will not feel pain. Teach the client about the reason for the TEE. Auscultate the client's precordium for murmurs. Validate that the client has remained NPO.

Validate that the client has remained NPO.

Which conditions could cause a client to develop acidosis? (Select all that apply.) . Ventilator at too low a tidal volume Sepsis Severe diarrhea Hypovolemic shock Prolonged nasogastric suctioning Hyperventilation

Ventilator at too low a tidal volume Sepsis Severe diarrhea Hypovolemic shock Sepsis and hypovolemic shock result in anaerobic metabolism and increased production of carbon dioxide, lactic acid, and free hydrogen ions. When a ventilator is set at too low of a tidal volume for the client's size, hypoventilation occurs with poor gas exchange and retained carbon dioxide. Severe diarrhea causes excess loss of bicarbonate ions in the stool, resulting in a base-deficit metabolic acidosis. Hyperventilation can result in respiratory alkalosis, not acidosis. Prolonged nasogastric suctioning results in a loss of hydrochloric acid and leads to an acid-deficit metabolic alkalosis

The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus women. Which teaching will the nurse include? Men more than women tend to deny the importance of symptoms. Men do not tend to report chest pain. Women may experience extreme fatigue and dizziness as sole symptoms. Men are more likely than women to die after MI.

Women may experience extreme fatigue and dizziness as sole symptoms