Unit 2
The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest?
5TH INTERCOSTAL SPACE
The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate?
Instruct the client to request help when getting out of bed.
The nurse is caring for a client with acute pulmonary edema. The health care provider (HCP) tells the nurse that medication will be prescribed to help reduce preload and afterload. Based on the HCP's statement, what medication should the nurse anticipate administering?
Nitroprusside sodium
The nurse is caring for an older client who is complaining of insomnia. What are some of the contributing factors to insomnia in the acute and long-term care setting?
Pain, chronic disease, staff conversations, environmental noise
The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise?
Passage of meconium
The nurse is caring for a client who is pulseless and experiencing this dysrhythmia. Which interventions should the nurse anticipate implementing in collaboration with the health care provider (HCP)?
Prepare to administer amiodarone. 4. Prepare to administer epinephrine. 5. Provide cardiopulmonary resuscitation (CPR).
The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status?
The neurovascular status is normal because of increased blood flow through the leg.
The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion?
Uterine hyperstimulation Late decelerations of the fetal heart rate
A client who has had a myocardial infarction asks the nurse why she should not bear down or strain to ensure having a bowel movement. The nurse provides education to the client based on which physiological concept?
Vagus nerve stimulation causes a decrease in heart rate and cardiac contractility.
A new nursing graduate is caring for a client who is attached to a cardiac monitor. While assisting the client with bathing, the nurse observes the sudden development of ventricular tachycardia (VT), but the client remains alert and oriented and has a pulse. Which interventions would the nurse take?
administer oxygen, obtain ECG, contact provider, asses abc's
The nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which assessment would be the initial priority in caring for this client?
assessing peripheral pulses
A 2-year-old child is admitted to a hospital burn unit with partial- and full-thickness burns involving 35% of body surface area. After admission assessment and review of the health care provider's prescriptions, the priority nursing intervention should focus on which action?
catheter
A client in labor is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which finding indicates that the rate of infusion needs to be decreased?
fhr 180
A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse should anticipate observing which sign or symptom?
flushing
The nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client's laboratory results and determines that which result would be consistent with the observation?
k+ 2.8
The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus the assessment on which structures?
lips, earlobes, mucous membranes
The nurse is caring for a client with a long bone fracture at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by performing an assessment of which item(s)?
neuro and respiratory
The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation?
silver lines on breast
A client's electrocardiogram (ECG) strip shows atrial and ventricular rates of 70 complexes/minute. The PR interval is 0.16 second, the QRS complex measures 0.06 second, and the PP interval is slightly irregular. How should the nurse report this rhythm?
sinus dysrhythmia
The graduate nurse is caring for a client with decreased renal perfusion. The registered nurse determines that the graduate nurse demonstrates understanding of why this is occurring if which statement is made?
"It may be a consequence of decreased dopaminergic receptor stimulation."
A nursing student who is researching a medication at the nurses' station asks the registered nurse (RN) what the function of an alpha-adrenergic receptor is, and where the receptors are primarily found. The RN educates the nursing student. Which statement by the nursing student indicates that teaching has been effective?
"The peripheral arteries and veins; when stimulated they cause vasoconstriction."
A hospitalized client with diabetes mellitus receives NPH insulin in the morning. The nurse monitors the client for hypoglycemia, knowing that the peak action is expected to occur how soon after the medication administration?
4-12 hours
The nurse prepares to teach a client with subarachnoid hemorrhage about the effects of nimodipine. The nurse plans to explain which information about the type and action of this medication?
Calcium channel blocker that will decrease spasm in cerebral blood vessels
A client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. The nurse should make which response to the client?
Contact HCP
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)?
FHR 180
The nurse is reviewing the record of a client who arrives at the health care clinic. The nurse notes that irbesartan has been prescribed for the client. The nurse should suspect that the client has which condition?
HTN
The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding should the nurse interpret as a sign or symptom of portal hypertension?
abdominal distention
The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability?
amniotomy, fetal hypoxia, metabolic acidemia, congenital anom
A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal and vital signs are noted on the client's chart. The nurse should alert the health care provider because these changes are most consistent with which complication? Refer to chart below. Time Pulse Respiratory Blood pressure 11:00 a.m. 92 beats/min 24 breaths/min 140/88 mm Hg 11:15 a.m. 96 beats/min 26 breaths/min 128/82 mm Hg 11:30 a.m. 104 beats/min 28 breaths/min 104/68 mm Hg 11:45 a.m. 118 beats/min 32 breaths/min 88/58 mm Hg
cardiogenic shock
A client whose cardiac rhythm was normal sinus rhythm suddenly exhibits a different rhythm on the monitor. The nurse should take which action?
contact provider
The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation?
cyanosis
The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)?
give tsp of honey, prepare glucagon
The nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report?
heamtocrit of 60%
A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse should determine that which finding documented in the client's record is an expected finding with this client?
hyperinflation
The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client?
immobilization
The nurse explains to a group of clients that methamphetamine abuse results in which vascular system dysfunction?
impaired wound healing
A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for following the client's labor?
postpartum infection
A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position?
supported, suppine
The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF?
tachy
A client has received antidysrhythmic therapy for the treatment of premature ventricular contractions (PVCs). The nurse evaluates this therapy as most effective if which finding is noted with regard to the PVCs?
they decrease to a frequency of 6 per minute
