Uworld
The practical nurse is performing a cardiac assessment in collaboration with the registered nurse. Where does the nurse expect to feel the client's point of maximal impulse?
4th and 5th intercostal space
The nurse is checking for a murmur in a client with severe mitral valve stenosis. Identify the area on the image where the nurse would best auscultate a murmur in this client.
5th intercostal space
The practical nurse is assisting the registered nurse in caring for 4 clients. Which client is at greatest risk for the development of deep venous thrombosis?
80 year old client who is 4 days post op from repair of a fractured hip
The nurse is reviewing a client's health history during a primary care visit. Which of the following findings should the nurse identify as risk factors for developing hypertension?
AA ethnicity, type 2 diabetes, stress at work, smoking cigarettes
A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors?
Amphetamine use, cigarette smoking, cold exposure, sexual intercourse
The nurse is caring for 4 clients. Which client should the nurse see first?
Aortic anuerism with weak pedal pulses and mottled skin on legs
A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure?
B-type natriurectic peptide
The nurse is preparing to administer 40 mg of oral furosemide. Prior to administering the medication, the nurse should evaluate which parameters?
Blood pressure, BUN, Potassium
Which clinical finding would the nurse anticipate in a client with chronic venous insufficiency?
Brownish, hardened skin on lower extremities
A client is in suspected shock state from major trauma. Which parameters best indicate the adequacy of peripheral perfusion?
Capillary refill, Skin color and temperature
A client with myocardial infarction underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider about resuming sexual relations. What teaching should the nurse reinforce with this client?
Client may be ready for sexual activity if no symptoms occur when climbing to flights of stairs
The nurse reinforces discharge instructions to a client who was hospitalized for deep venous thrombosis that has now resolved. Which instructions should the nurse include to prevent reoccurrence?
Drink plenty of fluids daily and limit caffeine and alcohol intake, elevate legs on a footstool when sitting and dorsiflex the feet often, resume the walking or swimming excercise program as soon as possible after getting home
The nurse is caring for a hospice client with advanced heart failure who is having trouble breathing. Which comfort intervention should the nurse implement first?
Elevate the head of the bed
The nurse is reinforcing instructions to a client scheduled for cardiac pharmacologic nuclear stress testing. Which client statements indicate appropriate understanding?
I should stop drinking coffee 24 hours before the procedure
The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions?
I will apply moisturizing lotion on my legs every day, keep legs below heart level when sitting, start walking outside with neighbor
A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective?
I will let my daughter fix my hair until my health care provider says i can do it
The nurse is reinforcing discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective?
I will shave with an electric razor from now on
The practical nurse is caring for a client with newly diagnosed infective endocarditis. Which assessment finding by the nurse is the highest priority to report to the registered nurse?
Pain and pallor in one foot
A 62-year-old client admitted to the telemetry unit after an acute myocardial infarction 3 days ago reports that the left calf is very tender and warm to the touch. Which nursing intervention is the priority?
Perform a neurovascular check on the lower extremities
The nurse is caring for a client after percutaneous placement of a coronary stent for a myocardial infarction. The client rates lower back pain as 5 on a scale of 0-10 and has blood pressure of 140/92 mm Hg. The cardiac monitor shows normal sinus rhythm with occasional premature ventricular contractions. Which prescription should the nurse administer first?
Potassium chloride IVPB
The client was diagnosed 6 months ago with hypertension and had a recent emergency department visit for a transient ischemic attack. The client's blood pressure today is 170/88 mm Hg. What teaching topic is a priority for the nurse to reinforce with this client?
Taking blood pressure medications as prescribed
The nurse reviews laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires the most immediate action by the nurse?
Troponin
The practical nurse is assisting the registered nurse during admission of a client with heart failure-related fluid overload. Which action should be completed first?
assess the clients breath sounds
A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action?
auscultate the clients breath sounds
The nurse is reinforcing teaching to a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include?
avoid excess caffeine, practice yoga or tai chi, refrain from using tobacco products, wear gloves when handling cold objects
A client with aortic stenosis is scheduled for surgery in 2 weeks. The client reports episodes of angina and passing out twice at home. Which would be the best response by the nurse to explain the appropriate activity for this client at this time?
avoid strenous activity before the surgery
The nurse is inspecting the legs of a client with a suspected lower-extremity deep venous thrombosis. Which of the following clinical manifestations should the nurse expect?
calf pain, lower leg warmth and redness, unilateral leg edema
The nurse is caring for a client recently diagnosed with an active deep vein thrombosis (DVT). Which action by the client would require an immediate intervention by the nurse?
client is massaging the leg at the site of inflammation
The nurse is reinforcing discharge instructions for several clients. Which client should receive information about the need for prophylactic antibiotics prior to dental procedures?
client who had mechanical aortic valve replacement
A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client?
diffuse bilateral crackles at lung bases
A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse?
i will weigh myself every other day, ibuprofen works best for me when i have pain
The clinic nurse is reinforcing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client?
keep a diary of activities and any symptoms experienced
The emergency department nurse is caring for a 70-year-old client with a history of type 2 diabetes mellitus who reports sudden-onset nausea, sweating, dizziness, and fatigue. The nurse should anticipate the initiation of which protocol?
myocardial infarction
The nurse is reinforcing discharge instructions to a client who has had coronary artery bypass grafting. Which teachings are correct?
notify doc of redness swelling or drainage at incision site, refrain from lifting object wieghing over 5 lbs, take shower daily without soaking chest and incisions
A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off?
partial thromboplastin time of 110 seconds
After assisting a client with a lower gastrointestinal bleed back to bed, the nurse finds approximately 600 mL of frank red blood in the toilet. The client is pale and diaphoretic and reports dizziness. Which action should the nurse perform first?
Lower the head of the bed
A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first?
Auscultate breath sounds
A client with heart failure has gained 5 lb (2.26 kg) over the last 3 days. The nurse reviews the client's blood laboratory results. Based on this information, what medication administration does the nurse anticipate?
Furosemide
A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin. Which client statement regarding digoxin toxicity indicates that teaching reinforcement is needed?
I will need to increase my potassium intake
The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next?
Resume chest compressions at a rate of 100/min
The nurse auscultates the heart sounds of a 77-year-old client with chronic heart failure. Which heart sound should the nurse document?
S3 extra heart sound
A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse reinforces teaching to the client that the pain will improve with?
Sitting up and Leaning forward
A client who developed heart failure after a myocardial infarction is scheduled to be discharged this afternoon. Based on the discharge data, the nurse plans to reinforce which home care instructions?
Take own pulse, monitor daily weight, reduction of sodium in diet
A nurse is reinforcing discharge instructions to a client during the fifth hospitalization for pulmonary edema caused by congestive heart failure exacerbation. Which statement by the client indicates that further teaching is required?
potato chips are acceptable snack in moderation
After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is most concerning?
right calf is 4cm larger than left calf
A client is diagnosed with Buerger disease (thromboangiitis obliterans). The nurse anticipates reinforcing education about which treatment option?
smoking cessation
A client with mitral valve prolapse has been experiencing occasional palpitations, lightheadedness, and dizziness. The health care provider prescribes a beta blocker. What additional teaching should the nurse reinforce for this client?
stay well hydrated and avoid caffeine
The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention?
the client has a new dependent edema of the feet
