What should a nurse do to decrease or control the sensory and cognitive disturbances that can occur after a client has open-heart surgery?
Plan for maximum periods of rest
A client is scheduled to be transferred from the coronary care unit to a progressive care unit. The client asks a nurse, “Are you sure I’m ready for this move?” What does the nurse conclude the client most likely is experiencing?
A nurse provides teaching regarding vitamin B12 injections to a client with pernicious anemia. The nurse concludes that the teaching was understood when the client states, “I must take the drug:
Monthly, for the rest of my life.
A client admitted to the hospital has edematous ankles. What should the nurse do to best reduce edema of the lower extremities?
Elevate the legs.
A client hospitalized for heart failure is receiving digoxin (Lanoxin) and will continue taking the drug after discharge. What should be included in the plan of care for the next few days?
Taking the apical pulse before drug administration and teaching the client how to count the pulse.
The nurse should monitor the client for which clinical finding indicating digoxin toxicity?
A client who is scheduled for a modified radical mastectomy decides to have family members donate blood in the event it is needed. The client has type A negative blood. Blood can be used from relatives whose blood is:
Type A or O negative
A client asks a nurse why captopril (Capoten) was prescribed. What specific drug classification should the nurse include in the explanation to the client?
A client who is complaining of severe midsternal pain is brought to the emergency department. The client is diagnosed with a myocardial infarction. Which drug can the nurse expect to be prescribed to control this client’s pain?
Morphine sulfate (MS Contin)
What is the most objective way that a nurse can assess the extent of edema in a client?
Weighing the client
After sustaining multiple internal injuries when hit by a motor vehicle, a client has a sudden drop in blood pressure to 80/60 mm Hg. What does the nurse determine probably caused this response?
Reduction in circulating blood volume
The nurse is assessing a client for signs of right ventricular failure. What should the nurse expect if this occurs?
Neck vein distention
The nurse is assessing a client with the diagnosis of chronic heart failure. Which clinical finding should the nurse expect the client to experience?
Dependent edema in the evening
The nurse is providing teaching to a client who is scheduled for a cardiac catheterization via the femoral approach. The teaching includes that the client will be:
In the supine position with the affected leg extended for several hours postprocedure.
A nurse is evaluating the results of treatment with erythropoietin (Epogen). Which client response is considered significant?
Elevation in hematocrit level
The nurse provides medication discharge instructions to a client who received a prescription for digoxin (Lanoxin) following the client’s myocardial infarction. The nurse concludes that the teaching was effective when the client says, “I should:
Check my radial pulse rate daily.
The nurse is caring for a client who is experiencing signs and symptoms of a cardiac dysrhythmia who is scheduled to wear a Holter monitor for 24 hours. During the test, the client should be instructed to:
Keep a diary of activities
A client is recovering from a myocardial infarction. Before developing the client’s teaching plan, it is important for the nurse to:
Identify the learning needs of the client
A client with bilateral varicose veins of the lower extremities questions the nurse about the brownish discoloration of the lower legs. The best response by the nurse is, “This is probably the result of:
Leakage of red blood cells through the vascular wall.”
A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care?
Perform a neurovascular assessment every two hours
A client develops a non-healing ulcer of a lower extremity and complains of leg cramps after walking short distances. The client asks the nurse what causes these leg pains. The nurse’s best response is:
“Pain occurs in the legs while walking because there is a lack of oxygen to the muscles.”
A client who is receiving a cardiac glycoside, a diuretic, and a vasodilator has been placed on bed rest. The client’s apical pulse rate is 44 beats per minute. The nurse concludes that the decreased heart rate most likely is a result of the:
What should the nurse assess to determine if a client is experiencing the therapeutic effect of valsartan (Diovan)?
A client diagnosed with multiple myeloma has been given a poor prognosis. After discharge, the client plans to travel on an airplane and attend sporting events with friends and family. The nurse prepares a discharge teaching plan for this client and includes:
Preventing infection; the client is at risk for leukopenia
A client admitted to the hospital for chest pain is diagnosed with angina. The nurse should teach the client that the most common characteristic of anginal pain is that it is:
Relieved by rest
A client is admitted with stage 2 hypertension. What diastolic pressure does the nurse consider to be consistent with this diagnosis?
More than 100 mm Hg
A client is scheduled to have a cardiac catheterization via the femoral approach. The nurse teaches the client about post-procedure interventions that protect the catheter insertion site. The nurse instructs the client that the leg used for catheter insertion will be:
Kept extended while on bed rest
The nurse is conducting a nutrition class for a group of clients with congestive heart failure (CHF). It would be most important for the nurse to explain the importance of:
Choosing fresh or frozen vegetables instead of canned ones
A client has untreated stage 1 hypertension. What is the minimum systolic pressure the nurse expects when obtaining this client’s blood pressure?
140 to 159 mm Hg
A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, the nurse expects the client to state:
“I have trouble breathing when I walk rapidly.”
A nurse in the postanesthesia care unit identifies a progressive decrease in blood pressure in a client who had major abdominal surgery. What clinical finding supports the conclusion that the client is experiencing internal bleeding?
The nurse is caring for a client that is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear what lung sounds?
A nurse is discussing discharge instructions with a client who had a coronary artery bypass graft (CABG). The client states, “My spouse is afraid to have sex with me. When will it be safe to have sex again?” Which is the most appropriate response by the nurse?
“You can resume sexual activity as soon as you can climb one flight of stairs without fatigue or discomfort.”
A 75-year-old client has a baseline blood pressure of 140/90 mm Hg. The nurse obtains a sitting blood pressure in the client’s left arm, and the reading is 160/100 mm Hg. What action should the nurse take next?
Take the blood pressure in the right arm, and then take the blood pressure in both arms while the client is standing
A client’s cardiac monitor shows a PQRST wave for each beat and indicates a rate of 120 beats per minute. The rhythm is regular. The nurse concludes that the client is experiencing:
A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the drug, the client complains of feeling dizzy. What action should the nurse take?
Place the client in the supine position and take the vital signs
A nurse is teaching a health class to older adult women about heart disease. The nurse discusses the most common prodromal symptom reported by women with acute coronary heart disease that usually is not experienced by men. What response indicates that a woman understood the teaching?
A client develops a nosebleed (epistaxis) and seeks treatment at a first-aid station. The nurse can help control the bleeding by:
Pinching the nostrils together
An 85-year-old client has a serum potassium level of 6.7 mEq/L. Which nursing action is a priority at this time?
Monitor for cardiovascular irregularities
The nurse is caring for a client undergoing chemotherapy for cancer treatment. The client’s laboratory results indicate bone marrow suppression. The nurse should encourage the client to:
Use an electric razor when shaving
Which client statement indicates an understanding of the nurse’s instructions concerning a Holter monitor?
The monitor will record any abnormal heart rhythms while I go about my usual activities.
A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk?
A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected first?
A client being treated for hypertension reports having a persistent hacking cough. What class of antihypertensive should the nurse identify as a possible cause of this response when reviewing a list of this client’s medications?
Angiotensin-converting enzyme (ACE) inhibitors
A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming, “I can’t breathe!” The nursing priority action is:
Elevate the head of the bed and obtain vital signs
A nurse witnesses a person fall. The person becomes unresponsive and pulseless. The nurse plans to use an automated external defibrillator (AED) that is available on site. What should the nurse do first?
Remove any medication patches
A client is admitted to the hospital with atrial fibrillation. A diagnosis of mitral valve stenosis is suspected. The nurse concludes that it is most significant if the client presents with a history of:
Childhood strep throat
A client develops severe bone marrow suppression related to cancer treatment. What is important for the nurse to include in the client’s teaching?
Use a soft toothbrush for oral hygiene
A client with stage III-B Hodgkin disease is started on chemotherapy. The nurse teaches the client to notify the health care provider to seek treatment for which response to chemotherapy?
Sores in the mouth
An older client tells the nurse, “My legs begin to hurt after walking the dog for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking.” Which condition does the nurse consider as the most likely cause of the client’s responses?
A client experiences elevated triglycerides and cholesterol. The client appears discouraged and says, “Well, I guess I’d better cut out all the fat and cholesterol in my diet.” Which is the nurse’s most appropriate response?
“You need some fat to supply the necessary fatty acids, so it’s mainly just a need to cut down on the amount of fat you consume.”
A client is in cardiogenic shock. What explanation of cardiogenic shock should the nurse include when responding to a family member’s questions about the condition?
A failure of the circulatory pump
A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity has a femoral angiogram. What is the priority nursing action after the angiogram?
Assess the client’s affected extremity
A client with a history of type 1 diabetes is diagnosed with heart failure. Digoxin (Lanoxin) is prescribed. When administering the medication, the nurse should:
Monitor the client for atrial fibrillation and first-degree heart block
Amlodipine (Norvasc) is prescribed for a client with hypertension. Which response to the medication should the nurse instruct the client to report to the health care provider?
An older adult tells the nurse, “I read about a vitamin that may be related to aging because of its effect on the structure of cell walls. I wonder whether it is wise to take it.” The nurse concludes the client probably is referring to:
A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication?
A client with a long history of bilateral varicose veins questions a nurse about the brownish discoloration of the skin on the lower extremities. What should the nurse include in the response to the client’s question?
There is leakage of red blood cells (RBCs) through the vascular wall.
A client who is hospitalized after a myocardial infarction asks the nurse why the client is receiving morphine. The nurse replies that morphine:
Relieves pain and prevents shock
A client is receiving warfarin (Coumadin). Which test result should the nurse use to determine if the daily dose of this anticoagulant is therapeutic?
International Normalized Ratio (INR)
For what client response must the nurse monitor to determine the effectiveness of amiodarone (Cordarone)?
Presence of cardiac dysrhythmias
A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates the need for further instruction?
Whole milk with oatmeal
A child with a congenital heart defect has a cardiac catheterization. What is an essential element of nursing care after this procedure?
Monitoring the extremity distal to the insertion site
What is the most important information the nurse and the rapid response team must keep in mind when caring for a client who had a cardiac arrest?
How long the client was anoxic
How should the nurse make the bed of a client who is in the acute phase after a myocardial infarction?
Replace the top linen and only the necessary bottom linen.
The nurse is reviewing a teaching plan for a client that has been prescribed a 2-gram sodium diet. The plan should include which foods that are low in sodium?
Fruits and juices
What clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block?
A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client’s aphasia. What is a common cause of this type of occlusion?
Emboli associated with atrial fibrillation
A client with a distal femoral shaft fracture is at risk for developing a fat embolus. The nurse considers that a distinguishing sign that is unique to a fat embolus is:
A client takes isosorbide dinitrate (Isordil) daily. The client states, “I would like to start taking sildenafil (Viagra) for erectile dysfunction. I was told I can’t take sildenafil and isosorbide dinitrate at the same time.” The nurse explains that taking both of these medications concurrently may result in severe:
A client is admitted to the emergency department with chest pain and shortness of breath. An electrocardiogram indicates that the client is experiencing a myocardial infarction. An emergency cardiac catheterization is scheduled. What information should the nurse include in the pre-procedure teaching?
Mild sedation is maintained during the procedure
When supporting vasodilation by the use of warmth for a client with peripheral arterial insufficiency, the nurse cautions the client to avoid:
Using a heating pad to warm the extremities
A client with rheumatoid arthritis has been taking a steroid medication for the past year. For which complication of prolonged use of this medication should the nurse assess the client?
Decreased white blood cells
A nurse concludes that the simvastatin (Zocor) being administered to a client is effective. A decrease in what clinical finding supports this conclusion?
A client is admitted with a higher than expected red blood cell (RBC) count. What physiological alteration does the nurse expect will result from this clinical finding?
Increased blood viscosity