MT Flashcards
A client is concerned about a rash that has developed on their abdomen. What is the nurse’s best response to the client?
a. A rash is similar to infection.”
b. “Inflammation always leads to gangrene.”
c. “A rash is a sequential reaction to injury.”
d. “Rashes indicate the presence of harmful microorganisms that are thriving.”
c.“A rash is a sequential reaction to injury.”
Diphenhydramine was prescribed to a client with an allergic reaction. The client asks “how does this medication work?” The nurse states “Diphenhydramine works by inhibiting the release of _____________.”
a. Histamine
b. Serotonin
c. Bradykinins
d. Prostaglandins
a. Histamine
A surgeon’s progress notes indicated “sanguineous drainage on wound gauze.” The nurse’s best description for the drainage is which of the following?
a. Bloody
b. Purulent
c. Clear
d. Thick
a. Bloody
A trauma nurse is replacing an old chest tube canister filled with clear-pinkish secretions. What is the best description of the exudate the nurse should enter in the progress notes?
a. Catarrhal
b. Hemorrhagic
c. Serosanguineous
d. Sanguineous
c. Serosanguineous
A wound care nurse is managing a client with Stage IV pressure ulcer. The wound was noted to be foul-smelling with yellowish discharge draining copiously. Which of the following findings is most concerning for the nurse?
a. Purulent discharge
b. Serous secretions
c. Fibrinous plaque
d. Catarrhal drainage
a. Purulent discharge
A local response to inflammation involved release of histamine. Which of the following are effects of histamine? Select all that apply.
a. Vasoconstriction
b. Edema
c. Redness
d. Heat
b. Edema
c. Redness
d. Heat
A patient with Pneumothorax underwent emergency insertion of chest tube. Which of the following assessment findings is most concerning to nurse?
a. Bubble arising from the suction control chamber.
b. Drainage is lower than the patient
c. Hemorrhagic secretions 400 ml in the chamber
d. Suction is at -20 cm H2O
c. Hemorrhagic secretions 400 ml in the chamber
Inflammation involves different transmitters. Which of the following mediators of inflammation causes contraction of smooth muscles? Select all that apply.
a. Complement component
b. Serotonin
c. Kinins
d. Histamine
b. Serotonin
c. Kinins
According to CDC, in 2004 about 159,000 of all nursing home residents developed pressure ulcers. What are the common causes of pressure ulcers? Select all that apply.
a. Immobility
b. Prolonged moisture exposure
c. Bedbound
d. Shearing forces
a. Immobility
b. Prolonged moisture exposure
c. Bedbound
d. Shearing forces
A nurse is preparing a plan of care for a client with a sacral pressure ulcer. What intervention should the nurse include in the client’s care plan to prevent worsening of the ulcer?
a. Frequent repositioning
b. Accurate titration of vasoactive drugs
c. Pain control
d. Proper nutrition
a. Frequent repositioning
A wound care nurse is conducting a lecture about complications of improper wound healing. Which complication is described as: the creation of connecting wound from original source to adjacent structure?
a. Adhesion
b. Fistula
c. Infection
d. Evisceration
b. Fistula
A nurse is entering a physician’s request for a wound vacuum into the electronic medical system. Which pressure ulcer is this device being prescribed to treat?
a. Stage I Pressure Ulcer
b. Stage II Pressure Ulcer
c. Mildly draining Stage III Pressure Ulcer
d. Copiously draining Stage IV Pressure Ulcer
d. Copiously draining Stage IV Pressure Ulcer
A surgeon ordered: “Cleanse Sacral Stage IV Pressure Ulcer with normal saline, apply clean moist gauze with normal saline, cover abdominal pad, secure with tape.” What type of debridement has the physician prescribed to treat this wound?
a. Surgical debridement
b. Mechanical debridement
c. Enzymatic debridement
d. Autolytic debridement
b. Mechanical debridement
A client with abdominal surgical incision is being investigated for delayed wound healing. Which of the following can cause delayed wound healing? Select all that apply
a. Infection
b. Smoking
c. Advanced age
d. Diabetes Mellitus
a. Infection
b. Smoking
c. Advanced age
d. Diabetes Mellitus
A nurse is documenting a wound assessed on client. What is the accurate pressure ulcer stage for the wound shown below:
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
e. Unstageable
f. Suspected Deep Tissue Injury
f. Suspected Deep Tissue Injury
A nurse is documenting a wound assessed on client. What is the accurate pressure ulcer stage for the wound shown below:
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
e. Unstageable
f. Suspected Deep Tissue Injury
e. Unstageable
A nurse performs a wound assessment on a client. How should the nurse document this wound?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
e. Unstageable
f. Suspected Deep Tissue Injury
d. Stage IV
A nurse assesses a client’s wound. What pressure ulcer stage should the nurse document for this client?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
e. Unstageable
c. Stage III
A nurse assesses a client’s wound. What pressure ulcer stage should the nurse document for this client?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
e. Unstageable
b. Stage II
A nurse assesses a client’s wound. What pressure ulcer stage should the nurse document for this client?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
e. Unstageable
a. Stage I
Which of the following diets would place a client at the highest risk for macrocytic anemia?
a. Lacto-ovo-vegetarian
b. Lacto-vegetarian
c. Macrobiotic
d. Vegan
d. Vegan
The nurse is caring for a 50-year-old client in the clinic. The client’s annual physical examination revealed a hemoglobin value of 10 g/dL (100 g/L) compared to 13 g/dL (130 g/L) a year ago. What should be the nurse’s initial action?
a. Encourage intake of over-the-counter iron pills
b. Encourage intake of red meat and egg yolks
c. Facilitate a screening colonoscopy
d. Facilitate another blood test in 6 months
c. Facilitate a screening colonoscopy
A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL (50 g/L). The nurse should anticipate which findings? Select all that apply.
a. Coarse crackles
b. Dyspnea
c. Pallor
d. Respiratory depression
e. Tachycardia
b. Dyspnea
c. Pallor
e. Tachycardia
The nurse teaches a client diagnosed with iron-deficiency anemia about iron-rich foods. The nurse determines teaching has been effective when the client chooses which of the following meals?
a. Chicken salad with lettuce on French bread, chocolate pudding, and milk
b. Fat-free yogurt, carrot sticks, apple slices, and diet soda
c. Ham, steamed carrots, green beans, gelatin dessert, and iced tea
d. Kale salad with boiled eggs and dried fruit, a brownie, and orange juice
d. Kale salad with boiled eggs and dried fruit, a brownie, and orange juice
The nurse is caring for a client with severe chronic obstructive pulmonary disease (COPD). The nurse anticipates which laboratory results for this client?
a. Anemia
b. Neutropenia
c. Polycythemia
d. Thrombocytopenia
c. Polycythemia
A elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission laboratory results and identifies which value as the most likely cause of the client’s symptoms?
a. Brain natriuretic peptide 70 pg/mL (70 pmol/L)
b. Hematocrit 21% (0.21)
c. Leukocytes 3,500/mm3 (3.5 x 109/L)
d. Platelets 105,000/mm3 (105 x 109/L)
b. Hematocrit 21% (0.21)
A client with polycythemia vera comes to the clinic for treatment. The nurse knows that the monthly treatment for this condition involves which of the following?
a. Blood transfusion
b. Fluid bolus
c. Phlebotomy
d. Steroid injection
c. Phlebotomy
The nurse plans discharge teaching for a client newly diagnosed with polycythemia vera. Which actions will the nurse include in the teaching plan? Select all that apply.
a. Elevate the legs and feet when sitting
b. Increase dietary intake of foods rich in iron
c. Increase fluid intake during exercise and hot weather
d. Increase water temperature to reduce post-bath itching
e. Report swelling or tenderness in the legs
a. Elevate the legs and feet when sitting
c. Increase fluid intake during exercise and hot weather
e. Report swelling or tenderness in the legs
A medical surgical nurse has been assigned to four patients in the unit. Which assessment findings should the nurse report to the physician?
a. Iron Deficiency Anemia, Colorectal Cancer Hemoglobin 4.1 gm/dl
b. Acute Myelocytic Leukemia with a WBC of 55,000
c. Sickle-Cell Disease, receiving treatment for Acute Vaso-Occlusive Crisis
d. Aplastic Anemia with a Platelet level of 75,000
a. Iron Deficiency Anemia, Colorectal Cancer Hemoglobin 4.1 gm/dl
A nurse received a low hemoglobin level for a patient. Which of the following is the most likely diagnosis for the patient?
a. Iron Deficiency Anemia
b. Megaloblastic Anemia
c. Sideroblastic Anemia
d. Thalassemia
a. Iron Deficiency Anemia
A male client (75 kg) diagnosed with Acute Myelocytic Leukemia is to receive Bleomycin (Cytotoxic glycopeptide) which comes in 30 units/100 ml. The physician ordered 0.5 units/kg via intravenous route. How many total ml of drug should the patient receive?
a. 123 cc
b. 125 cc
c. 127 cc
d. 129 cc
b. 125 cc
A client (80 Kg) with Sickle Cell Anemia is ordered transfusion of packed RBC for a hemoglobin level of 6.8 gms/dl. The blood product has a total volume of 375 ml. The hematologist ordered to transfuse in 4 hours. How many ml per hour should the nurse
a. 93.75 ml/hr
b. 72.55 ml/hr
c. 51.2 ml/hr
d. 87.8 ml/hr
a. 93.75 ml/hr
Which of the following blood cancers is most commonly associated with younger clients?
a. Acute Myelocytic Leukemia
b. Acute Lymphocytic Leukemia
c. Chronic Myelocytic Leukemia
d. Chronic Lymphocytic Leukemia
b. Acute Lymphocytic Leukemia
A 27-year-old male client informed their health care provider that they were diagnosed with leukemia but has been in remission for many years. The nurse obtaining the history is aware that the client was most likely diagnosed with which of the following types of leukemia?
a. Acute Myelocytic Leukemia
b. Acute Lymphocytic Leukemia
c. Chronic Myelocytic Leukemia
d. Chronic Lymphocytic Leukemia
b. Acute Lymphocytic Leukemia
A client with Sickle Cell Disease was recently admitted in the Medical-Surgical Ward at Queen of the Valley Hospital. The nurse formulating nursing diagnoses should include which of the following as a priority?
a. Acute Pain
b. Anxiety
c. Ineffective tissue perfusion
d. Activity intolerance
c. Ineffective tissue perfusion
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? Select all that apply.
a. Amphetamine use
b. Cigarette smoking
c. Cold exposure
d. Deep sleep
e. Sexual intercourse
a. Amphetamine use
b. Cigarette smoking
e. Sexual intercourse
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?
a. Hematocrit of 30%
b. Partial thromboplastin time of 110 seconds
c. Platelet count of 80,000/mm3 (80 x 109/L)
d. Prothrombin time of 11 seconds
b. Partial thromboplastin time of 110 seconds
An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit. The new RN is measuring orthostatic blood pressure (BP) for a client. Which situation would warrant intervention by the experienced nurse?
a. Nurse has client lie supine for 5-10 minutes prior to starting procedure
b. Nurse interprets a decrease in systolic BP by 10 mm Hg as a normal finding
c. Nurse starts by measuring BP and heart rate (HR) with the client standing
d. Nurse takes BP and HR after standing at 1- and 3-minute intervals
c. Nurse starts by measuring BP and heart rate (HR) with the client standing
A client develops sinus bradycardia with blood pressure of 90/40 mm Hg and a heart rate of 46/min. Which of the following actions should the nurse take?
a. Give scheduled dose of metoprolol 50 mg orally
b. Instruct client to cough forcefully
c. Place client in reverse Trendelenburg position
d. Prepare to administer atropine 0.5 mg intravenous (IV) push
d. Prepare to administer atropine 0.5 mg intravenous (IV) push
The clinic nurse is providing 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?
a. How to transmit the readings over the phone
b. Keep a diary of activities and any symptoms experienced
c. Refrain from exercising while wearing the monitor
d. The monitor may be removed only when bathing
b. Keep a diary of activities and any symptoms experienced
A registered nurse is making pre-procedure phone calls to clients scheduled for cardiac pharmacologic nuclear stress testing the following day. Which instructions should the nurse give the clients? Select all that apply.
a. Decaffeinated coffee or tea can be consumed
b. Do not consume caffeine for 24 hours before the test
c. Do not smoke on the day of the test
d. Do not take beta blockers on the day of the test
e. Take diabetic medications as usual before the test
b. Do not consume caffeine for 24 hours before the test
c. Do not smoke on the day of the test
d. Do not take beta blockers on the day of the test
A nurse is making initial client rounds at the beginning of the shift. Which client should the nurse see first?
a. 36-year-old client with endocarditis who has a temperature of 100.6 F (38.1 C), chills, malaise, and a heart murmur
b. 40-year-old client with pericardial effusion who has blood pressure of 84/62 mm Hg and jugular venous distension
c. 67-year-old client admitted for pneumonia with new-onset atrial fibrillation, who has blood pressure of 130/90 mm Hg and heart rate of 110/min
d. 70-year-old client with advanced heart failure who is receiving intravenous (IV) diuretics, has blood pressure of 80/60 mm Hg, and is watching TV
b. 40-year-old client with pericardial effusion who has blood pressure of 84/62 mm Hg and jugular venous distension
The nurse is caring for a client with newly diagnosed infective endocarditis (IE). Which assessment finding by the nurse is the highest priority to report to the health care provider (HCP)?
a. Pain and pallor in one foot
b. Pain in both knees
c. Splinter hemorrhages in the nail beds
d. Temperature of 102.2 F (39 C)
a. Pain and pallor in one foot
The nurse should plan to teach which client about the need for prophylactic antibiotics prior to dental procedures?
a. Client who had a large anterior wall myocardial infarction (MI) with subsequent heart failure
b. Client who had a mitral valvuloplasty repair
c. Client with a mechanical aortic valve replacement
d. Client with mitral valve prolapse with regurgitation
c. Client with a mechanical aortic valve replacement
A client is in suspected shock state from major trauma. Which parameters best indicate the adequacy of peripheral perfusion? Select all that apply.
a. Apical pulse
b. Capillary refill
c. Lung sounds
d. Pupillary response
e. Skin color and temperature
b. Capillary refill
e. Skin color and temperature
A client with an implantable cardioverter defibrillator (ICD) develops ventricular tachycardia (VT) with a pulse while admitted to the medical-surgical unit. The ICD fires multiple times without successfully stopping the VT, causing the client to become confused and difficult to rouse. Which action by the nurse is appropriate?
a. Attempt to stimulate a vagal response by having the client cough
b. Deactivate the client’s implantable cardioverter defibrillator with an external magnet
c. Obtain a STAT 12-lead ECG to verify the cardiac rhythm
d. Prepare for synchronized cardioversion with the external defibrillator
d. Prepare for synchronized cardioversion with the external defibrillator
The nurse is caring for a client who just had a permanent ventricular pacemaker inserted. The nurse observes the cardiac monitor and sees a pacing spike followed by a QRS complex for each heartbeat. How should the nurse assess for mechanical capture of the pacemaker?
a. Auscultate the client’s lungs sounds
b. Measure the client’s blood pressure
c. Obtain a 12-lead ECG
d. Palpate the client’s radial pulse rate
d. Palpate the client’s radial pulse rate
The nurse is planning discharge teaching for a client who just received a permanent pacemaker. Which topics should the nurse include? Select all that apply.
a. Avoid MRI scans
b. Do not place cell phones directly over the pacemaker
c. Notify airport security when traveling
d. Perform shoulder range-of-motion exercises
e. Refrain from using microwave ovens
a. Avoid MRI scans
b. Do not place cell phones directly over the pacemaker
c. Notify airport security when traveling
A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse explains that the pain will improve with which of the following?
a. Coughing and deep breathing
b. Left lateral position
c. Pursed-lip breathing
d. Sitting up and leaning forward
d. Sitting up and leaning forward
The nurse receives handoff of care report on four clients. Which client should the nurse see first?
a. Client with atrial fibrillation who reports feeling palpitations and has an irregular pulse of 122/min
b. Client with liver cirrhosis who reports bleeding from an IV insertion site and has a platelet count of 48,000 mm3 (48 x 109/L)
c. Client with pericarditis whose blood pressure has decreased from 122/70 mm Hg to 98/68 mm Hg over the past hour
d. Client with pneumonia whose white blood cell count has increased from 14,000 mm3 (14 x 109/L) 8 hours ago to 30,000 mm3 (30 x 109/L)
c. Client with pericarditis whose blood pressure has decreased from 122/70 mm Hg to 98/68 mm Hg over the past hour
A parent calls the nursing triage line during the evening. The parent says that a 7-year-old was found playing in an area with poison ivy and asks what to do. Which is the most important instruction to give the parent?
a. Apply cool, wet compresses for itching
b. Apply topical cortisone ointment to the area
c. Discourage the child from scratching the area
d. Wash the skin where the contact occurred
d. Wash the skin where the contact occurred
The nurse assesses the sacral wound of a newly admitted client. How should the nurse document the wound? Picture 1.png
a. Stage 2 pressure injury
b. Stage 3 pressure injury
c. Suspected deep-tissue injury
d. Unstageable pressure injury
d. Unstageable pressure injury
The nurse is assessing a 2-year-old who has a blistered sunburn across the back and shoulders. Which of the following parent statements indicates an appropriate understanding of care for sunburn? Select all that apply.
a. “I am allowing my child to play outdoors only very early in the morning and late in the evening since the sunburn.”
b. “I am encouraging extra fluids since my child got sunburned.”
c. “I have been giving my child acetaminophen to help relieve the pain.”
d. “I have been placing cool, wet washcloths on my child’s back.”
e. “I have rubbed hydrocortisone cream on the area to help reduce inflammation and promote healing.”
a. “I am allowing my child to play outdoors only very early in the morning and late in the evening since the sunburn.”
b. “I am encouraging extra fluids since my child got sunburned.”
c. “I have been giving my child acetaminophen to help relieve the pain.”
d. “I have been placing cool, wet washcloths on my child’s back.”
The nurse is conducting an educational community outreach program on melanoma screening. Which statement by a resident indicates the need for further education?
a. “Abrupt changes in the size or color of a mole are warning signs.”
b. “All new growths and pigmentations must be biopsied to rule out cancer.”
c. “Melanoma can occur as multiple different colors.”
d. “Melanoma does not always occur as a new mole.”
b. “All new growths and pigmentations must be biopsied to rule out cancer.”
The nurse is caring for a client with hemophilia admitted for a facial laceration and hemarthrosis of the left knee after falling at home. Which of the following actions by the nurse are appropriate? Select all that apply.
a. Administers coagulation factor replacement IV push
b. Administers ibuprofen PO PRN for pain
c. Applies ice packs to the affected joint hourly for 15 minutes
d. Elevates the affected leg in the extended position
e. Performs neurologic assessment every 30 minutes for 6 hours
a. Administers coagulation factor replacement IV push
c. Applies ice packs to the affected joint hourly for 15 minutes
d. Elevates the affected leg in the extended position
e. Performs neurologic assessment every 30 minutes for 6 hours
The nurse provides home care education to a client newly diagnosed with von Willebrand disease. Which of the following client statements demonstrate correct understanding of the education? Select all that apply.
a. “I can use a humidifier to help prevent nosebleeds.”
b. “I need to avoid contact sports such as soccer or hockey.”
c. “I should use a soft-bristled toothbrush and floss carefully.”
d. “I will call my health care provider if I soak a menstrual pad every hour.”
e. “I will take naproxen to decrease inflammation if I am injured.”
a. “I can use a humidifier to help prevent nosebleeds.”
b. “I need to avoid contact sports such as soccer or hockey.”
c. “I should use a soft-bristled toothbrush and floss carefully.”
d. “I will call my health care provider if I soak a menstrual pad every hour.”
The nurse provides care for a client diagnosed with polycythemia vera. Which statement by the client would require immediate follow-up?
a. “I am trying to find makeup to cover my unattractive, ruddy facial complexion.”
b. “I must have injured my leg in some way. It is sore, swollen, and red.”
c. “I take a baby aspirin to relieve my occasional headaches.”
d. “My skin itches so severely, and no lotion or cream seems to help.
b. “I must have injured my leg in some way. It is sore, swollen, and red.”
A medical surgical nurse is attending to four patients in the unit. Which assessment findings should the nurse report to the physician?
a. Iron Deficiency Anemia, Colorectal Cancer Hemoglobin 4.1 gm/dl
b. Acute Myelocytic Leukemia, WBC: 55,000
c. Sickle-Cell Disease, Acute Vaso-Occlusive Crisis
d. Aplastic Anemia, Platelets 75,000
a. Iron Deficiency Anemia, Colorectal Cancer Hemoglobin 4.1 gm/dl
A nurse received a low hemoglobin level for a patient. Which of the following is the most likely diagnosis for the patient?
a. Iron Deficiency Anemia
b. Megaloblastic Anemia
c. Sideroblastic Anemia
d. Thalassemia
a. Iron Deficiency Anemia
A 27-year-old male client informed his health care provider that he was once diagnosed with leukemia but has been in remission for many years. The nurse obtaining the history is aware that which type of leukemia is the most likely type?
a. Acute Myelocytic Leukemia
b. Acute Lymphocytic Leukemia
c. Chronic Myelocytic leukemia
d. Chronic Lymphocytic Leukemia
b. Acute Lymphocytic Leukemia
The nurse responds to a call for help from another staff member. Upon entering the client’s room, the nurse observes an unlicensed assistive personnel (UAP) performing chest compressions on an unconscious adult client while another nurse is calling for the emergency response team. What action by the arriving nurse is the priority?
- Ask the UAP to stop compressions and check for a pulse
- Establish additional IV access with large-bore IVs
- Obtain the defibrillator and apply the pads to the client’s chest
- Prepare to administer 100% O2 with a bag valve mask
- Obtain the defibrillator and apply the pads to the client’s chest
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 mmHg. The cardiac monitor shows normal sinus rhythm with occasional premature ventricular contractions. Which prescription should the nurse administer first?
Potassium 3.3 | Sodium 149 | Glucose 157
1. Captopril PO every 8 hours
2. Morphine IV PRN for pain
3. Potassium chloride IVPB once
4. Regular insulin subcutaneous with meals
- Potassium chloride IVPB once
A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the health care provider (HCP). which assessment data is most important for the nurse to report to the HCP? 12
- Blood pressure (BP) of 140/86 mm Hg
- Difficulty swallowing
- Dry, hacking cough
- Low back pain
- Difficulty swallowing
The telemetry nurse reports the cardiac monitor rhythms of 4 clients to the medical unit nurse assigned to care for them. The nurse should assess the client with which rhythm first?
- Atrial fibrillation with a pulse of 76/min in a client prescribed rivaroxaban
- Bradycardia in a client with a demand pacemaker set at 70/min
- First-degree atrioventricular block in a client prescribed atenolol
- Sinus tachycardia in a client with gastroenteritis and dehydration
- Bradycardia in a client with a demand pacemaker set at 70/min
A nurse cares for a client after cardiac catheterization. During assessment of the groin site, the nurse notices that the dressing is saturated with blood and a small trickle leaks down the client’s leg. What should the nurse do first?
- Apply direct manual pressure at and above the skin puncture site
- Call the health care provider to report active bleeding
- Check the peripheral pulse distal to the catheterization site
- Place a new pressure dressing over the catheterization site
- Apply direct manual pressure at and above the skin puncture site
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
- Check for peripheral edema
- Measure the client’s vital signs
- Review the client’s weight log over the past several days
- Auscultate breath sounds
A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective?
- I’m not worried about the device firing now because I know it won’t hurt.
- I will let my daughter fix my hair until my health care provider says I can do it
- I will looks into public transportation because I won’t be able to drive again
- I will notify my travel agent that I can no longer travel by plane
- I will let my daughter fix my hair until my health care provider says I can do it
The nurse on the step-down cardiothoracic unit receives the change-of-shift hand-off report. Which client should the nurse assess first?
- 2 days post abdominal aortic aneurysm repair with a pedal pulse decreased from baseline
- 2 days post coronary bypass graft surgery with a while blood cell count of 18,000/mm3
- Cardiomyopathy with an ejection fraction of 25% and dyspnea on exertion
- Pneumothorax with a chest tube to negative suction and subcutaneous emphysema
- 2 days post abdominal aortic aneurysm repair with a pedal pulse decreased from baseline
Which client is in need of follow-up education by the nurse?
1. Client with peripheral arterial disease (PAD) who insists on dangling leg over the side of the bed when
sleeping
2. Client with Raynaud’s phenomenon who routinely soaks hands in warm water before going out
3. Client with venous leg ulcer who refuses to wear elastic compression stockings during the day
4. Postsurgical client who points and flexes feet when lying in bed
- Client with venous leg ulcer who refuses to wear elastic compression stockings during the day
A client with peripheral arterial disease is visiting the health clinic. The nurse completes a health assessment. Which statement by the client indicates a priority need for follow-up teaching?
- I always take my simvastatin in the evening
- I prop my legs up in the recliner and use a heating pad when my feet are cold
- I’ve been walking on my treadmill at home for 15 minutes each day
- I’ve noticed that I don’t have much hair on my lower legs anymore
- I prop my legs up in the recliner and use a heating pad when my feet are cold
During assessment of a client who underwent a coronary artery bypass graft 10 hours ago, the nurse notes that the amount of drainage from the mediastinal chest tube has decreased from 100 mL to 20 mL over the last hour. Which of the following nursing actions is appropriate?
- Auscultate the client’s heart sounds
- Notify the client’s health care provider
- Position the tubing with a dependent loop
- Strip the chest tube to remove possible clots
- Auscultate the client’s heart sounds
What clinical symptoms might the nurse expect to find in a client with a central venous pressure (CVP) of 24 mm Hg? SATA
- Crackles in lungs
- Dry mucous membranes
- Hypotension
- Jugular venous distention
- Pedal edema
- Crackles in lungs
- Jugular venous distention
- Pedal edema
The nurse is caring for a client who just had aortic valve replacement surgery. Which assessment information is most important to report to the health care provider (HCP)?
- Chest tube output of 175 mL in past hour
- International Normalized Ratio (INR) of 1.5
- Temperature of 100.3F
- Total urine output of 85 mL over past 3 hours
- Chest tube output of 175 mL in past hour
The nurse is caring for a client on the organ donation waiting list for cardiac transplantation. Which teaching topic is most important for the nurse to emphasize at this time?
- Immunosuppressive therapy as a lifelong commitment
- Importance of accurate daily weight monitoring
- Importance of periodic endomyocardial biopsies
- Maintenance of meticulous surgical incision care
- Immunosuppressive therapy as a lifelong commitment
The client was diagnosed 6 months ago with hypertension and had a recent emergency department visit for a transient ischemic attack (TIA). the client’s blood pressure today is 170/88 mm Hg. What teaching topic is a priority for the nurse to discuss with this client?
- Decreasing sodium intake
- Decreasing stress levels at work and home
- Increasing activity level
- Taking blood pressure medications as prescribed
- Taking blood pressure medications as prescribed
The nurse is caring for a client diagnosed with a deep venous thrombosis 1 day ago. Which action by the client would require an immediate intervention by the nurse?
- Ambulates through the hallway several times per day
- Applies a warm compress to the site of inflammation
- Elevates the limb above the level of the heart while in bed
- Massages the affected leg to reduce pain and swelling
- Massages the affected leg to reduce pain and swelling
The nurse is monitoring a client following a radiofrequency catheter ablation. The nurse notes that the P waves are not associated with the QRS complexes on the cardiac monitor. Which intervention is most appropriate at this time?
- Call a code and begin chest compressions
- Call the rapid response team and prepare for cardioversion
- Document the findings in the chart and continue to monitor
- Notify the cardiologist and prepare for temporary pacing
- Notify the cardiologist and prepare for temporary pacing
A client with severe vomiting and diarrhea has a blood pressure of 90/70 mm Hg and pulse of 120/min. IV fluids of 2-liter normal saline were administered. Which parameters indicate that adequate rehydration has occurred?
- Capillary refill is less than 3 seconds
- Pulse pressure is narrowed
- Systolic blood pressure drops only when standing
- Urine output is 360 mL in 4 hours
- Urine specific gravity is 1.020
- Capillary refill is less than 3 seconds
- Urine output is 360 mL in 4 hours
- Urine specific gravity is 1.020
An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit. Which assessment technique by the new nurse requires intervention by the RN?
- Nurse carefully auscultates for heart murmurs at Erb’s point
- Nurse palpates bilateral carotid arteries simultaneously to assess for symmetry
- Nurse places client in semi-fowler’s position to assess for jugular venous distension
- Nurse positions client supine to assess the point of maximal impulse
- Nurse palpates bilateral carotid arteries simultaneously to assess for symmetry
The nurse is preparing to administer 40 mg of IV furosemide. Prior to administering the medication, the nurse
should assess which parameters? SATA
1. Blood pressure
2. Blood urea nitrogen
3. Liver enzymes
4. Potassium
5. White blood cell count
- Blood pressure
- Blood urea nitrogen
- Potassium
A client is hospitalized with worsening chronic heart failure. Which clinical manifestations does the admitting
nurse most likely assess in this client? SATA
1. Crackles on auscultation
2. Dry mucous membranes
3. Increased jugular venous distention
4. Rhonchi on auscultation
5. Skin “tenting”
6. 3+ pitting edema of the lower extremities
- Crackles on auscultation
- Increased jugular venous distention
- 3+ pitting edema of the lower extremities
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? SATA
1. Blue, cyanotic toes
2. Calf pain
3. Dry, shiny, hairless skin
4. Lower leg warmth and redness
5. Unilateral leg edema
- Calf pain
- Lower leg warmth and redness
- Unilateral leg edema
The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment
findings would indicate possible graft leakage and require a report to the primary care provider? SATA
1. Ecchymosis of the scrotum
2. Increased abdominal girth
3. Increased urinary output
4. Report of groin pain
5. Report of increased thirst and appetite loss
- Ecchymosis of the scrotum
- Increased abdominal girth
- Report of groin pain
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 not shock is advised.
Which action should the nurse perform next?
1. Check for a carotid pulse for at least 10 seconds
2. Provide rescue breaths at a rate of 10-12/min
3. Resume chest compressions at a rate of 100/min
- Use the jaw-thrust maneuver to assess the airway
- Resume chest compressions at a rate of 100/min
The nurse is admitting a client from the post-anesthesia care unit who just received a permanent
atrioventricular pacemaker for a complete heart block. Which action should the nurse implement first?
1. Assess incision for bleeding or hematoma formation
2. Auscultate bilateral anterior and posterior lung sounds
3. Initiate continuous cardiac monitoring
4. Reestablish IV fluids and postoperative antibiotics
- Initiate continuous cardiac monitoring
A nurse is caring for a client on the first day postop after having minimally invasive direct coronary artery
bypass (MIDCAB) grafting. The client thought that this surgery was supposed to have a much easier recovery
and asks the nurse why it is so painful to take deep breaths. What is the best response by the nurse?
1. I am sorry you have so much pain. I’ll go get your pain medication right now.
2. Let me call the health care provider (HCP) to see if we can increase the dose of your pain medicine
3. Take deep breaths while splinting your chest with a pillow, and use you incentive spirometer every 2
hours. This will help your recovery.
4. The overall recovery time is expected to be shorter, but initial postop pain can actually be higher with
MIDCAB because the incision are made between the ribs
- The overall recovery time is expected to be shorter, but initial postop pain can actually be higher with
MIDCAB because the incision are made between the ribs
The nurse is admitting a client with a diagnosis of right-sided heart failure resulting from pulmonary
hypertension. What clinical manifestations are most likely to be assessed? SATA
1. Crackles in lung bases
2. Increased abdominal girth
3. Jugular venous distention
4. Lower extremity edema
5. Orthopnea
- Increased abdominal girth
- Jugular venous distention
- Lower extremity edema
The nurse is caring for a client who had a large anterior wall myocardial infarction (MI) 24 hours ago. Which
finding is most important to report to the health care provider (HCP)?
1. Nausea and vomiting
2. New S3 heart sound
3. Occasional unifocal premature ventricular contractions (PVCs)
4. Temperature of 100.4F
- New S3 heart sound
A client with mitral valve prolapse (MVP) has been experiencing occasional palpitations, lightheadedness, and
dizziness. The health care provider prescribes a beta blocker. What additional teaching should the nurse
include for this client?
1. Avoid aerobic exercise
2. Ensure you receive antibiotics prior to dental work
3. Stay well hydrated and avoid caffeine
4. Wear a medical alert bracelet
- Stay well hydrated and avoid caffeine
A client with chronic heart failure calls the clinic reports a weight gain of 3 lb over the last 2 days. Which
information is most important for the nurse to ask this client?
1. Diet recall for this current week
2. Fluid intake for the past 2 days
3. Medications and dosages taken over the past 2 days
4. Presence of shortness of breath, coughing, or edema
- Presence of shortness of breath, coughing, or edema
The nurse is teaching a client diagnosed with Raynaud phenomenon about ways to prevent recurrent
episodes. Which introductions should the nurse include? SATA
1. Avoid excessive caffeine
2. Immerse hands in cold water
3. Practice yoga or tai chi
4. Refrain from using tobacco products
- Wear gloves when handling cold objects
- Avoid excessive caffeine
- Practice yoga or tai chi
- Refrain from using tobacco products
- Wear gloves when handling cold objects
The home care nurse visits the house of an elderly client. Which assessment finding requires immediate
intervention?
1. The client cannot remember what was done yesterday
2. The client has a painful red area on the buttocks
3. The client has new dependent edema of the feet
4. The client has strong, foul smelling urine
- The client has new dependent edema of the feet
A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature
99.2F, 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?
1. Arterial blood gasses (ABGs)
2. B-type natriuretic peptide (BNP)
3. Cardiac enzymes (CK-MB)
4. Chest x-ray
- B-type natriuretic peptide (BNP)
A critical care nurse is caring for a newly admitted client with acute aortic dissection. Which prescription should
the nurse prioritize while awaiting surgical revision of the client’s aortic dissection?
1. Administer IV labetalol to maintain blood pressure within prescribed parameters
2. Initiate and maintain strict bed rest and a low-stimulation environment
3. Monitor bilateral lower extremity peripheral pulse strength
4. Prepare the client’s consent form for surgical repair of the aorta
- Administer IV labetalol to maintain blood pressure within prescribed parameters
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?
1. Glucose 200 mg/dL
2. Hematocrit 38%
3. Potassium 3.4 mEq/L
4. Troponin 0.7 ng/mL
- Troponin 0.7 ng/mL
**An elderly client tells the nurse “I have experienced leg pain for several weeks when I walk to the mailbox
each afternoon, but it goes away once I stop walking.” What is the priority assessment the nurse should
perform?
1. Assess for dry, scaly skin on the lower legs
2. Assess for presence or absence of hair growth on lower extremities
3. Check for presence and quality of posterior tibial and dorsalis pedis pulses
4. Obtain a dietary history
- Check for presence and quality of posterior tibial and dorsalis pedis pulses
Which interventions should the nurse include when caring for a client who has had endovascular repair of an
abdominal aortic aneurysm? SATA
1. Assess abdominal incision every 4 hours
2. Check for bleeding at groin puncture sites
3. Measure chest tube drainage
4. Monitor fluid intake and urine output
5. Palpate and monitor peripheral pulses
- Check for bleeding at groin puncture sites
- Monitor fluid intake and urine output
- Palpate and monitor peripheral pulses
The cardiac care unit has standing instructions that the health care provider (HCP) should be notified of an
abnormal mean arterial pressure (MAP). The nurse will need to notify the HCP about which client?
1. A client from the cardiac catheterization lab with a blood pressure (BP) of 102/58 mm Hg
2. A client just admitted from the emergency department with a BP of 150/72 mm Hg
3. A client with a BP of 92/60 mm Hg who just received a dose of nitroglycerin
4. A client with heart failure on metoprolol with a BP of 106/42 mm Hg
- A client with heart failure on metoprolol with a BP of 106/42 mm Hg
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?
1. Bronchial breath sounds at lung periphery
2. Clear vesicular breath sounds at lung bases
3. Diffuse bilateral crackles at lung bases
4. Strider in upper airways
- Diffuse bilateral crackles at lung bases
A 62 year old client was admitted to the telemetry unit after having an acute myocardial infarction 3 days ago.
The client reports to the nurse that the left calf is very tender and feels warm to the touch. Which assessment
by the nurse is the priority?
1. Ask the client how long the leg has been tender and warm
2. Assess the electrocardiogram (ECG) for any ectopic beats
3. Check vital signs including pulse oximetry
4. Complete neurovascular assessment on lower extremities
- Complete neurovascular assessment on lower extremities
A client comes to the emergency department with crushing, substernal chest pain. Temperature is 98.6F, blood
pressure is 173/84 mm Hg, pulse is 92/min, and respirations are 24/min. Oxygen saturation is 95% on room
air. What is the nurse’s next priority action?
1. Attach defibrillator pads to the client’s chest
2. Check the lipid profile laboratory results
3. Obtain a 12-lead electrocardiogram (ECG)
4. Prepare to administer a heparin drip
- Obtain a 12-lead electrocardiogram (ECG)
The nurse has just completed 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?
1. I’m glad that I can continue taking my Ginkgo biloba
2. I will increase my intake of leafy green vegetables
3. I will start applying vitamin E to my chest incision after showering
4. I will shave with an electric razor from now on
- I will shave with an electric razor from now on
The nurse has just completed discharge teaching for a client recently diagnosed with hypertension. Which of
the following statements by the client indicate understanding of the Dietary Approaches to Stop Hypertension
(DASH) diet? SATA
1. I need to eat less red meat and more fresh vegetables
2. I’ll limit drinking soda to only one at a time as an occasional treat
3. I’m going to replace potato chips with fruit during meals and snacking
4. I’m really going to miss drinking as much milk as I normally do
5. Taking the salt shaker off the table should be enough to reduce my sodium intake
- I need to eat less red meat and more fresh vegetables
- I’ll limit drinking soda to only one at a time as an occasional treat
- I’m going to replace potato chips with fruit during meals and snacking
A nurse is discussing discharge education with a client after his fifth hospitalization for pulmonary edema
caused by his congestive heart failure. Which of the following statements indicates that further teaching is
required?
1. I should supplement my potassium intake
2. I should weigh myself daily
3. Moderate exercise may be helpful in my condition
4. Potato chips are an acceptable snack in moderation
- Potato chips are an acceptable snack in moderation
A client with heart failure has gained 5 lbs 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?
Sodium 126
Potassium 4.8
Calcium 9.0
1. 0.45% sodium chloride IV
2. Calcium gluconate18
3. Furosemide
4. Sodium polystyrene sulfonate
- Furosemide
The nurse receives hand-off report on assigned clients. Which client should the nurse assess first?
1. Client 1 day post femoral-popliteal bypass surgery who now has a nonpalpable pedal pulse present
only with Doppler
2. Client with chronic venous insufficiency who has edema and brown discoloration of the lower
extremities
3. Client with peripheral arterial disease and gangrene of the foot who has a cool-to-the-touch, hairless
extremity
4. Client with peripheral arterial disease who reports severe cramping in the calf with activity such as
walking
- Client 1 day post femoral-popliteal bypass surgery who now has a nonpalpable pedal pulse present
only with Doppler
A client with myocardial infarction (MI) 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 (HCP) about resuming sexual relations after an MI. What teaching should the nurse initiate with this client?
1. If the client is able to climb 2 flight of stairs without symptoms, the client may be ready for sexual
activity if approved by the HCP
2. Inform the client that medications such as sildenafil or tadalafil are available as prescriptions from the
HCP
3. It will be 6 months before the heart is healthy enough for sexual activity
4. The client will be ready for sexual activity after completion of cardiac rehabilitation
- If the client is able to climb 2 flight of stairs without symptoms, the client may be ready for sexual
activity if approved by the HCP
A nurse in the intensive care unit is caring for postoperative cardiac transplant client. What intervention is most important to include in the plan of care?
- Apply sequential compression devices to prevent deep vein thrombosis
- Assist client to change positions slowly to prevent hypotension
- Encourage coughing and deep breathing to prevent pneumonia
- Use careful hand washing and aseptic technique to prevent infection
- Use careful hand washing and aseptic technique to prevent infection
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 strenuous activity before the surgery
- Continue to exercise, even if angina occurs. It will strengthen your heart muscles.
- Take short walks 3 times a day
- There are no activity restrictions unless angina occurs
- Avoid strenuous activity before the surgery
The nurse cares for a transgender client who is prescribed estrogen therapy. Which side effect is most important for the nurse to report to the health care provider?
- Breast tenderness
- Generalized weight gain
- Leg swelling
- Nausea and vomiting
- Leg swelling
A client with coronary artery disease is being seen in the clinic for a follow-up examination. During medication reconciliation, the nurse identifies which reported medication as requiring further investigation?
- 10 mg isosorbide dinitrate twice daily
- 20 mg atorvastatin once daily
- 500 mg naproxen twice daily
- 2,000 mg fish oil once daily
- 500 mg naproxen twice daily
A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse’s first action?
- Auscultate the client’s breath sounds
- Encourage the client to increase fluid intake
- Report the findings to the health care provider (HCP)
- Start an intravenous line for diuretic administration
- Auscultate the client’s breath sounds
A client admitted to the cardiac care unit with markedly elevated blood pressure and heart failure is receiving a continuous infusion of nitroprusside. Thirty minutes later, the client appears pale with cold, clammy skin and reports being lightheaded. Which is the priority nursing action?
- Auscultate the client’s lungs
- Check the client’s capillary refill
- Measure the client’s blood pressure
- Review the client’s electrocardiogram (ECG)
- Measure the client’s blood pressure
The nurse identifies which risk factors as contributing to the development of peripheral artery disease? SATA
- Cigarette smoking
- Diabetes mellitus
- Hyperlipidemia
- Oral contraceptive use
- Prolonged standing
- Cigarette smoking
- Diabetes mellitus
- Hyperlipidemia
A nurse on the telemetry unit observes the following rhythm on the monitor of a client admitted with coronary artery disease. What action should the nurse take first?
- Administer atropine 0.5 mg IV push
- Measure the client’s vital signs
- Move the client back to bed from chair
- Obtain a temporary pacemaker
- Measure the client’s vital signs
The nurse is assessing a client with a possible diagnosis of peripheral artery disease. Which client statement is consistent with the diagnosis?
- At the end of the day, my shoes and socks are tight
- I have a slow-healing sore right above my ankle
- My legs ache when I stand for extended periods
- When I sit down to rests and elevate my legs, the pain increases
- When I sit down to rests and elevate my legs, the pain increases
The charge nurse is assisting with a non emergent cardioversion for a client with supraventricular tachycardia. Which action by the primary nurse would cause the charge nurse to intervene?
- Administers a one-time dose of IV midazolam
- Disengages the “sync” function on the defibrillator
- Places defibrillator pads on upper right and lower left chest
- Turns off the client’s oxygen and moves it away from the bed
- Disengages the “sync” function on the defibrillator
The nurse is providing discharge teaching to a client with a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which food? SATA
1. Bananas
- Broccoli
- Liver
- Oranges
- Spinach
- Broccoli
- Liver
- Spinach
The nurse is planning care for a child being admitted with Kawasaki disease and should give priority to which nursing intervention?
- Apply cool compresses to the skin of the hands and feet
- Monitor for a gallop heart rhythm and decreased urine output
- Prepare a quiet, non-stimulating, and restful environment
- Provide soft foods and liberal amounts of clear liquid
- Monitor for a gallop heart rhythm and decreased urine output
A client with suspected moderate to large pericardial effusion is admitted for monitoring. The nurse performs a head-to-toe assessment. Which of these findings indicate likely cardiac tamponade and require immediate intervention? SATA
- Blood pressure of 90/70 mm Hg
- Bounding peripheral pulses
- Decreased breath sounds on left side
- Distant heart tones
- Jugular venous distention
- Blood pressure of 90/70 mm Hg
- Distant heart tones
- Jugular venous distention
The home health nurse visits a client with atrial fibrillation who is newly prescribed digoxin 0.25 mg orally on even-numbered days. Which of the following client statements show that teaching has been effective? SATA
- I need to call the health care provider (HCP) if I have trouble reading
- I need to check my blood pressure before taking my medicine
- I should call the HCP if I develop nausea and vomiting
- I should check my heart rate prior to taking this medication
- I will call the HCP if I feel dizzy and lightheaded
- I need to call the health care provider (HCP) if I have trouble reading
- I should call the HCP if I develop nausea and vomiting
- I should check my heart rate prior to taking this medication
- I will call the HCP if I feel dizzy and lightheaded
The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown in the exhibit. Which medications due at this time are safe to administer? SATA
Temperature 98.4F
Blood pressure 124/78 mm Hg
Heart rate 46/min and irregularly irregular Respirations 22/min
1. Diltiazem extended-release PO
- Heparin subcutaneous injection
- Lisinopril PO
- Metoprolol PO
- Timolol ophthalmic
- Heparin subcutaneous injection
- Lisinopril PO
A nurse receives an electrocardiogram of a client with type 2 diabetes, heart failure, and hypothyroidism. Based on the findings, which of the following medications should the nurse suspect as the most likely cause?
- Captopril
- Carvedilol
- Glimepiride
- Levothyroxine
- Carvedilol
A client with hypertension is prescribed lisinopril. The nurse instructs the client to notify the health care provider immediately if which adverse effect occurs when taking this medication?
- Cough
- Dizziness
- Rapid-onset confusion
- Swelling of the lips and tongue
- Swelling of the lips and tongue
The nurse is caring for a client with cardiomyopathy and coronary artery disease. The client is reporting increasing chest pain and has bilateral lung crackles on auscultation. The health care provider has written several new prescriptions. Which new prescription should the nurse clarify? SATA
Blood pressure 84/58 mm Hg
Heart rate 108/min Respirations 28/min Oxygen saturation 90%
- Administer 2,000 mL normal saline bolus
- Administer IV nitroglycerin
- Apply 4 L oxygen by nasal cannula
- Obtain a STAT 12-lead ECG
- Obtain blood for cardiac enzyme testing
- Administer 2,000 mL normal saline bolus
- Administer IV nitroglycerin
The nurse is providing discharge instructions to the parent of a child with Kawasaki disease. The nurse informs the parent that the presence of which symptoms should be immediately reported to the health care provider?
- Fever
- Irritability
- Knee pain
- Skin peeling
- Fever
An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately?
- Is there anything I can take for my dry, hacking cough?
- My blood pressure this morning was 158/84 mm Hg.
- Sometimes I feel dizzy when I stand up.
- Will you look at my tongue? It feels thicker than normal.
- Will you look at my tongue? It feels thicker than normal.
A client with long-term hypertension and hypercholesterolemia comes to the clinic for an annual checkup. The client takes nifedipine, simvastatin, and spironolactone and reports some occasional dizziness. Which statement by the client would warrant intervention by the nurse?
- I’ve been better about walking for 20 minutes 3 days a week on my treadmill.
- I’ve been trying to eat more fruits and vegetables. I discovered that I really like grapefruit.
- I’ve heard that having a glass of red wine with dinner every night is good for my heart.
- We no longer add salt when preparing meals. It has really been hard to get used to that.
- I’ve been trying to eat more fruits and vegetables. I discovered that I really like grapefruit.
A client with coronary artery disease and atrial fibrillation is being discharged home following coronary artery stent placement. Discharge medications are shown in the exhibit. The nurse identifies which educational topic as the highest priority for this client?
Aspirin | Clopidogrel | Rivaroxaban | Metoprolol | Rosuvastatin | Lisinopril
1. Bleeding risk
2. Bronchospasm
3. Muscle injury
4. Tinnitus
- Bleeding risk
Which prescriptions for these clients does the nurse question? SATA
1. Client with clostridium difficile colitis, prescribed vancomycin 125 mg PO
2. Client with diabetes and elevated mealtime glucose, prescribed lispro insulin scale 6 units
subcutaneously
3. Client with gastrointestinal bleed and nasogastric tube, prescribed pantoprazole 40 mg intravenous
4. Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50
mg PO
5. Client with otitis media and penicillin allergy, prescribed ampicillin 500 mg PO
- Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50
mg PO - Client with otitis media and penicillin allergy, prescribed ampicillin 500 mg PO
A client is 6 hours postoperative from hip surgery after receiving regional anesthesia and has epidural continuous anesthesia in place. Which is the most important reason for the nurse to contact the health care provider?
- Client reports paresthesia bilaterally since the surgery
- Fondaparinux is prescribed for STAT administration
- Lower-extremity muscle strength is 3⁄5 bilaterally
- Postoperative laboratory results show hemoglobin of 909 g/dL
- Fondaparinux is prescribed for STAT administration
A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin (NTG) to treat angina. Which statement by the client indicates that further teaching is required?
- I may experience flushing but will continue to take the medication as prescribed
- I should lie down before taking the medication
- I should not swallow the tablet
- I will wait to call 911 if I don’t experience relief after the third tablet.
- I will wait to call 911 if I don’t experience relief after the third tablet.
The nurse elevates morning laboratory results for several clients who were admitted 24 hours earlier. Which laboratory report requires priority follow-up?
- Client with chronic obstructive pulmonary disease who has a PaCO2 of 52 mm Hg
- Client with heart failure who has a brain natriuretic peptide level of 800 pg/mL
- Client with infected pressure ulcer who has a white blood cell count of 13,000/mm3
- Client with pulmonary embolism who has a partial thromboplastin time of 127 seconds
- Client with pulmonary embolism who has a partial thromboplastin time of 127 seconds
The nurse is performing a cardiac assessment on a client. The nurse auscultates a loud blowing sound at the second intercostal space, right sternal border. How should the nurse document this finding?
- Arterial bruit
- Murmur heard at the aortic area
- Pericardial friction rub
- S3 gallop heard at the mitral area
- Murmur heard at the aortic area
The nurse is preparing medications for a group of clients. Which prescription should the nurse clarify with the health care provider before administering?
- Client diagnosed with cirrhosis had 2 stools today; laxative lactulose prescribed daily
- Client is prescribed lisinopril PO daily; serum potassium level is 5.6 mEq/L
- Client is receiving vancomycin IV; mild facial flushing noted after 30 minutes
- Client with diabetes has insulin glargine prescribed; current blood glucose is 100 mg/dL
- Client is prescribed lisinopril PO daily; serum potassium level is 5.6 mEq/L
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? SATA
- I don’t plan on eating any more frozen meals
- I plan to take my diuretic pill in the morning
- I will weigh myself at least every other day
- I’m going to look into joining a cardiac rehabilitation program
- Ibuprofen works best for me when I have pain
- I will weigh myself at least every other day
- Ibuprofen works best for me when I have pain
The nurse is preparing to administer medications after assessing a client with a myocardial infarction. Based on the collected data, which of the following prescribed medications are appropriate for the nurse to administer? SATA
Temperature 98.4F
Blood pressure 126/81 mm Hg Heart rate 49/min
Respirations 16/min Hematocrit 40%
Hemoglobin 14.0 g/dL Platelets 200,000.mm3 Potassium 4.0 mEq/L
HDL cholesterol 21 mg/dL LDL cholesterol 200 mg/dL
- Aspirin
- Atorvastatin
- Docusate sodium
- Lisinopri
- Metoprolol
- Aspirin
- Atorvastatin
- Docusate sodium
- Lisinopri
The emergency nurse is admitting a 12 year old client who reports palpitations. Which action should the nurse anticipate?
Temperature 97.1F
Blood pressure 114/74 mm Hg
Heart rate 234/min Respirations 24/min spO2 97%
1. Administering epinephrine by rapid IV push
2. Assisting the client to a tripod position
3. Instructing the client to hold their breath and bear down
4. Sedating the client for immediate asynchronous defibrillation
- Instructing the client to hold their breath and bear down
Which subjective or objective assessment finding would the nurse expect to find in a client with severe aortic stenosis?
- Bounding peripheral pulses
- Diastolic murmur
- Loud second heart sound
- Syncope on exertion
- Syncope on exertion
A client in the emergency department has an acute myocardial infarction. The health care provider (HCP) has prescribed thrombolytic therapy. Which assessment data should the nurse report immediately to the HCP?
- Client has a history of cerebral arteriovenous malformation
- Client is currently menstruating
- Client rates chest pain as 8 on a scale of 0-10
- Current blood pressure is 170/92 mm Hg
- Client has a history of cerebral arteriovenous malformation
The nurse is assessing a 70-year-old client with a long history of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the emergency department. Which hospital protocol would be the most appropriate to follow initially?
- Food poisoning
- Influenza
- Myocardial infarction
- Stroke
- Myocardial infarction
The nurse is monitoring a client who has been on clopidogrel therapy. Which assessments are essential? SATA
- Assess for bruising
- Assess for tarry stools
- Monitor intake and output
- Monitor liver function tests
- Monitor platelets
- Assess for bruising
- Assess for tarry stools
- Monitor platelets
The nurse is reviewing laboratory data of a client who is receiving warfarin therapy for atrial fibrillation. Today’s INR is 5.0. Which action should the nurse take?
- Administer the next scheduled dose of warfarin
- Anticipate infusing fresh, frozen plasma
- Call the pharmacy to see if protamine is available
- Request a prescription from the health care provider (HCP) for vitamin K
- Request a prescription from the health care provider (HCP) for vitamin K
The nurse provides instructions to a client discharged on warfarin, after being treated for a pulmonary embolism (PE) following surgery. Which statements made by the client indicate the need for further teaching? SATA
1. I will need to take my blood thinner for about 3-6 months
- I will place small rugs on my wood floors to cushion a fall
- I will take a baby aspirin if I have mild chest pain
- I will use a soft-bristled toothbrush to clean my teeth
- I will wear a blood thinner MedicAlert tag
- I will place small rugs on my wood floors to cushion a fall
- I will take a baby aspirin if I have mild chest pain
The clinic nurse is reviewing telephone messages from four clients. Which client’s call should the nurse return first?
1. Client who has just taken albuterol and reports a heart rate of 108/min and a coarse tremor in both arms
2. Client who is prescribed azithromycin and reports frequent, foul-smelling, liquid stools and abdominal cramping
3. Client who is prescribed metformin and reports a blood glucose of 284 mg/dL and frequent urination
4. Client who takes amiodarone and reports a dry cough and increased dyspnea when walking around the
house
- Client who takes amiodarone and reports a dry cough and increased dyspnea when walking around the
house
An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently?
- Apical heart rate is 62/min
- Blood sugar is 240 mg/dL
- Client is taking 20 mg fluoxetine daily
- Serum creatinine is 2.3 mg/dL
- Serum creatinine is 2.3 mg/dL
A nurse in the cardiac intermediate care unit is caring for a client with acute decompensated heart failure (ADHF). The client also has a history of coronary artery disease and peripheral vascular disease. The nurse is preparing to administer medications. Based on the assessment data, the nurse should question which medication?
Blood pressure 110/60 mm Hg
Pulse 80/min
Respirations 22/min
Oxygen saturation 90% on room air
Crackles in middle & lower lung fields
Moderate jugular venous distention
3+ pedal edema
1. Aspirin
2. Atorvastatin
- Furosemide
- Metoprolol
- Metoprolol
The nurse is assessing a client with hypertension and essential tremor 2 hours after receiving a first dose of propranolol. Which assessment is most concerning to the nurse?
- Client reports a headache
- Current blood pressure is 160/88 mm Hg
- Heart rate has dropped from 70/min to 60/min
- Slight wheezes auscultated during inspiration
- Slight wheezes auscultated during inspiration
The nurse has received report on 4 pediatric clients on a telemetry unit. Which client should the nurse assess first?
- Adolescent client with coarctation of the aorta and diminished femoral pulses
- Infant client with ventricular septal defect with reported grunting during feeding
- Newborn client with patent ductus arteriosus and a loud machinery-like systolic murmur
- Preschool client with tetralogy of Fallot who has finger clubbing and irritability
- Infant client with ventricular septal defect with reported grunting during feeding
The nurse is assessing for the presence of jugular venous distention (JVD) on a newly admitted client with a history of heart failure. Which is the best position for the nurse to place the client in when observing for JVD?
1. Head of the bed elevated to a 45-degree angle
2. Head of the bed elevated to a 60-degree angle
4. Client who takes amiodarone and reports a dry cough and increased dyspnea when walking around the
house 25
3. Head of the bed elevated to a 90-degree angle
4. Head of the bed flat
- Head of the bed elevated to a 45-degree angle
A client with uncontrolled hypertension is prescribed clonidine. What instruction is most important for the clinic nurse to give this client?
- Avoid consuming high-sodium foods
- Change positions slowly to prevent dizziness
- Don’t stop taking this medication abruptly
- Use an oral moisturizer to relieve dry mouth
- Don’t stop taking this medication abruptly
The health care provider prescribes simvastatin for a client with hyperlipidemia. The nurse instructs the client to take this medication in which manner?
- At noon with a meal
- In the morning on an empty stomach 3. In the morning with breakfast
- With the evening meal
- With the evening meal
A nurse caring for a client with a central venous catheter (CVC) enters the client’s room and notes that the CVC is dislodged and lying in the client’s bed linens. The client appears cyanotic and is tachypneic and diaphoretic. Which of the following actions by the nurse are appropriate? SATA
- Administers oxygen via non-rebreather mask
- Apply an occlusive dressing over the insertion site
- Assist the client to high Fowler position
- Monitor vital signs and respiratory effort
- Notify the health care provider
- Administers oxygen via non-rebreather mask
- Apply an occlusive dressing over the insertion site
- Monitor vital signs and respiratory effort
- Notify the health care provider
What clinical symptoms might the nurse expect to find in a client with a central venous pressure (CVP) of 24 mm Hg? SATA
- Crackles in lungs
- Dry mucous membranes
- Hypotension
- Jugular venous distention
- Pedal edema
- Crackles in lungs
- Jugular venous distention
- Pedal edema
The nurse is providing community health screening. Which of the following clients should be referred to a health care provider for further evaluation?
- 30-year-old athlete with a heart rate of 50/min
- 45-year-old client with a body mass index of 35 kg/m2 and fingerstick glucose of 150 mg/dL
- 55-year-old client missing all the hair on the lower legs and failing the pinprick test
- 80-year-old client with a blood pressure of 150/90 mm Hg
- 55-year-old client missing all the hair on the lower legs and failing the pinprick test
A client is started on lisinopril therapy. Which assessment finding requires immediate action?
- Blood pressure 129/80 mm Hg
- Heart rate 100/min
- Serum creatinine 2.5 mg/dL
- Serum potassium 3.5 mEq/dL
- Serum creatinine 2.5 mg/dL
A client with heart failure is started on furosemide. The laboratory results are shown in the exhibit. The nurse is most concerned about which condition?
Sodium 134
Potassium 3.4 chloride 108
Magnesium 0.9
1. Atrial fibrillation
2. Atrial flutter
3. Mobitz 2
4. Torsades de pointes
- Torsades de pointes
The nurse is caring for a client who has been admitted to the hospital for an acute exacerbation of heart failure. Blood pressure is 104/62 mm Hg, pulse is 96/min, respirations are 22/min, and oxygen saturation is 91%. Which of these findings supports the diagnosis of acute heart failure exacerbation?
- B-type natriuretic peptide (BNP) 1382 pg/mL
- Flat jugular veins when seated at a 45-degree angle
- Sodium 150 mEq/L
- Urine output greater than 100 mL/hr
- B-type natriuretic peptide (BNP) 1382 pg/mL
A nurse is assessing a 1-month old infant with an atrial septal defect (ASD). which assessment finding does the nurse expect?
- Muffled heart tones
- Murmur
- Cyanosis
- Weak femoral pulses
- Murmur
A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a history of type 2 diabetes, coronary artery disease, and bipolar disorder. Which medications may be contributing to the client’s symptoms? SATA
- Atorvastatin
- Metformin
- Metoprolol
- Olanzapine
- Omeprazole
- Metoprolol
- Olanzapine
A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication? SATA
- Blood pressure of 140/84 mm Hg
- Heart rate of 98/min
- Platelet count of 200,000/mm3
- Report of Ginkgo biloba use
- Report of peptic ulcer disease
- Report of Ginkgo biloba use
- Report of peptic ulcer disease
A client is being discharged with a prescription for apixaban after being treated for a pulmonary embolus. Which clinical data is most concerning to the nurse?
- Client eats a vegetarian diet
- Client has chronic atrial fibrillation
- Client takes indomethacin for osteoarthritis
- Client’s platelet count is 176x10^3/mm3
- Client takes indomethacin for osteoarthritis
A client was medicated with intravenous morphine 2 mg 2 hours ago to relieve moderate abdominal pain after appendectomy. The client becomes lethargic but arouses easily to verbal and tactile stimuli, and is oriented to time, place and person. The pulse oximeter reading has dropped from 99% to 89% on room air. Which oxygen delivery device is the most appropriate for the nurse to apply?
The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted to evacuate a pneumothorax caused by fractured ribs. Where would the nurse observe an air leak?
- Section A
- Section B
- Section C
- Section D
- Section C
The nurse is teaching a client who is scheduled to have an INFERIOR VENA CAVA FILTER inserted via the right femoral vein. Which statement by the client requires FURTHER teaching?
- “I need to make all health care providers aware of my filter before I have body scans”
- “I need to stay active and avoid crossing my legs for extended periods when I get home”
- “I should call the health care provider if I develop numbness, tingling and swelling in my right leg.”
- “It is normal to have some chest or back discomfort for a few days after filter placement. “
- “It is normal to have some chest or back discomfort for a few days after filter placement. “
