Quiz 3 Flashcards
which assessment finding would be the earliest and most sensitive indicator that there is an alteration in intracranial regulation?
change in LOC
a nurse assesses a client who is prescribed a medication that inhibits angiotensin 1 from converting into angiotensin 2. For which expected therapeutic effect should the nurse assess?
blood pressure decrease from 180/72 to 144/60
after teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client’s understanding. Which food choice for lunch indicates the client correctly understood the teaching?
grilled chicken breast with glazed carrots
a nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?
a 34 yr old NPO status who is receiving IV D5W
a nurse assesses a client on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure?
a 36 yr old woman with aortic stenosis
when assessing a 56 yo male on a cardiac unit, a nurse identifies the presence of an S1 gallop. Which action should the nurse take next?
assess for other signs of left heart failure
a nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client’s teaching?
do not take this medication within 1 hr of taking an antacid
a nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?
assess respiratory status
a nurse cares for an older adult client with HF. The client states I dont know what to do. I dont want to be a burden to my daughter, but I cant do it alone. Maybe I should die. How should the nurse respond?
would you like to talk more about this
a nurse collaborates with an UAP to provide care for client with congestive HF. Which instructions should the nurse provide to the UAP when delegating care? SATA
- accurately record intake and output
- use the same scale to weigh the client each morning
- make sure the client changes positions every 2 hrs
a nurse receives report on a client who had a L sided stroke and has homonymous hemaniaopsia. What action by the nurse is most appropriate for this client?
rotate the client’s meal tray when the client stops eating
a client with a stroke is being evaluated for fibrinolytic therapy. What info from the client or family is most important for the nurse to obtain?
time of symptom onset
a student nurse is preparing morning meds for a client who had a stroke. The student plans to hold the docusate sodium because the client had a large stool earlier. What action by the supervising nurse is best?
inform the student the reasons the docusate should be given to this patient
a client in the ED is having a stroke and needs a carotid artery angioplasty with stent placement. The client’s mental status is deteriorating. What action by the nurse is most appropriate?
attempt to find the family to sign a consent
Discharge teaching related to digoxin for a 3 month old infant with a cardiac defect should include what info.. SATA
- give the med at regular intervals
- notify the HP if more than 2 consecutive doses are missed
