20-Cardiovascular.docx

A nurse is caring for a client with Raynaud's phenomenon secondary to systemic lupus erythematosus (SLE). Which of the client statements demonstrates an understanding of the nurse's teaching about this disorder? Select all that apply. "I probably got this disorder because I am also diagnosed wit...

A nurse is caring for a client with Raynaud's phenomenon secondary to systemic lupus erythematosus (SLE). Which of the client statements demonstrates an understanding of the nurse's teaching about this disorder? Select all that apply. "I probably got this disorder because I am also diagnosed with lupus." Correct answer "I don't need to report any other skin problems with my fingers or hands to my health care provider." "I will have to discuss medication that might treat this problem with my health care provider." Correct answer "This problem is caused by a temporary lack of circulation in my hands." Correct answer "I can't continue to wash dishes and do my cleaning because of this problem." "My hands get pale and bluish, and feel numb and painful when I'm really stressed." Correct answer  Feedback Good work  Question 2 / 1.4 The nurse is preparing the client with heart failure to go home. The nurse should instruct the client to: monitor urine output daily. maintain bed rest for at least 1 week. monitor daily potassium intake. monitor weight daily. Correct answer  Feedback Good work  Question 3 / 1.4 A client is about to undergo cardiac catheterization for which informed consent was obtained. As the nurse enters the room to administer sedation for the procedure, the client states, "I'm really worried about having this open heart surgery." Based on this statement, how should the nurse proceed? Withhold the medication and notify the physician immediately. Correct answer Withhold the medication and cancel the procedure. Medicate the client and document his comment. Explain that cardiac catheterization does not involve open heart surgery, and then medicate the client.  Feedback Good work  Question 4 / 1.4 A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? urine output of 150 ml/hour and heart rate of 45 beats/minute blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Correct answer blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute urine output of 15 ml/hour and 2+ hematuria  Feedback Good work  Question 5 / 1.4 What is the highest nursing priority in the plan of care for a client with peripheral vascular problems? Promote arterial and venous circulation. Correct answer Monitor skin integrity. Provide a self-care program for the client and family. Relieve pain caused by decreased circulation.  Feedback Good work  Question 6 / 1.4 Which clinical manifestation would be most indicative of complete arterial obstruction in the lower extremities? aching pain burning sensations coldness Correct answer numbness and tingling  Feedback Good work  Question 7 / 1.4 The client is to receive digoxin 0.25 mg. Available are 0.125-mg scored tablets. How many tablets should the nurse administer? 0.5 tablet 2 tablets Correct answer 1 tablet 1.5 tablets  Feedback Good work  Question 8 / 1.4 A registered nurse is mentoring a new graduate nurse. Which action by the new graduate demonstrates a need for further teaching? administers lidocaine to a client experiencing frequent premature ventricular contractions (PVCs) turns the defibrillator to synchronize before defibrillating a client with ventricular fibrillation Correct answer administers adenosine as a rapid I.V. push over 2 seconds to a client with supraventricular tachycardia administers diltiazem to a client with atrial fibrillation  Feedback Good work  Question 9 / 1.4 A client is admitted to the hospital through the emergency department with chest pain. Which intervention is the priority? assessing troponin 1 levels Correct answer monitoring the white blood cell count monitoring the platelet count assessing B-type natriuretic peptide levels  Feedback Good work  Question 10 / 1.4 A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital sign? respirations blood pressure Correct answer temperature pulse  Feedback Good work  Question 11 / 1.4 When caring for a client with a left radial arterial line, the nurse notes that the left hand is cool and the capillary refill time in the finger is 6 seconds. What is the appropriate action by the nurse? Change arterial line to the right radial artery. Perform square wave test. Contact the health care provider. Correct answer Assess for bleeding at the insertion site.  Feedback Good work  Question 12 / 1.4 The nurse is taking a nursing history from a client prior to surgery. Which information in the client's history would have a significant impact on the client's recovery postoperatively? The client: drinks about 2 beers a week on a regular basis. has smoked 1 pack of cigarettes a day for 12 years. Correct answer had a cold 6 weeks ago. is 10 lbs (4.5 kg) overweight.  Feedback Good work  Question 13 / 1.4 A client is admitted for a revascularization procedure for arteriosclerosis in the left iliac artery. What should the nurse do to promote circulation in the extremities? Position the client on a firm mattress. Encourage the client to raise and lower his leg four times every hour. Keep the involved extremity warm with blankets. Position the left leg at or below the body's horizontal plane. Correct answer  Feedback Good work  Question 14 / 1.4 A client recovering from an acute myocardial infarction makes sexual comments to the nurse during morning care. What action should the nurse take? Ask the client if there are questions related to sexuality they would like to discuss. Correct answer Ignore the client's comments to avoid rewarding attention-seeking behavior. Firmly explain to the client that sexual harassment will not be tolerated. Respond in a light-hearted way to reduce the tension between nurse and client.  Feedback Good work  Question 15 / 1.4 Which is an expected outcome for a client on the second day of hospitalization after a myocardial infarction (MI)? The client continues to have severe chest pain. The client participates in a cardiac rehabilitation walking program. The client can perform personal self-care activities without pain. Correct answer The client can identify risk factors for MI.  Feedback Good work  Question 16 / 1.4 A client is recovering from an acute myocardial infarction (MI). During the first week of the client's recovery, the nurse should stay alert for which abnormal heart sound? ejection click Graham Steell's murmur pericardial friction rub Correct answer opening snap  Feedback Good work  Question 17 / 1.4 Three days after surgery to insert a mechanical mitral valve, the client asks what can be done to muffle the clicking sound since it is embarrassing and others will know an artifical valve is in the heart. The nurse's response should reflect the understanding that the client may be experiencing which concern? anxiety related to altered body image Correct answer anxiety related to altered health status lack of knowledge regarding the postoperative course altered tissue perfusion  Feedback Good work  Question 18 / 1.4 When starting a client on oral or I.V. diltiazem hydrochloride, for which potential complication should the nurse monitor? flushing renal failure atrioventricular block Correct answer hypertension  Feedback Good work  Question 19 / 1.4 The client with Raynaud's phenomenon has a skin ulcer on the forearm. The skin surrounding the ulcer is dry. The health care provider prescribed nitroglycerine cream. What should the nurse instruct the client about the purpose of nitroglycerine? It promotes healing. Correct answer It treats pain. Incorrect: It prevents an infection. It softens the surrounding skin.  Feedback That's not correct  Question 20 / 1.4 When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should asses the client for which changes? hypertension hypothermia cardiac arrhythmias Correct answer seizure  Feedback Good work  Question 21 / 1.4 The nurse is monitoring a client undergoing a cardiac stress test using a treadmill. Which of the client symptoms will require the nurse's immediate action? heart rate of 130 beats per minute oxygen saturation of 91% chest pain at a level 3 (0-10 scale) Correct answer blood pressure of 156/88 mmHg  Feedback Good work  Question 22 / 1.4 Six hours after pacemaker insertion, a client reports sudden onset of chest pain and shortness of breath with a drop in SpO2 from 98% on 2 LPM of oxygen to 90% on 2 LPM of oxygen. Which action should the nurse take first? Assess the client's breath sounds and chest movement. Correct answer Notify the health care provider to obtain a chest X-ray. Assess the incision site for redness, pain, drainage, and/or swelling. Check the client's blood pressure and heart rate.  Feedback Good work  Question 23 / 1.4 A client with migraine headaches and a history of angina asks the nurse why the health care provider does not prescribe one of the newer medications for migraine, such as sumatriptan. The nurse responds that: sumatriptan is contraindicated in clients with angina. Correct answer these drugs are very expensive. sumatriptan is used only for migraines with an aura. sumatriptan is used only for prophylactic treatment of migraines.  Feedback Good work  Question 24 / 1.4 While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this as a fourth heart sound (S4). a third heart sound (S3). Correct answer a first heart sound (S1). a murmur.  Feedback Good work  Question 25 / 1.4 The nurse is assessing a client with Buerger's disease. The nurse should determine if the client is experiencing: Vasospasm lasting several minutes. Inflammation and fibrosis of arteries, veins, and nerves. Correct answer Thickening of the intima and media of the artery. Pain, pallor, and pulselessness.  Feedback Good work  Question 26 / 1.4 Which statement indicates that a family member of a client in cardiogenic shock understands the need for an intra-aortic balloon pump? "This device helps stop life-threatening heart rhythms." "This device decreases the blood flow in the heart." "This device decreases the heart's need for oxygen." Correct answer "This device increases how hard the heart has to work."  Feedback Good work  Question 27 / 1.4 A nurse administers the first dose of nadolol to a client with a blood pressure of 180/96. During an assessment 4 hours later, which information indicates that the client needs immediate intervention? The client has wheezing throughout the lung fields. Correct answer The client's heart rate has decreased from 88 to 76 beats/minute. The client's blood pressure (BP) is 142/90 mm Hg. Incorrect: The client has cool fingers and toes bilaterally.  Feedback That's not correct  Question 28 / 1.4 A client has mitral stenosis and is a prospective valve recipient. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following prescription would pose the greatest health hazard to this client at this time? medication therapy Correct answer diet modification dental care activity restrictions  Feedback Good work  Question 29 / 1.4 A nurse is monitoring a client receiving dobutamine for heart failure. During the past several hours the client's heart rate has increased from 78 to 110 and the cardiac monitor shows an increased amount of premature ventricular contractions (PVCs) and couplets. What is the nurse's best action? Discontinue the dobutamine and notify the physician. Correct answer Administer PRN amiodarone to reduce the amount of premature ventricular contractions. Titrate the dobutamine rate to a higher dose to reduce the dysrhythmia. Assess the client for signs of cardiogenic shock.  Feedback Good work  Question 30 / 1.4 A client with deep vein thrombosis has been receiving warfarin for 2 months. The client is to go to an anticoagulant monitoring laboratory every 3 weeks. The last visit to the laboratory was 2 weeks ago. The client reports bleeding gums, increased bruising, and dark stools. What should the nurse should instruct the client to do? Decrease the dose of the warfarin. Decrease the amount of vitamin K in the diet. Return to laboratory for analysis of prothrombin times. Correct answer Notify the health care provider (HCP) about the bleeding.  Feedback Good work  Question 31 / 1.4 As an initial step in treating a client with angina, the health care provider (HCP) prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: improved conductivity in the myocardium. vasodilation of peripheral vasculature. Correct answer causing an increased myocardial oxygen demand. antispasmodic effects on the pericardium.  Feedback Good work  Question 32 / 1.4 The nurse is providing discharge teaching for a client with rheumatic endocarditis but no valvular dysfunction. On which nursing diagnosis should the nurse focus her teaching? Impaired memory Impaired gas exchange Risk for infection Correct answer Chronic pain  Feedback Good work  Question 33 / 1.4 A home care nurse is visiting a left-handed client who has an implantable cardioverter-defibrillator (ICD) implanted in their left chest. The client tells the nurse how excited they are because the client's planning to go rifle hunting with a grandson. How should the nurse respond? "You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site." Correct answer "Enjoy your time with your grandson." "Being that close to a rifle might make your ICD fire." "You'll need to take an extra dose of your antiarrhythmic before you shoot."  Feedback Good work  Question 34 / 1.4 A client with supraventricular tachycardia is prescribed esmolol. What should the nurse monitor in the client because of this medication? heart rate and blood pressure Correct answer intracranial pressure ocular pressure alteration in level of consciousness  Feedback Good work  Question 35 / 1.4 After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. What is the expected outcome of this exercise? Promote urinary and intestinal elimination. Prevent thrombophlebitis and blood clot formation. Correct answer Decrease the likelihood of pressure ulcer formation. Prepare the client for ambulation.  Feedback Good work  Question 36 / 1.4 A client has acute arterial occlusion. The health care provider has prescribed IV heparin. What should the nurse do before starting the medication? Count the client's apical pulse for 1 minute. Review the blood coagulation laboratory values. Correct answer Check the 24-hour urine output record. Test the client's stools for occult blood.  Feedback Good work  Question 37 / 1.4 A client had a repair of a thoracoabdominal aneurysm 2 days ago. Which finding should the nurse consider unexpected and report to the health care provider immediately? urine output of 2,000 mL in 24 hours adominal pain at 5 on a scale of 0 to 10 for the last 2 days heart rate of 100 beats per minute after ambulating 200 feet (0.06 km) weakness and numbness in the lower extremities Correct answer  Feedback Good work  Question 38 / 1.4 A client was transferring a load of fire wood from their front driveway to the backyard woodpile at 10 a.m.,when the client experienced a heaviness in their chest and dyspnea. The client stopped working and rested, and the pain subsided. At noon, the pain returned. At 1:30 p.m., the client's spouse took them to the emergency department. Around 2:30 p.m., the emergency department physician diagnoses an anterior myocardial infarction (MI). The nurse should anticipate which orders by the physician? sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry Correct answer streptokinase, aspirin, and morphine administration morphine administration, stress testing, and admission to the cardiac care unit serial liver enzyme testing, telemetry, and a lidocaine infusion  Feedback Good work  Question 39 / 1.4 A client is prescribed metoprolol 25 mg by mouth twice per day for an atrial arrhythmia. Which should the nurse assess to determine the effectiveness of this medication? Presence of peripheral edema Breath sounds Peripheral pulses Heart rate Correct answer  Feedback Good work  Question 40 / 1.4 When a client has a troponin level of 0.9 ng/mL, which nursing intervention should be implemented?  Feedback Good work  Question 41 / 1.4 A client with chest pain, dyspnea, and an irregular heartbeat comes to the emergency department. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit (ICU). Which nursing diagnosis is the priority at this time? ineffective tissue perfusion (cardiopulmonary) related to arrhythmia Correct answer activity Intolerance related to decreased cardiac output social isolation related to restricted visiting hours in the ICU fear related to threat of death  Feedback Good work  Question 42 / 1.4 A client with a history of coronary artery disease (CAD) has been diagnosed with peripheral arterial disease. The health care provider (HCP) started the client on pentoxifylline once daily. Approximately 1 hour after receiving the initial dose of pentoxifylline, the client reports having chest pain. The nurse should first: advise the client to rest. have the client rest in bed. start an intravenous infusion of normal saline. Inform the HCP. Correct answer  Feedback Good work  Question 43 / 1.4 After evaluating a client for hypertension, a physician orders atenolol, 50 mg P.O. daily. Which therapeutic effect should atenolol have? decreased cardiac output and decreased systolic and diastolic blood pressure Correct answer decreased peripheral vascular resistance decreased blood pressure with reflex tachycardia increased cardiac output and increased systolic and diastolic blood pressure  Feedback Good work  Question 44 / 1.4 A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's blood pressure. Correct answer temperature. hemoglobin level. Incorrect: heart rate.  Feedback That's not correct  Question 45 / 1.4 The nurse teaches a client who has recently been diagnosed with hypertension about following a low-calorie, low-fat, low-sodium diet. Which menu selection would best meet the client's needs? hot dogs, baked beans, and celery and carrot sticks ham sandwich on rye bread and an orange mixed green salad with blue cheese dressing, crackers, and cold cuts baked chicken, an apple, and a slice of white bread Correct answer  Feedback Good work  Question 46 / 1.4 A client has undergone an amputation of three toes and a femoral-popliteal bypass. The nurse should teach the client that after surgery which leg position is contraindicated while sitting in a chair? elevating the legs flexing the ankles extending the knees crossing the legs Correct answer  Feedback Good work  Question 47 / 1.2 The nurse is conducting a health history on a client with peripheral vascular problems. Which statements would suggest increasing problems with the peripheral vascular circulation? Select all that apply. Acute lower leg pain and swelling to the left calf over the past 24 hours Correct answer numbness and tingling in both feet when sitting for long periods of time Correct answer increased pain in the legs at rest and a chronic ulceration on the right heel Correct answer mild chest pain that is relieved with rest. more swelling in the feet at the end of the day. Correct answer  Feedback Good work  Question 48 / 1.2 A group has asked the nurse to discuss how lifestyle factors affect heart health. Which statements by members of the group would indicate that the teaching was effective? Select all that apply. "Gradually increasing my exercise levels will help enhance circulation through the heart." Correct answer "Walking is excellent exercise to strengthen my heart." Correct answer "If I change my diet and lessen my intake of saturated fats and trans fatty acids, this may decrease my cholesterol levels." Correct answer "As a borderline diabetic, if I lose weight and lessen my intake of simple carbohydrates, this should benefit my heart." Correct answer "Chewing tobacco rather than smoking it lessens the negative effect on the heart."  Feedback That's not correct  Question 49 / 1.2 When assessing a client with heart failure, the nurse should immediately report which findings to the health care provider (HCP)? Select all that apply. bibasilar crackles O2 saturation 94% on room air 2-pound (0.9- Kg) weight gain in 5 days confusion Correct answer blood pressure 108/62 mm Hg, heart rate 88 beats per minute urine output 20 mL/hr Correct answer  Feedback Good work  Question 50 / 1.2 A client with peripheral vascular disease has poor circulation. The nurse should assess the client for changes in: (Select all that apply.) pain in extremity. Correct answer nail bed color. Correct answer nausea. skin temperature. Correct answer fluid intake.  Feedback Good work  Question 51 / 1.2 The nurse is revising a care plan for a client with peripheral arterial disease and a risk for impaired skin integrity. Which client outcomes would indicate the client was successful with interventions? Select all that apply. Adheres to meticulous hygiene schedule. Correct answer Avoids prolonged standing or sitting. Experiences decreased muscle pain with walking. Wears protective shoes. Correct answer Avoids trauma and irritation to skin. Correct answer  Feedback Good work  Question 52 / 1.2 The unlicensed assistive personnel (UAP) reports to the nurse that a client is "feeling short of breath." The client's blood pressure was 124/78 mm Hg 2 hours ago with a heart rate of 82 bpm; the unlicensed assistive personnel reports that blood pressure is now 84/44 mm Hg with a heart rate of 54 bpm, and the client stated, "I just don't feel good." What actions should the nurse take? Select all that apply. Stay with and reassure the client. Correct answer Call the health care provider (HCP) and report the situation using SBAR format. Correct answer Inform the charge nurse of the change in condition and initiate the hospital's rapid/emergency response team. Correct answer Confirm the client's vital signs and complete a quick assessment. Correct answer Place the client in the semi-Fowler's position. Correct answer Make a quick check on other assigned clients before spending the time required to take care of this client.  Feedback That's not correct  Question 53 / 1.2 What instructions should the nurse give the client who will be starting a prescription for simvastatin 40 mg/day client? Select all that apply. "If you miss a dose, take it when you remember it." Correct answer "Be sure to take the pill with food." "Report muscle pain or tenderness to your health care provider." Correct answer "Continue to follow a diet that is low in saturated fats." Correct answer "Take once a day in the morning."  Feedback Good work  Question 54 / 1.2 The nurse is documenting postoperatively on the client's electronic health record after a permanent pacemaker insertion. Which information would be important to record regarding the pacemaker? Select all that apply. location of generator Correct answer pacemaker model Correct answer pacer settings Correct answer location of epicardial leads stimulation threshold Correct answer  Feedback That's not correct  Question 55 / 1.2 A nurse is caring for a client with Raynaud's phenomenon secondary to systemic lupus erythematosus (SLE). Which of the client statements demonstrates an understanding of the nurse's teaching about this disorder? Select all that apply. "I don't need to report any other skin problems with my fingers or hands to my health care provider." "This problem is caused by a temporary lack of circulation in my hands." Correct answer "I probably got this disorder because I am also diagnosed with lupus." Correct answer "I will have to discuss medication that might treat this problem with my health care provider." Correct answer "My hands get pale and bluish, and feel numb and painful when I'm really stressed." Correct answer "I can't continue to wash dishes and do my cleaning because of this problem."  Feedback That's not correct  Question 56 / 1.2 When caring for a client with a newly diagnosed cardiac dysrhythmia, which laboratory values are the priority for the nurse to monitor? Select all that apply. hematocrit of 40% hemoglobin of 14 g/dL sodium of 124 mEq/L Correct answer calcium of 8.5 mEq/L Correct answer potassium of 3.1 mEq/L Correct answer prothrombin time of 12 seconds with INR of 1 blood urea nitrogen (BUN) of 20 mg/dL  Feedback That's not correct  Question 57 / 1.2 A client who has undergone a mitral valve replacement has had a mediastinal chest tube inserted. The client has persistent bleeding from the sternal incision during the early postoperative period. What actions should the nurse take? Select all that apply. Administer warfarin. Confirm availability of blood products. Correct answer Start a dopamine drip for a systolic BP less than 100 mm Hg. Check the postoperative CBC, INR, PTT, and platelet levels. Correct answer Monitor the mediastinal chest tube drainage. Correct answer  Feedback Good work  Question 58 / 1.2 A client is prescribed furosemide to manage heart failure. What laboratory values should the nurse monitor while the client receives this medication? Select all that apply. complete blood count Correct answer serum potassium Correct answer prothrombin time (PT) international normalized ratio thrombin time  Feedback Good work  Question 59 / 1.2 A client is scheduled for insertion of a coronary stent with right groin access. Which teaching points should the nurse include in this client's preoperative teaching plan? Select all that apply. "You will need to remain flat during the procedure and for 3 to 6 hours after the procedure." Correct answer "You will be given general anesthesia and will be asleep for throughout this procedure." "If you have chest pain during this procedure, please tell the staff when or if this should occur." Correct answer "If you have a hearing aid, you will need to remove it prior to leaving for the procedure." "You will need to keep your right leg in a flexed position for 1 to 2 hours following the procedure." "The stitches at your right groin will be able to be removed in 7 to 10 days following the procedure."  Feedback Good work  Question 60 / 1.2 A nurse is caring for a client with a new prescription of digoxin. Which client statement would require further teaching about digoxin? Select all that apply. "I will take my pulse before each dose of digoxin." "If I forget a dose, I will catch-up by doubling the next dose." Correct answer Incorrect: "I will take the digoxin at 9 AM daily." "I understand that I will need annual blood work to check therapeutic levels." Correct answer "I will notify my health care provider if experiencing increased fatigue or muscle weakness." "I will take the digoxin with my antacids at night." Correct answer  Feedback That's not correct  Question 61 / 1.2 The client returns to the hospital 3 days after diagnosis of deep vein thrombosis, with reports of cough, hemoptysis, shortness of breath, and sharp pain under the right scapula. The client is subseqently is diagnosed with a pulmonary embolus (PE). The client asks the nurse, "How did I even get a pulmonary embolus?" What is the best response by the nurse? Select all that apply. venous endothelial changes Correct answer having any condition that produces venous stasis Correct answer increased blood coagulability Correct answer frequent falls taking medications such as warfarin sodium  Feedback Good work  Question 62 / 1.2 What instructions should the nurse give a client experiencing signs and symptoms related to decreased arterial insufficiency? Select all that apply. Take aspirin or clopidogrel as prescribed. Correct answer Avoid smoking and exposure to the cold. Correct answer Use additional bed clothes at night. Correct answer Take acetaminophen if experiencing pain at night. Wear tight socks to keep feet warm.  Feedback Good work  Question 63 / 1.2 The nurse is evaluating the cardiac function of a client with history of left ventricular hypertrophy and new diltiazem administration. Which client statements indicate therapeutic use of diltiazem leading to adequate cardiac functioning? Select all that apply. "My blood pressure has been consistently in the 130/70 range." Correct answer "In the morning, I notice 2 plus edema in my ankles." "My lab results reveal a serum potassium of 3.5 mEq/L (3.5 mmol/L.)" "I am completing all of my activities of daily living independently." Correct answer "I am tolerating my new low fat diet." "I am sleeping well in the second floor bedroom." Correct answer  Feedback Good work  Question 64 / 1.2 The nurse is caring for a client receiving digoxin who has begun vomiting and reports seeing colorful halos around the lights in the room. Which actions should the nurse implement? Select all that apply. Discontinue administration of digoxin. Correct answer Insert nasogastric tube. Begin continuous electrocardiographic monitoring. Correct answer Administer low flow oxygen. Determine serum digoxin and electrolyte levels. Correct answer  Feedback That's not correct  Question 65 / 1.2 When providing care for clients with possible arterial disease, the nurse recognized which clients should have a baseline ankle-brachial index (ABI) assessed? Select all that apply. 65-year-old client with decreased pulses Correct answer 75-year-old client with diabetes Correct answer 55-year-old client with family history of arterial disease 50-year-old client with hypertension 72-year-old client in the nursing home Correct answer  Feedback Good work  Question 66 / 1.2 The nurse is teaching a client who has had a myocardial infarction about using nitroglycerin spray. Which information should the nurse include in the teaching plan? Select all that apply. "Spray the medication under your tongue as soon as you have chest pain." Correct answer "Call 911 if chest pain continues after 10 minutes of using the third spray." Correct answer "Store the medication in the refrigerator when not in use." "Swallow the medication as soon as you have sprayed it in your mouth." "If the chest pain continues after 2 spays of the medication, wait 5 minutes and use one more spray." Correct answer "Shake the medication container before using."  Feedback Good work  Question 67 / 1.2 A client is admitted to the emergency department with sudden onset of chest pain. Which prescriptions should the nurse implement immediately? Select all that apply. Insert a Foley catheter. Administer morphine. Correct answer Administer acetaminophen Provide oxygen. Correct answer Administer aspirin. Correct answer Administer nitroglycerin. Correct answer  Feedback Good work  Question 68 / 1.2 The nurse is caring for a client diagnosed with end stage heart disease. Which orders will the nurse question to protect the safety of the client? Select all that apply. valsartan 160mg po bid physical therapy for increased ambulation Correct answer consult for hospice care furosemide 40mg po tid maintain HOB < 30° for comfort Correct answer regular diet Correct answer  Feedback Good work  Question 69 / 1.2 A well-nourished client is admitted with a stasis ulcer. The nurse assesses the ulcer and finds excavation of the skin surface as a result of sloughing of inflammatory necrotic tissue. The health care provider (HCP) has prescribed the ulcer to be flushed with a fibrinolytic agent. Which goals are appropriate for this client? Select all that apply. Improve nutrition. Increase oxygen to the tissues. Correct answer Reduce pain. Correct answer Prevent infection. Correct answer Prevent direct trauma to the ulcer. Correct answer  Feedback Good work  Question 70 / 1.2 When teaching a client about self-care following placement of a new permanent pacemaker to his left upper chest, the nurse should include which information? Select all that apply.  Feedback Good work  Question 71 / 1.2 A client has Raynaud's phenomenon. What information should the nurse include in a teaching plan about managing an attack? Select all that apply. Massage the fingers and toes. Correct answer Place hands under the armpits. Correct answer Incorrect: Place hands under hot, running water. Move the fingers and toes. Correct answer Go to a warm room. Correct answer  Feedback That's not correct  Question 72 / 1.2 A client has been diagnosed with Raynaud's phenomenon on the tip of the nose and fingertips. The health care provider has prescribed reserpine to determine if the client will obtain relief. The client often works outside in cold weather and also smokes two packs of cigarettes per day. The nurse should include which instructions in the discharge plan for this client? Select all that apply. Report signs of orthostatic hypotension. Correct answer Wear a face covering and gloves in the winter. Correct answer Incorrect: Place fingertips in cool water to rewarm them. Incorrect: Find employment that can be done in a warm environment. Stop smoking. Correct answer  Feedback That's not correct  Question 73 / 1.2 A client is taking clonidine for treatment of hypertension. The nurse should teach the client about which common adverse effects of this drug? Select all that apply. pancreatitis dry mouth Correct answer hyperkalemia impotence Correct answer sleep disturbance Correct answer  Feedback Good work  Question 74 / 1.2 Several clients have come to the emergency department after a possible terrorist act of arsenic overexposure. The nurse should assess these clients for which signs or symptoms immediately following the poisoning? Select all that apply. abdominal pain Correct answer violent vomiting Correct answer severe diarrhea Correct answer persistent cough sensory neuropathy  Feedback Good work  Question 75 / 1.2 A client who had an exploratory laparotomy 3 days ago now has a white blood cell (WBC) count of 15,000 µL (15x109/L). For which clinical findings of this laboratory report should the nurse assess the client? Select all that apply. elevated temperature Correct answer redness around the incision Correct answer weak pedal pulses nonproductive cough swelling around the incision Correct answer  Feedback Good work  Question 76 / 1.2 A client receiving a loop diuretic should be encouraged to eat which foods to prevent potassium loss? Select all that apply. banana Correct answer dried fruit Correct answer angel food cake orange juice Correct answer peppers Feedback