PT 3

55問 • 1年前

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A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.)

Assess for allergies to iodine., Administer intravenous fluids, Assess blood urea nitrogen (BUN) and creatinine results

An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.)

Fatigue despite adequate rest, Shortness of breath, Indigestion

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.)

Serum potassium of 2.9 mEq/L, Expanding groin hematoma, Rhythm changes on the cardiac monitor

A nurse reviews a clients laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.)

Total cholesterol: 280 mg/dL, Triglycerides: 200 mg/dL, Low-density lipoprotein cholesterol: 160 mg/dL

A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.)

Prepare for continuous blood pressure and pulse monitoring., Give the client nothing by mouth 3 to 6 hours before the procedure., Explain to the client that dobutamine will simulate exercise for this examination.

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.)

Thrombophlebitis, Pulmonary embolism, Cardiac tamponade

A nurse assesses clients 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-year-old woman with aortic stenosis

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left- sided heart failure?

"I must stop halfway up the stairs to catch my breath."

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure?

"My shoes fit really tight lately."

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next?

Assess for symptoms of left-sided heart failure.

A nurse cares for a client with right-sided heart failure. The client asks, Why do I need to weigh myself every day? How should the nurse respond?

"Weight is the best indication that you are gaining or losing fluid."

A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this clients teaching?

"Avoid using salt substitutes."

After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client?

Instruct the client to ask for assistance when rising from bed.

A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take?

Administer PRN acetaminophen.

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this clients teaching?

"Do not take this medication within 1 hour of taking an antacid."

A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this clients discharge teaching?

Weigh yourself daily while wearing the same amount of clothing."

A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?

Assess the client's respiratory status.

A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the clients stenosis has progressed?

dyspnea on exertion

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, Why will I need to take anticoagulants for the rest of my life? How should the nurse respond?

"Blood clots form more easily in artificial replacement valves."

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the clients understanding. Which client statement indicates a need for additional teaching?

"I will have my teeth cleaned by my dentist in 2 weeks."

A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use

standard precautions

A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find?

Friction rub at the left lower sternal border

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, Why is this important? How should the nurse respond?

"Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes."

A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this clients discharge teaching?

"Avoid large crowds and people who are sick."

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, I know a transplant is my last chance, but I dont want to become a vegetable. How should the nurse respond?

"Would you like information about advance directives?"

A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the clients heart failure?

"Are you able to walk upstairs without fatigue?"

A nurse cares for an older adult client with heart failure. 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 teaches a client with heart failure about energy conservation. Which statement should the nurse include in this clients teaching?

"Gather everything you need for a chore before you begin."

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement?

Sit the client up with a pillow to lean forward on.

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess?

atrial fibrillation

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.)

Pulmonary crackles, Confusion, restlessness, Cough that worsens at night

A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply.)

Hematocrit: 32.8%, Serum sodium: 130 mEq/L, Proteinuria, Microalbuminuria

A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.)

A 36-year-old woman with systemic lupus erythematosus (SLE), A 42-year-old man recovering from coronary artery bypass graft surgery, An 80-year-old man with a bacterial infection of the respiratory tract

After teaching a client with congestive heart failure (CHF), the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.)

"I'll read the nutritional labels on food items for salt content.", "I will eat oatmeal for breakfast instead of ham and eggs.", "Substituting fresh vegetables for canned ones will lower my salt intake."

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply.)

"Reposition the client every 2 hours.", "Accurately record intake and output.", "Use the same scale to weigh the client each morning."

A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.)

Teach the client about dietary restrictions., Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor., Confirm that an echocardiogram has been completed.

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this clients safety prior to discharging home? (Select all that apply.)

"Are your bedroom and bathroom on the first floor?", "What social support do you have at home?", "What spiritual beliefs may impact your recovery?"

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.)

Shortness of breath, Abdominal bloating, New-onset bradycardia

A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should

Night sweats, Cardiac murmur, Oslers node

A 74-yr-old patient has just arrived in the emergency department. After assessment reveals a pulse deficit of 46 beats, the nurse will anticipate that the patient may require

electrocardiographic (ECG) monitoring.

The nurse is reviewing the 12-lead electrocardiograph (ECG) for a healthy 74-yr-old patient who is having an annual physical examination. What finding is of most concern to the nurse?

The heart rate (HR) is 41 beats/min.

During a physical examination of an older patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The best follow-up action for the nurse to take will be to

assess for symptoms of left ventricular hypertrophy

To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the

Bell of the stethoscope with the patient in the left lateral position

To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory test result will the nurse plan to review?

B-type natriuretic peptide (BNP)

While doing the hospital admission assessment for a thin older adult, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take next?

Document the finding in the patient chart.

A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that

a flushed feeling may be noted when the contrast dye is injected.

The nurse notes that a patient who was admitted with heart failure has jugular venous distention (JVD) when lying flat in bed. Which follow-up action should the nurse take nex

Observe for JVD with the patient elevated 45 degrees.

The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to

keep a diary of daily activities while the monitor is worn.

When auscultating over the patient's abdominal aorta, the nurse hears a loud humming sound. The nurse documents this finding as a

bruit

The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The laboratory test result most helpful in indicating myocardial damage will be

troponins T and I

When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To acquire more information about the murmur, which action will the nurse take?

Determine the timing of the sound.

The nurse hears a murmur between the S1 and S2 heart sounds at the patient's left fifth intercostal space and midclavicular line. How will the nurse record this information?

Systolic murmur heard at mitral area

A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse

palpates both carotid arteries simultaneously to compare pulse quality.

Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan?

Teach the patient about the procedure.

Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be important to report to the health care provider before the MRI?

The patient has a permanent cardiac pacemaker.

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