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194 Cards in this Set
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a nurse is caring for an older adult client who has a new diagnosis of type 2 diabetes and reports difficulty following the diet and remembering to take meds, what are some appropriate actions by the nurse? |
ask the dietitian to assist with meal planning contact the clients support system encourage the use of a daily med dispenser provide educational materials for home use |
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a nurse in a health care clinic is evaluating the level of wellness for clients using the health/wellness/illness continuum tool, what is an ex of someone at the center of the continuum? |
a young male who has a long hx of well-controlled rheumatoid arthritis |
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a nurse is evaluating clients at a health fair for modifiable variables affecting health and wellness. the nurse identifies which of the following as a modifiable variable? |
a male who smokes on social occasions a female with BMI of 28 an infant with reflux |
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a nurse is caring for a client who has just told she has breast cancer and the nurse evaluates the client's response, what is an ex of lack of understanding |
i need a second opinion there is no lump |
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a nurse on a medical surgical unit is caring for a group of clients. the nurse should notify the RRT for what kind of pt |
client who reports right calf pain and shortness of breath |
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a nurse is caring for a client who has ingested a toxic agent. what are some actions the nurse can take |
instill activated charcoal perform gastric lavage with aspiration complete a whole-bowel irrigation |
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a nurse in the ER is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly, what are some appropriate actions by the nurse? |
remove wet clothing apply warm blankets apply a heat lamp infuse warmed IV fluids |
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a nurse in the ER is assessing a client who is unresponsive. the clients partner states, 'he was pulling weeds in the yard and dropped to the ground", how should the nurse open the clients airway? |
head-tilt, chin-lift |
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a nurse is reviewing the common emergency management protocol for clients during a cardiac emergency, what medication should be administered? |
IV epinephrine (adrenaline) |
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a nurse is caring for a client post lumbar puncture who reports a throbbing headache when sitting upright for meals, what care should the nurse perform? |
assist client to eat meals while lying flat in bed administer an opioid medication encourage client to increase fluid intake |
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a nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter for ICP monitoring, what complication should the nurse monitor for? |
infection |
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a nurse is assessing a client for changes in the level of consciousness using the glasgow coma scale, the client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied, how would this be scored? |
E3+V4+M4= 11 |
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a nurse is is developing a plan of care for a client who is scheduled for a cerebral angiogram with contrast dye, what are some statements that should be reported to the provider? |
"i think i may be pregnant" "i take coumadin" "i am allergic to shrimp" |
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a nurse is providing education to a client who is to undergo an EEG the next day, what is important to include in the teaching? |
try and stay awake most of the night prior to the procedure |
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a nurse is assessing the pain level of a client who has come to the ER reporting severe abdominal pain, the nurse asks the client whether he has nausea and has been vomitting, what is the nurse assessing? |
presence of associated symptoms |
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a nurse is assessing a client who is reporting pain despite analgesia, the nurse can best assess the intensity of the clients pain by? |
offering the client a pain scale to measure his pain |
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a nurse is obtaining a hx from a client who has pain, the nurses guiding principle throughout this process should be that? |
pain is whatever the client says it is |
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a nurse is caring for a client who is receiving morphine via a patient controlled analgesia infusion device after abdominal surgery, what is an ex of a statment indicating the client knows how to use the device? |
i should tell the nurse if the pain doesnt stop after i use this device |
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a nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication, what SE should the nurse anticipate? |
orthostatic hypotension nausea |
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a nurse is assessing a client who reports severe headache and a stiff neck. the nurse's assessment reveals a positive kernig's and brudzinski's signs, what action should be taken first? |
implement droplet isolation precautions |
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a nurse is assessing for the presence of brudzinski's sign in a client who has suspected meningitis. what are some nursing interventions that should be implemented? |
place client in supine position place hands behind the client's neck bend client's head toward chest |
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a nurse is reviewing the health record of a student newly admitted to a university and living in a dormitory, what organism should the nurse suspect? |
Neisseria meningitis |
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a nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure, what are some appropriate nursing actions? |
implement seizure precautions turn off room lights and tv monitor for impaired extraocular movement |
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a nurse is planning care for a client who has a bacterial meningitis what actions should the nurse implement |
provide an emesis basin at bedside administer antipyretic medication as prescribed perform a skin assessment |
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a nurse is assessing a client who has a seizure disorder, the client reports that he thinks he is about to have a seizure, what interventions should a nurse implement |
provide privacy ease the client to the floor if standing move furniture away from the client loosen the client's clothing protect the client's head with padding |
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a nurse is caring for a client who just experienced a generalized seizure, what action should be performed first |
keep the client in a side lying position |
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a nurse is providing discharge instructions to a female client who has a prescription for phenytoin (dilantin) what is key to include in the teaching? |
take the medication at the same time every day |
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a nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures, what is important to include in the review? |
overwhelming fatigue should be avoided caffeinated products should be removed from the diet looking at flashing lights should be limited |
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a nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity, what info should the nurse include in the teaching |
place a magnet over the implantable device when an aura occurs |
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a nurse is caring for a client who displays signs of stage 3 parkinson's disease, what should be included in the plan of care |
provide a walker for ambulation |
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a nurse is developing a plan of care for the nutritional needs of a client who has stage 4 parkinsons disease, what is important to add to the plan of care |
record diet and fluid intake daily add thickener to liquids offer nutritional supplements between meals |
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a nurse is reinforcing teaching with a client who has parkinsons disease and has received a prescription for bromocriptine (parlodel) what is important to include in the teaching? |
rise slowly when standing |
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a nurse is assessing a client for manifestations of parkinson's disease, what are expected findings? |
pill rolling tremor of fingers shuffling gait drooling lack of facial expressions |
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a nurse is caring for a client who has parkinsons disease and displays signs of bradykinesia what is important to include when planning care? |
assist with hygiene as needed |
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a nurse is providing teaching to the partner of an older adult client who has alzheimers disease and has a new prescription for donepezil (aricept) what is an ex of a client statement that shows effective teaching |
this medication should help my husbands daily function |
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a nurse is making a home visit to a client who has AD, the clients partner states that the client is often disoriented to time and place, is unsteady on his feet, and has a hx of wandering, what should the nurse include as safety meassures |
remove floor rugs provide increased lighting in stairwells install handrails in the bathroom place the mattress on the floor |
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a nurse is caring for a client who has AD and falls frequently, what should happen first when planning for safety |
place the client in a room close to the nurses station |
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a nurse is working in a long term care facility is planning care for a client in stage 5 of alzheimers disease , what should be included when planning care |
assist with ADLs |
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a nurse is caring for a client who has AD a family member of the client asks the nurse about risk factors, what are some risk factors |
exposure to metal waste products previous head trauma hx of herpes infection |
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as nurse is caring for a client who is having surgery for the removal of an encapsulated acoustic tumor, what are some possible complications? |
increased ICP hydrocephalus seizures |
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a nurse is caring for a client who has just undergone a craniotomy for a supratentorial tumor, what medication is contraindicated |
morphine sulfate |
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a nurse is completing an assessment of a client who has increased ICP what are some expected findings |
disoriented to time and place restlessness and irritability unequal pupils headache |
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a nurse is reviewing a prescription for dexamethasone (decadron) with a client who has an expanding brain tumor what are ex of appropriate statements by the nurse |
it is given to reduce swelling of the brain you may notice weight gain it can cause you to retain fluids |
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a nurse is caring for a client who has a benign brain tumor, the client asks the nurse if he can expect this same type of tumor to occur in other areas of his body, what is an appropriate response by the nurse |
it is limited to brain tissue |
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a nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive rombergs sign, how do you assess this sign |
have the client stand erect with eyes closed |
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a nurse is caring for a client admitted to the hospital with respiratory difficulty after being diagnosed with ALS 1 yr ago, what findings should be expected |
incontinence ineffective cough |
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a nurse is teaching a client who has ALS about a new prescription for riluzole (rilutek) what is an important instruction to include |
avoid consuming alcoholic beverages |
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a nurse is caring for a client who has myasthenia gravis and has developed drooping eyelids, what are important nursing actions |
apply lubrication eye drops tape eyes closed at night |
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a nurse instructs a client who has MG about home care and the risk factors that can exacerbate the disease, what is an example of a patient statement that indicates teaching has been ineffective |
i will soak in a warm bath every day |
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a nurse is beginning a physical assessment of a client who was recently diagnosed with multiple sclerosis, what are expected findings |
areas of paresthesia involuntary eye movements ataxia |
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a nurse in a clinic is caring for a client who has frequent migraine headaches the client asks about foods that may cause headaches, what food should be avoided |
salted cashews |
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a nurse in a clinic is teaching a client who has a hx of migraine headaches about a new prescription for zolmitriptan (zomig) what is an ex of pt understanding for this medication |
i should take this medication as soon as i notice symptoms developing |
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a nurse in a providers office is obtaining a nursing hx from a client who has cluster headaches what are expected findings |
client is experiencing altered sleep-wake cycle headache occurs at approx the same time of the day nasal congestion and drainage occur |
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a nurse is reviewing discharge instructions with a client who has a new diagnosis of migraine headaches, what instruction is important to include |
apply a cool cloth to the face during a headache |
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a nurse is obtaining a health hx from a client who is being evaluated for the cause of frequent headaches, what is an important question to ask to determine if they are migraines |
is there a pattern of headaches among family members |
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a nurse is caring for an older adult client who has diabetes the client reports loss of peripheral vision, what is the client at risk for? |
open angle glaucoma |
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a nurse is caring for a client following a trabeculectomy what should the nurse include in the teaching |
you need to limit your housekeeping activities |
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a nurse is caring for a male older adult client who has a new diagnosis of glaucoma what are some associated factors of this disease |
genetic predisposition hypertension age DM |
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a nurse is caring for a client who has a new diagnosis of cataracts what are clinical manifestations |
blurred vision white pupils |
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a nurse is assessing a client following cataract surgery, the client reports nausea and severe eye pain, what is a priority action by the nurse |
notify the provider |
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a nurse is performing an otoscopic examination of a client , what is an expected finding |
black cerumen partially occluding the TM |
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a nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks, what are some ways to control the vertigo |
reduce exposure to bright lighting move head slowly when changing positions plan evenly spaced daily fluid intake |
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a nurse is caring for a client who has suspected menieres disease what is an expected finding |
unilateral hearing loss |
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a nurse is reviewing the health record of a client who has a middle ear disorder, what are expected findings |
enlarged adenoids report of recent colds report of frequent ingestion of ibuprofen |
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a nurse is completing discharge teaching to a client following a stapedectomy, what is an ex of a client statement which indicates understanding |
i will cover my ear when washing my hair |
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a nurse is caring for a client who was recently admitted to the ER following a head on MVC the client is unresponsive, has spontaneous resp of 22/min and laceration on his forehead that is bleeding, what is the priority nursing action |
keep neck stabilized |
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a nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma, what is the priority assessment |
oxygen saturation |
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a nurse is caring for a client who has a closed head injury with ICP readings range from 16 to 22, what actions should the nurse take to decrease the chance of the ICP increasing |
hyperventilate the client administer a stool softener |
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a nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head, what assessment findings indicate and increased ICP |
headache dilated pupil decorticate posturing |
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a nurse is caring for a client who has increased ICP and a script for mannitol (osmitrol), what is an adverse effect that should be monitored for |
hyponatremia |
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a nurse is caring for a client who had experienced a right hemispheric stroke what are some expected findings |
impulse control difficulty left hemiplegia loss of depth perception lack of awareness |
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a nurse is caring for a client wo has left homonymous hemianopsia, what is an appropriate nursing intervention |
place the clients bedside table on the right side of the bed |
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a nurse is planning care for a client who has dysphagia and has a new dietary script, what should be included in the plan of care |
have suction equipment available for use use thickened liquids place food on the clients unaffected side of her mouth teach the client to swallow with her neck flexed |
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a nurse is caring for a client who has global aphasia, what should the nurse include in the clients plan of care |
speak to the client at a slower rate look directly at the client when speaking allow extra time for the client to answer give instructions one step at a time |
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a nurse is assessing a client who has experienced a left hemispheric stroke, what is an expected finding |
inability to recognize familiar objects |
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a nurse is planning care for a client who suffered a spinal cord injury involving T12 fracture 1 week ago, the client has no muscle control of the lower limbs, bowel and bladder, what is the highest priority |
prevention of further damage to the spinal cord |
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a nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely, vital signs include BP 220/110 with an apical heart rate of 54 what intervention should be taken first |
sit the client upright in bed |
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a nurse is caring for a client who has a C4 spinal cord injury, what is the greatest concern |
respiratory compromise |
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a nurse is caring for a client who experienced a cervical spine injury 24 hr ago, what type of medication should the nurse clarify with the provider |
muscle relaxants |
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a nurse is caring for a client who experienced a cervical spine injury 3 months ago, what type of bladder control in indicated |
condom catheter |
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a nurse is caring for a client who is scheduled for a thoracentesis, prior to the procedure what is a priority action for the nurse to take |
position the client in an upright position, leaning over the bedside table |
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a nurse is assessing a client who is in respiratory distress, the nurse should recognize that what factors can cause a low SpO2 |
nail polish inadequate peripheral circulation edema |
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a nurse is assessing a client following a bronchoscopy, what findings should be reported to the provider |
bronchospasms |
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a nurse is caring for a client who is scheduled for a thoracentesis, what supplies are needed |
oxygen equipment pulse oximeter sterile dressing |
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a nurse is caring for a client following a thoracentesis what are risks for complications |
dyspnea fever hypotension |
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a nurse is preparing to care for a client following chest tube placement, what should be in the patient room |
oxygen sterile water enclosed hemostat clamps occlusive dressing |
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a nurse is caring for a client who has a chest tube and drainage system in place the nurse observes that the clients chest tube was accidentally removed , what action should the nurse take first |
apply sterile gauze to the insertion site |
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a nurse is assessing a client who has a chest tube and drainage system in place, what are expected findings |
gentle constant bubbling in the suction chamber rise and fall in the level of water in the water seal chamber with inspiration and expiration |
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a nurse is assisting a provider with the removal of a chest tube, what should the nurse instruct the client to do |
perform the valsalva maneuver |
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a nurse is planning care for a client following the insertion of a chest tube and drainage system what should be included in the plan of care |
encourage the client to cough every 2 hr check for continuous bubbling in the suction chamber obtain a chest x ray |
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a nurse is orienting a newly licensed nurse who is caring for a client that is receiving mechanical ventilation, which has been placed on pressure support ventilation mode, what is an ex of a statement which demonstrates understanding |
it permits spontaneous ventilation to decrease the work of breathing |
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a nurse is caring for a client who is experiencing respiratory distress, what are early manifestations of hypoxemia |
pale skin elevated blood pressure |
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a nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via endothracheal tube, what should be included in the treatment |
assess breath sounds every 1 to 2 hr |
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a nurse is caring for a client who has a dyspnea and is to receive oxygen continuously , what O2 device should be used |
venturi mask |
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a nurse is planning care for a client who is receiving mechanical ventilation which mode of ventilation increases the effort of the client's respiratory muscles |
synchronized intermittent mandatory ventilation continuous positive airway pressure pressure support ventilation |
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which clients have an increased risk for developing pneumonia |
client who has dysphagia client who has aids client who has a closed head injury and is receiving ventilation client who has myasthenia gravis |
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a nurse in a clinic is caring for a client who was brought to the the clinic by her partner. the partner states the client woke up this morning, did not recognize him and did not know where she was, the client reports chills and chest pain that is worse on inspiration, what is the priority nursing action |
obtain baseline vital signs and oxygen saturations |
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a nurse in a clinic is caring for a client who has sinusitits what technique should be used to identify clinical manifestations of this disorder |
palpation of the orbital areas |
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a nurse is teaching a group of clients about influenza what is a statement that would require clarification |
i need to avoid drinking fluids if i develop symptoms |
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a nurse in the ER is caring for a client who was admitted with an acute asthma attack, what signs indicate respiratory status is declining |
wheezing retraction of sternal muscles PVC |
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a nurse working on a med surg unit admits a client, two hrs later the SaO2 is 91% and he is audibly wheezing using his accessory muscles, what medication should the nurse expect to administer |
beta 2 agnoist |
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a nurse is completing discharge teaching with a client who has a new script for prednisone for asthma, what is an ex of a client statement which requires more teaching |
i will take my medication on en empty stomach |
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a nurse is assessing a client with asthma, what is a risk factor associated with this disease |
environmental allergies |
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a nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator, what is an ex of a client statement which means that teaching is effective |
i take this medication to prevent asthma attacks |
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a nurse is providing discharge teaching to a client who has COPD and has a new script for albuterol, what information should be included in the teaching |
this medication can increase your heart rate |
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a nurse is preparing to administer a new prescription prednisone (deltasone) to a client who has COPD, what should the nurse monitor for |
monitor the client for hypokalemia observe the client for fluid retention advise the client to report black tarry stools |
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a nurse is instructing a client on the use of an incentive spirometer, how is this device used? |
take a deep breath in and hold it before exhaling |
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a nurse is discharging a client who has COPD, upon discharge the client is concerned that he will never be able to leave his house now that he is on continuous oxygen, what is an appropriate response by the nurse |
there are portable oxygen delivery systems that you can take with you |
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a nurse is planning to instruct a client on how to perform pursed lip breathing, what should the nurse include in the plan of care |
take a deep breath in through your nose |
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a home health nurse is teaching a client who has active tuberculosis, the provider has prescribed the following medication regimen: isoniazid (nydrazid), rifampin (rifadin), pyrazinamide, and ethambutol (myambutol), what are some education points to include in the teaching |
wash hands each time you cough wear a mask when you are in a public area |
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a nurse is teaching a client who has tuberculosis, what should be included in the teaching |
you will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication |
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a nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multimedication regimen, what instruction should be included for the med ethambutol |
watch for changes in vision |
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a nurse is preparing to administer a new script for isoniazid (INH) to a client who has tuberculosis, what is important info to include in the teaching |
you may notice tingling of your hands |
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a nurse is providing information to a group of clients at a local community center about tuberculosis, what should be included in the teaching |
persistent cough fatigue night sweats purulent sputum |
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a nurse is caring for several clients, what type of clients would be at risk for a PE |
a client with a BMI of 30 a client who has a fractured femur a client who has chronic atrial fibrillation |
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a nurse is reviewing scripts for a client who has acute dyspnea and diaphoresis, the client states that she is anxious because she feels that she cannot get enough air, VS are HR 117, RR 38, T 101.2, BP 100/54, what is the priority action? |
administer oxygen therapy |
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a nurse is caring for a client who has a new script for heparin therapy, what type of medication should not be taken with this med |
antacids |
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a nurse is assessing a client who has a PE what clinical manifestation should the nurse expect to find |
pleural friction rub petechae tachycardia |
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a nurse is caring for a client who is to receive fibrinolytic thromblytic therapy what is a contraindication to the therapy |
hip arthroplasty 2 weeks ago |
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a nurse is assessing a client who has experienced a gunshot wound, VS BP 108/55, HR 124, RR 36 T101.4 SaO2 95 on 15 O2 via nonrebreather, client reports dyspnea and pain the nurse reassess the client 30 min later, what should the nurse report to the provider |
distended neck veins tracheal deviation heart rate 154 |
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a nurse is reviewing the script for a client who has a pneumothorax, what action should the nurse perform first |
obtain a large-bore IV needle for decomposition |
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a nurse is reviewing discharge instructions for a client who experienced a pneumothorax, what should be included in the teaching |
notify your provider if you experience a cough |
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a nurse is preparing to administer morphine 2.5 mg IV bolus to a client who has pneumothorax, available is morphine injection 10 mg/ml, how many ml should the nurse administer |
0.3ml |
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a nurse in the ER is assessing a client with a suspected flail chest, what clinical findings would confirm this diagnosis |
cyanosis hypotension dyspnea paradoxic chest movement |
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a nurse in the ER is assessing a client who was in a motor vehicle crash, findings include absent breath sounds in the left lower lobe with dyspnea, BP 118/68, HR124, RR 38, T101.4 SaO2 92 on RA, what action should the nurse take first |
administer oxygen via a high-flow mask |
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a nurse is orienting a newly licensed nurse on the purpose of administrating vecuronium (norcuron) to a client who has acute respiratory distress syndrome, why is this medication given? |
this medication is given to facilitate ventilation |
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what are examples of pt who may be at risk for developing ARDS |
a client who experienced a near-drowning incident a client following coronary artery bypass graft surgery a client who has dysphagia a client who experienced a drug overdose |
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a nurse is planning care for a client who has severe acute respiratory distress system, what should be included in the plan of care for this client |
providing supplemental oxygen administration of bronchodilators maintaining ventilatory support |
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a nurse is caring for a client who is receiving vecuronium (norcuron) for ARDS, what medications should the nurse anticipate administering with this med |
fentanyl (duragesic) midazolam (versed) |
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a nurse is orienting a newly licensed nurse on the care of the client who is receiving hemodynamic monitoring, what is needed to verify placement |
a chest x ray |
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a nurse is caring for a client following a coronary artery bypass graft CABG, hemodynamic monitoring has been initiated, what actions by the nurse will facilitate correct monitoring |
level transducer to phlebostatic axis zero transducer to room air observe trends in readings compare readings to physical assessment |
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a nurse is caring for a client who s receiving hemodynamic monitoring and has the following readings: PAS 34, PAD 21, PAWP 16, and CVP 12, what is the client at risk for |
heart failure cor pulmonale pulmonary hypertension peripheral edema |
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a nurse is teaching a client the importance of remaining still following angiography, what is important to include in the teaching |
too much activity places you at risk for bleeding |
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a nurse is reviewing a new script to administer 0.9% NACL IV at 50 ml to a client who is recieving hemodynamic monitoring and has an indwelling IV catheter in the left hand what sites can be used for administration |
peripheral saline lock port on proximal CVP lumen of pulmonary artery PA catheter |
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a nurse on a cardiac unit is caring for a group of clients the nurse should recognize which type of clients are at risk for developing a dysrhythmia |
a client who has metabolic alkalosis a client who has COPD a client who underwent stent placement in a coronary artery |
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a nurse is caring for a client who experienced defibrillation what should be included in the documentation of this procedure |
follow up ECG energy settings used skin condition under electrodes |
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a nurse on a cardiac unit is caring for a client who is on telemetry, the recognizes the clients HR is 46and notifies the provider, what management strategy should be anticipated |
pacemaker insertion |
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a student nurse is observing a cardioversion procedure and hears the team leader call out "stand clear" this means what? |
they cannot be in contact with equipment connected to the client |
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a urse is admitting a client to the coronary care unit following placement of a temporary paceaker, what are ex of nursing actions to promote client safety |
wear gloves when handling pacemaker leads verify the use of three pronged grounding plugs minimize clients shoulder movements |
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a nurse is admitting a client who has complete heart block s demonstrated by ECG, HR 34, BP 83/48, he is lethargic and unable to complete sentences what action should the nurse perform first |
cleanse the clients skin with soap and water |
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a nurse is caring for a client following the insertion of a temporary venous pacemaker via the femoral artery that is set as a VVI pacemaker rate of 70, what findings should the nurse provide to the provider |
cool and clammy foot with capillary refill of 5 seconds twitching of intercostal muscle |
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a nurse is caring for a client who is 4 hr postop following coronary artery bypass graft surgery, he is complaining of pain upon inspiration what is an appropriate intervention |
administer IV bolus analgesic and return in 15 min |
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a nurse is caring for a client following peripheral bypass graft of the left lower extremity, what are examples of warning signs that pose immediate concern |
cap refill of affected limb at 6 sec mottled appearance of the limb |
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a nurse educator is reviewing the use of cardiopulmonary bypass during surgery for CABG with a group of nurses, what are topics that need to be included |
the clients demand for oxygen is lowered motion of the heart ceases rewarming of the client takes place |
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a nurse is caring for a client following an angioplasty that was inserted through he femoral artery, while turning the client the nurse discovers blood underneath the clients lower back what is an expected finding |
bleeding from the incisional site |
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a nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg, what is an expected finding |
report of intermittent claudication in the affected leg |
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a nurse is admitting client who has a suspected myocardial infarction and hx of angina, what distinguishes a MI from angina |
angina can be relieved with rest and nitro |
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a nurse on a cardiac unit is reviewing the lab finding of a client who has a diagnosis of a myocardial infarction and reports that his dyspnea began 2 weeks ago which enzyme would confirm this? |
Troponin T |
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a nurse is caring for a client in a clinic who asks the nurse why her provider prescribed 1 aspirin a day, what is an appropriate response |
aspirin reduces the formation of blood clots that could cause a heart attack |
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a nurse is instructing a client who has angina about a new script for metorprolol tartrate, what is important that the client learns from the teaching? |
i will call my dr if my pulse rate is less than 60 |
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a nurse is presenting a community education program on recommended lifestyle changes to prevent angina and MI, what lifestyle change should be encouraged |
smoking cessation |
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a nurse is caring for a client who has heart failure and reports increased SOB, besides O2 what intervention should the nurse implement |
assist the client into high fowlers |
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what is a good way to communicate fluid restriction to a client |
use bottles they are familiar with |
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what are examples of food high in salt |
cheddar cheese hot dog anned tuna baked ham |
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a nurse is completing discharge teaching to a client who has heart failure and is encouraged to increase K in his diet, what food is high in this |
potatoes |
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what are expected findings for pulmonary edema |
tachypnea persistant cough orthopnea |
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a nurse is completing discharge teaching with a client who has a surgical placement of a mechanical heart valve, what lab value needs to be checked on a regular basis |
prothrombin time |
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a nurse is completing the admission physical assessment of a client who has a hx of mitral valve insufficiency, what is an expected finding? |
crackles in lung bases |
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a nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease, what are risk factors for this condition |
surgical repair of an atrial septal defect at age 2 hypertension for 5 yr diastolic murmur present |
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what are expected findings of right sided valvular heart disease |
dyspnea client report of fatigue peripheral edema |
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what is an expected finding for someone with pericarditis |
friction rub |
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what type of pt is at greatest risk of acquiring rheumatic endocarditis |
a child who has an upper respiratory infection |
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a nurse in a clinic is caring for a client who has been on long term NSAID therapy to treat myocarditis, what lab value should be monitored |
platelets |
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a client has splinter hemorrhages in her nail beds and reports a fever, what is the client at risk for |
infective endocarditis |
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what laboratory test should be performed for someone with rheumatic endocarditis |
throat culture |
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a nurse is performing a physical assessment of a client who has chronic peripheral arterial disease, what is an expected finding |
pallor on elevation of the clients limbs and rubor when his limbs are dependent |
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a nurse is caring for a client who has severe peripheral arterial disease, the nurse should expect that the client would sleep most comfortably in what position |
with the affected limb hanging from the bed |
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a nurse is teaching a client who has a new script for clopidogrel (plavix), what is important to include in the teaching |
effects may not be apparent for several weeks monitor for the presence of black tarry stools |
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what is important to include when educating a pt on heparin who is switching to warfarin |
it take 3-4 days before warfarin begins to work and heparin can be discontinued |
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for a client with chronic venous insufficiency, how should the nurse instruct the client to use compression stockings |
apply stockings in the morning upon waking and before getting out of bed |
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a nurse is screening a client for hypertension, what can increase risk for hypertension |
eating popcorn from a theater consuming 36oz of beer daily |
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what time of day should a client be instructed to take furosemide |
morning |
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what should a client avoid in the diet if they are on aldactone |
potassium |
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what is a major complication of metoprolol |
hypoglycemia |
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why would a pt need a script for an afterload reducing medication |
cardiogenic shock |
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what is the priority action for someone in septic shock |
administering antibotic therapy |
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what medication should be administered for anaphylactic shock |
epinephrine IV |
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what are expected findings for someone in shock |
seizure activity respiratory rate 42/min weak, thready pulse |
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what should a nurse be prepared to do when a pt is being admitted for hemodynamic monitoring |
assist with insertion of pulmonary artery catheter |
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what is the priority intervention for someone with a possible dissecting abdominal aortic aneurysm |
administer IV fluids as prescribed |
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what interventions should be planned for a client who had a synthetic graft to repair aneurysm |
assess pedal pulses monitor for an increase in pain below the graft site administer prescribed antiplatelet agents |
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what is the primary cause of a ruptured aneurysm |
hypertension |
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what is an expected finding for a pt with an occlusion of an abd aorta |
increased ab girth |
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what are clinical manifestations of a thoracic aortic aneurysm |
cough SOB altered swallowing |
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which lab value is needed to deduce anemia |
HGB |
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what lab is needed for hemophilia |
aPTT |
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why does a nurse need to stay for the first 15 min a transfusion |
assess for an adverse reaction |
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what actions need to be taken when a client displays a reaction to a transfusion |
stop the transfusion send all parts to the blood bank maintain IV with NS |
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what are signs of a reaction to a transfusion |
temp goes from 98.6-99 dyspnea itching flushes |
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hgb of 7.5, hct of 21.5 what should be included in the plan of care |
provide assitance with ambulation monitor oxygen obtain stool specimen for occult blood schedule daily rest periods |
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when taking ferrous sulfate what should be taken with this to increase absorption |
foods high vitamin C |
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what is important to include in the teaching for someone having a gastrectomy |
you will need B12 supplementation for the rest of your life |
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what test should be taken if a client is taking epogen |
hemoglobin twice a week |
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what is an expected finding for someone with DIC |
epitaxis |
