Question: A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse?

Answer: "I took my warfarin last night according to my usually schedule."

Question: A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should recognize that an increase in which of the following is diagnostic of a MI?

Answer: Creatine kinase- MB

Question: A nurse is assessing a client in the emergency room who has a bradydysrhythmia. Which of the following findings should the nurse expect?

Answer: Confusion

Question: A nurse is reviewing the medical record of a client who is receiving heparin therapy for treatment of deep-vein thrombosis. Which of the following interventions should the nurse anticipate taking if the client's aptt is 96 seconds?

Answer: stop the heparin infusion

Question: A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?

Answer: valvular disease

Question: A nurse is admitting a client who has a leg ulcer and a history of DM. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer?

Answer: Inquire about the presence or absence of claudication

Question: A nurse in the emergency department is caring for a client who had an anterior MI. The client's history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated?

Answer: Assisting with thrombolytic therapy

Question: A nurse is caring for a client in the first hour following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider?

Answer: Urine output of 20 ml/hr

Question: A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure?

Answer: "I can't get rid of these hiccups."

Question: A nurse is reviewing the laboratory results of several clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which laboratory values?

Answer: The expected reference range of cholesterol is less than 200 mg/dL, HDL above 45 mg/dL for men and above 55 mg/dL for women, and LDL less than 130 mg/dL.

Question: A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure?

Answer: Previous allergic reaction to shellfish

Question: A nurse is caring for a client who presents to the ER with a BP of 254/138 mmhg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?

Answer: Elevate the head of the client's bed.

Question: A nurse is assessing a client who has left-sided HF. Which of the following manifestations should the nurse expect to find?

Answer: Weak peripheral pulses

Question: A nurse is providing discharge teaching for a client who has HF. The nurse should instruct the client to report which of the following findings immediately to the provider?

Answer: Weight gain of 0.9 kg (2 lb) in 24 hr

Question: A nurse is assessing a client who has pulmonary edema related to hear failure. Which of the following findings indicates effective treatment of the client's condition?

Answer: Absence of adventitious breath sounds

Question: A nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?

Answer: A client who has Diabetes mellitus

Question: A nurse is reviewing the ECG rhythm strip of a client who is receiving telemetry. Identify the area of the strip the nurse should examine to observe for atrial depolarization

Answer: P wave

Question: A nurse is caring for a client who is being treated for HF and has prescriptions for furosemide. The nurse should plan to monitor for which of the following as an adverse effect of this medication?

Answer: Lightheadedness

Question: A nurse is caring for a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect?

Answer: Dyspnea on exertion

Question: A nurse is providing teaching for a client who is 2 days post-op following a heart transplant. Which of the following statements should the nurse include in the teaching?

Answer: "you may no longer be able to feel chest pain."

Question: A nurse is caring for a client who has a history of angina and is schedules for a stress test at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling?

Answer: "I smoked a cigarette this morning to calm my nerves about having this procedure."

Question: A nurse is performing a cardiac assessment on a client. Identify the area the nurse should inspect when evaluating the point of maximal impulse.

Answer: 2nd ICS to the R of the atrium *apex left ventricular area

Question: A client who has a new diagnosis of hypertension has a prescription for an ACE inhibitor. The nurse instructs the client about adverse effects of the medication. The client demonstrates an understanding of the teaching by stating that he will notify his provider if he experiences which of the following?

Answer: A persistent cough

Question: A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. The nurse should plan to monitor for and report which of the following findings to the provider immediately?

Answer: Slurred speech

Question: A nurse is caring for a client in the first 8 hr following coronary artery bypass graft (CABG) surgery. Which of the following client findings should the nurse report to the provider?

Answer: report an elevated blood pressure

Question: A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching?

Answer: Place the patch on an area of skin away from skin folds and joints.

Question: A nurse is planning a presentation about hypertension for a community women's group. Which of the following lifestyle modifications should the nurse include?

Answer: limited alcohol intake, regular exercise, tobacco cessation

Question: A nurse is caring for a client who was admitted for a treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first?

Answer: Review serum electrolyte values

Question: A nurse is caring for a client who has a history of DVT and is receiving warfarin. Which of the following client findings provides the nurse with the best evidence regarding the effectiveness of the warfarin therapy?

Answer: INR 2.0

Question: A nurse is watching a client's ECG monitor and notes that the client's rhythm has changed from a normal sinus rhythm to supraventricular tachycardia. The client is conscious with a HR of 200-210 bpm and has a faint radial pulse. The nurse should anticipate assisting with which of the following interventions?

Answer: Vagal stimulation