ATI MEDSURG EXAM 2021/2022, (ANSWERED)-RASMUSSEN UNIVERSITY

which one of these clinical assessment findings should the nurse document and report for a client who has a diagnosis of right sided heart failure indicating a complication with cardiac perfusion? a. peripheral edema, ascites, JVD b. weight gain, crackles, JVD c. periorbital edema, moist cough, ascites d. frothy, pink sputum, RR - 30, anxious which nursing plan of action indicated the LPN understands how to appropriately care for a client with PAD a. measures the diameter of the calf and compares to the other leg b. positions the affected leg above heart level c. applies compression stockings after client gets out of bed d. assists client to dangle legs off the side of the bed which one of these physical assessment findings should the nurse document in the chart for a client who has chronic PAD? a. peripheral edema in bilateral ankes b. calf of the right leg is larger than the left c. when the legs are dependent, the color is rubor and pale when elevated d. walking increases circulation and helps relieve pain which one of these orders for a client who is in cardiogenic shock should the nurse question? a. give morphine IV b. monitor and document client's LOC c. monitor UO hourly d. start IV of NS at 150 ml/hour which one of these nursing actions, included in the quality assurance program for HF clients, is most appropriate to delegate to the UAP? a. assess breath sounds and check for edema daily b. check chats to make certain clients are receiving carvedilol as ordered c. encourage client to drink fluids hourly d. weight all clients as ordered which of these statements made by the charge nurse who is conducting an orientation program on the patho of cardiogenic shock indicates an appropriate understanding of this shock? a. occurs due to a mechanical blockage of the heart b. occurs due to a pump or heart failure c. occurs due to a decrease in intravascular volume d. occurs due to a widespread vasodilation and increased permeability which of these clinical findings would be a priority to report for a client who is experiencing cardiogenic shock a. CVP - 6 b. PAWP - 6 c. CO - 6 d. crackles which of these clinical assessment findings would alert the nurse to intervene due to complications from bleeding following surgery. select all that apply a. CVP - 2 b. UO - 60 to 38 c. BP - 140/95 d. PAWP - 15 e. HR - 80 to 120 which of these plans would be a priority for a client who is bleeding following a GI surgery and presenting with a BP of 96/58 a. benadryl b. raise HOB c. decrease fluid d. supine with legs elevated a nurse is teaching a client schedule for catheterization, what should the patient be educated to do after keep leg straight after A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting (CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, then refuses to cough because he is tired and it hurts too much. Which of the following is an appropriate nursing intervention? A. Allow the client to rest, and return in 1 hr. B. Administer IV bolus analgesic, and return in 15 min. C. Document the 200 mL as an appropriate inspired volume. D. Tell the client that he must try to cough if he does not want to get pneumonia. A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following client findings pose an immediate concern? (Select all that apply.) A. Trace of bloody drainage on dressing B. Capillary refill of affected limb of 6 seconds C. Mottled appearance of the limb D. Throbbing pain of affected limb that is decreased following IV bolus analgesic E. Pulse of 2+ in the affected limb A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary artery bypass grafting with a group of nurses. Which of the following should be included in the discussion? (Select all that apply.) A. The client's demand for oxygen is lowered. B. Motion of the heart ceases. C. Rewarming of the client takes place. D. The client's metabolic rate is increased. E. Blood flow to the heart is stopped. A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. The nurse should suspect A. retroperitoneal bleeding. B. cardiac tamponade. C. bleeding from the incisional site. D. heart failure. nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following is an expected finding? A. Rubor of the affected leg when elevated B. 3+ dorsal pedal pulse in left foot C. Thin, peeling toenails of left foot D. Report of intermittent claudication in the affected leg