A nurse is assessing a patient who has pulmonary edema related to heart failure. Which
of the following indicates effective treatment of this client's condition?
a. Absence of adventitious breath sounds
b. Presence of a nonproductive cough
c. Decrease in respiratory rate at rest
d. SaO2 86% on room air - Answer a. Absence of adventitious breath sounds
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?
a. "I can't get rid of these hiccups."
b. "I feel dizzy when I stand."
c. "My incision site stings."
d. "I have a headache." - Answer a. "I can't get rid of these hiccups.
This indicates that the pacemaker may be stimulating the chest wall or diaphragm.
Dizziness is expected after the procedure. Stinging at the insertion site is not a result of
the procedure but continue to monitor for infection. Headaches could explain another
disease process.
A nurse is caring for a post-op. client 1 hr following an aortic aneurysm repair. Which of
the following findings can indicate shock and should be reported to the provider?
a. Serosanguineous drainage on dressing
b. Severe pain with coughing
c. Urine output 20 mL/hr
d. Increase in temp. from 98.2 F to 99.5 F - Answer c. Urine output 20 mL/hr
Urine output less than 30 mL/hr is a manifestation of shock. Serosanguineous drainage
is expected. Coughing after an aortic aneurysm repair is painful. Temp. is within
expected range.
A nurse is assessing a client who has dilated cardiomyopathy. Which of the following
findings should the nurse expect?
a. Dyspnea on exertion
b. Tracheal deviation
c. Pericardial rub
d. Weight loss - Answer a. Dyspnea on exertion
, Tracheal deviation is a finding of tension pneumothorax. Pericardial rub is a finding of
pericarditis. Weight gain is an expected finding of dilated cardiomyopathy, not weight
loss.
A nurse is providing health teaching for a group of clients. Which of the following clients
is at risk for developing peripheral arterial disease?
a. Client with hypothyroidism
b. Client with diabetes mellitus
c. Client whose daily caloric intake includes 25% of fat
d. Client who consumes two 12 oz. bottles of beer a day - Answer b. Client with
diabetes mellitus
A nurse is caring for a client who has a BP of 254/139. The nurse recognizes the client
is in a hypertensive crisis. Which of the following actions should the nurse take first?
a. Initiate seizure precautions
b. Tell the client to report vision changes
c. Elevate the head of the bed
d. Start a peripheral IV - Answer c. Elevate the head of the bed
This reduces blood pressure and promotes oxygen to prevent organ damage and is
what the nurse should do FIRST.
A nurse is assessing a client who has a history of deep vein thrombosis and is receiving
warfarin. Which of the following indicates the medication is effective?
a. Hemoglobin 14 g/dL
b. Minimal bruising of extremities
c. Decreased BP
d. INR 2.0 - Answer d. INR 2.0
An INR of 2.0-3.0 is a measurement of effective warfarin therapy.
A nurse is caring for a client who was admitted for tx. of left-sided HF with IV loop
diuretics and digitalis therapy. The client is experiencing weakness and irregular HR.
Which of the following actions should the nurse take first?
a. Obtain client's current weight
b. Review serum electrolyte values
c. Determine the time of the last digoxin dose
d. Check the client's urine output - Answer b. Review serum electrolyte values
Weakness and irregular HR show that the client is at a great risk for electrolyte
imbalances, an adverse effect of loop diuretics. This is what the nurse should do FIRST,
the other actions come next.