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• Cardiac
601. The client has developed atrial fibrillation, with a ventricular rate of 150 beats
per minute. The nurse should assess the client for which associated signs and/or
symptoms? Select all that apply.
1. Syncope
2. Dizziness
3. Palpitations
4. Hypertension
5. Flat neck veins
602. A client is diagnosed with an ST segment elevation myocardial infarction
(STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is
a priority nursing intervention?
1. Monitor for kidney failure.
2. Monitor psychosocial
status. 3. Monitor for
signs of bleeding.
4. Have heparin sodium available.
603. The nurse in a medical unit is caring for a client with heart failure. The client
suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse
immediately asks another nurse to contact the primary health care provider and
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prepares to implement which priority interventions? Select all that apply.
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
6. Placing the client in a low-Fowler’s side-lying position
604. The nurse is assessing the neurovascular status of a client who returned to the
surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The
affected leg is warm, and the nurse notes redness and edema. The pedal pulse is
palpable. How should the nurse interpret the client’s neurovascular status? 1. The
neurovascular status is normal because of increased blood flow through the leg.
2. The neurovascular status is moderately impaired, and the surgeon should be
called.
3. The neurovascular status is slightly deteriorating and should be monitored for
another hour.
4. The neurovascular status shows adequate arterial flow, but venous complications
are arising.
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605. A client with myocardial infarction is developing cardiogenic shock. What
condition should the nurse carefully assess the client for?
1.Pulsus paradoxus
2.Ventricular dysrhythmias
3.Rising diastolic blood pressure
4.Falling central venous pressure
606. A client who had cardiac surgery 24 hours ago has had a urine output
averaging 20 mL/hr for 2 hours. The client received a single bolus of 500 mL of
intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily
laboratory results indicate that the blood urea nitrogen level is 45 mg/dL
(16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the
basis of these findings, the nurse would anticipate that the client is at risk for
which problem?
1.Hypovolemia
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2.Acute kidney injury
3.Glomerulonephritis
4.Urinary tract infection
607. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and
QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes
measure 0.06 seconds. The overall heart rate is 64 beats per minute. Which action
should the nurse take?
1. Check vital signs.
2. Check laboratory test
results. 3. Monitor for any
rhythm change.
4. Notify the primary health care provider.
608. A client is wearing a continuous cardiac monitor, which begins to sound its
alarm. The nurse sees no electrocardiographic complexes on the screen. Which is
the priority nursing action?
1.Call a code.
2.Check the client’s status.
3.Call the health care provider.
4.Document the lack of complexes.
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