Adult Health I - Chamberlain
1). A nurse is caring for a client who has a history of angina and is scheduled for exercise
electrocardiography at 1100. which of the following statements by the client requires the
nurse to contact the provider for possible rescheduling?
a. "i'm still hungry after the bowl of cereal i ate at 7 am."
b. "i didn't take my heart pi;;s this morning because the doctor told me not to."
c. "i have has chest pain a couple of times since i saw my doctor in the office last week."
d. "i smoked a cigarette this morning to calm my nerves about having this procedure."
Ans: D. "I smoked a cigarette this morning to calm my nerves about having this
procedure."
Smoking prior to this test can change the outcome and places the client at additional risk.
The procedure should be rescheduled if the client has smoked before the test.
2). A nurse is providing discharge teaching tp a client who has heart failure. the nurse should
instruct the client to report which of the following findings immediately to the provider?
a. weight gain of 0.9 kg (2 lb) in 24 hr
b. increase of 10 mm hg in systolic blood pressure
c. dyspnea with exertion
d. dizziness when rising quickly
Ans: A. Weight gain of 0.9 kg (2 lb) in 24 hr
When using the urgent vs. non-urgent approach to client care, the nurse should determine
that the priority finding is a weight gain 0.5 to 0.9 kg (1.1 to 2 lb) in 1 day.This weight gain
is an indication of fluid retention resulting from worsening heart failure.The client should
report this finding immediately.
3). A nurse is assessing a client who has a history of deep-vein thrombosis and is receiving
warfarin. which of the following findings should indicate to the nurse that the medication is
effective?
a. hemoglobin 14g/dl
b. minimal bruising of extremities
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, c. decreased blood pressure
d. inr 2.0
Ans: D. INR 2.0
The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to
3.0 for a client who has deep-vein thrombosis and is receiving warfarin to reduce the risk
of new clot formation and a stroke.
4). A nurse is caring for a client who is receiving heparin therapy and develops hematuria.
which of the following actions should the nurse take if the client's appt is 96 seconds?
a. increase the heparin infusion flow rate by 2 ml/hr
b. continue to monitor the heparin infusion as prescribed
c. request a prothrombin time (pt)
d. stop the heparin infusion
Ans: D. Stop the heparin infusion
The nurse should identify that the client's APTT is above the critical value and the client is
displaying manifestations of bleeding. Therefore, the nurse should discontinue the
heparin infusion immediately and notify the provider to reduce the risk of client injury.
aPPT = 25-35 secs
5). Appt
Ans: 25-35 sec
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