HESI Comprehensive Review for the NCLEX-RN Examination Study Guide

What types of procedures should be assigned to professional nurses? - ANSWERSSterile or invasive procedures. Negligence is measured by reasonableness. What question might the nurse ask when determining such reasonableness? - ANSWERSWould a reasonable and prudent nurse act in the same manner under the same circumstances? List the 4 elements that are necessary to prove negligence. - ANSWERSDuty. Failure to protect client again unreasonable risk. Breach of duty. Failure to perform according to established standards. Causation. A connection exists between conduct of the nurse and the resulting damage. Damages. Damage is done to the client, physical or mental. Define an intentional tort and five one example. - ANSWERSConduct causing damage to another person in a willful or intentional way without just cause. Example Hitting a client out of anger, not in a manner of self protection. Voluntary admission - ANSWERSClient admits self to an institution for treatment and restrains his or her civil rights. He or she may leave at any time. Involuntary admission - ANSWERSSomeone other than client applies for the client's admission to an institution requires certification by 1 or 2 health care providers that the person is a danger to self or others. List 5 activities a person who is declared incompetent cannot perform. - ANSWERSVote, make contracts or wills, drive a care, sue or be sued, hold a professional license. Name 3 legal requirements of a surgical permit - ANSWERSVoluntary, informed, and written. Who may give consent for medical treatment? - ANSWERSAlert, coherent, or otherwise competent adults, a parent or legal guardian, a person in loco parentis of minors or incompetent adults. What law protects the nurse who provides care or gives aid in an emergency situation? - ANSWERSThe Good Samaritan Act. What action should the nurse take if he or she questions a health care provider's prescription that they believe is wrong? - ANSWERSInform the health care provider. Record that the health care provider was informed and the health care provider's response to such information. Inform the nursing supervisor. Refuse to carry out the prescription. Describe the nurse's legal responsibility when asked to perform a task for which he or she is unprepared. - ANSWERSInform the health care provider or person asking the nurse to perform the task that he or she is unprepared to carry out the task. Refuse to perform the task. Describe nursing care of the restrained client. - ANSWERSApply restraints properly. Check restraints frequently to see that they are not causing injury and record such monitoring. Remove restraints as soon as possible. Use restraints as a last resort. By what authority may RNs delegate nursing care to others? - ANSWERSState Nurse Practice Act A UAP may perform care that falls within which components of the nursing process? - ANSWERSImplementation Which type of communication is necessary to implement a democratic leadership style? - ANSWERSAssertive communication skills What are the 4 rights of communication? - ANSWERSRight task, right circumstance, right person, right direction or communication, and right supervision. Which tasks can be delegated to a UAP? A. Inserting a Foley catheter. B. Measuring and recording the client's output through a Foley catheter. C. Teaching a client how to care for a catheter after discharge. D. Assessing for symptoms of a urinary tract infection. - ANSWERSA. is a sterile invasive procedure and should not be delegated to a UAP. B. Falls within the implementation phase, does not involve nursing judgement. Evaluation of the I & O must be done by the nurse. C. Client teaching requires the abilities of a nurse should not be delegated. D. Assessment must be performed by the nurse and should not be delegated. What are the essential steps of effective supervision? - ANSWERSDirection, evaluation, and follow-up. Which of the following is an example of assertive communication? A. You need to improve the way you spend your time so that all of your care gets performed. B. I've noticed that many of your clients did not get their care today. - ANSWERSA. This is an aggressive communication, which causes anger, hostility, and a defensive attitude. B. Assertive communication begins with I rather than you and clearly states the problem. List the three levels of disaster management - ANSWERSDisaster preparedness, disaster response, and disaster recovery. List examples of the three levels of prevention in disaster management. - ANSWERSPrimary: develop plan, train and educate personnel and public. Secondary: triage, treatment shelter, supervision. Tertiary: follow-up, recovery assistance, prevention of future disasters. Triage - ANSWERSTo sort or categorize Identify three bio-terrorism agents. - ANSWERSAnthrax, pneumonic plague, botulism, smallpox, inhalation tularemia, viral hemorrhage, fever, ricin, sarin, radiation. What Po2 value indicates respiratory failure in adults? - ANSWERSPo2 below 60 mmHg What blood value indicates hypercapnia? - ANSWERSPco2 above 45 mm Hg Identify the condition that exits when the Po2 is less than 50 mmHg and Fio2 is greater than 60%. - ANSWERSHypoxemia List three symptoms of respiratory failure in adults. - ANSWERSDyspnea tachypnea, intercostal and sternal retractions cyanosis. List four common causes of respiratory failure in children. - ANSWERSCongenital heart disease, infection or sepsis, respiratory distress syndrome, aspiration, fluid overload or dehydration. What percentage of O2 should a child in severe respiratory distress receive? - ANSWERS100% Acute Respiratory Distress Syndrome - ANSWERSIs an unexpected, catastrophic pulmonary complication occurring a person with no previous pulmonary problem. Mortality rate 50%. Interventions to prevent complications of clients on mechanical ventilation with ARDS - ANSWERSElevate head of bed at least 30 degrees. Assist with daily awakening. Implement a comprehensive oral hygiene program. Implement a comprehensive mobilization program. Suction - ANSWERSOnly when secretions are present. Allen Test - ANSWERSPerform prior to drawing ABGs. Ensures collateral circulation ot the hand if thrombosis of the radial artery should follow the puncture. Positive Allen test - ANSWERSMake the clients hand blanch by obliteration both the radial and the ulnar pulses. Then release the pressure over the ulnar artery only. If flow through the ulnar artery is good, flushing will be see immediately. Negative Allen Test - ANSWERSRepeat on the other arm. If this test is also negative, seek another site for arterial puncture. Cardinal signs of Acute Respiratory Failure in children - ANSWERSRestlessness, Tachypnea, Tachycardia, and Diaphoresis. pH - ANSWERS7.35-7.45 Pco2 - ANSWERS35-45 mm Hg HCO3 - ANSWERS21-28 mEq/L Po2 - ANSWERS80-100 mm Hg O2 Saturation - ANSWERS95%-100% Shock - ANSWERSWidespread, serious reduction of tissue perfusion, which leads to generalized impairment of cellular function. What is the most common cause of shock? - ANSWERSHypovolemia What causes septic shock? - ANSWERSRelease of endotoxins by bacteria, which act on nerves in vascular spaces in the periphery, causing vascular pooling, reduced venous return, and decreased cardiac output and result in poor systemic perfusion. What is the goal of treatment for hypovolemic shock? - ANSWERSQuick restoration of cardiac output and result in poor systemic perfusion. What intervention is used to restore cardiac output when hypovolemic shock exists? - ANSWERSRapid infusion of volume expanding fluids It is important to differentiate between hypovolemic and cardiogenic shock. How might the nurse determine the existence of cardiogenic shock? - ANSWERSHistory of MI with left ventricular failure or possible cardiomyopathy, with symptoms of pulmonary edema. If a client is in cardiogenic shock, what might result from administration of volume expanding fluids? - ANSWERSPulmonary Edema What intervention can the nurse expect to perform in the event of such an occurrence? - ANSWERSAdminister medications to manage preload, contractility and or after-load. For example to decrease after-load nitroprusside Nipride may be administered. List 5 assessment findings that occur in most shock victims. - ANSWERSTachycardia, tachypnea, hypotension, cool clammy skin, decrease in urinary output. Once circulating volume is restored, vasopressors may be prescribed to increase venous return. List the main drugs that are used. - ANSWERSEpinephrine bronkaid, Dopamine Intropin, Dobutamine dobutrex, norepenephrine levophed or isoproterenol isuprel. What is the established minimum renal output per hour? - ANSWERS30 mL/hr. List 4 measurable criteria that are the major expected outcomes of a shock crisis. - ANSWERSBP mean of 80 to 90mm Hg, Po2 greater than 50m mm Hg, Central venous pressure 2 to 6 mm HG. Urine output at least 30 mL/hr. DIC- Disseminated Intravascular Coagulation - ANSWERSA coagulation disorder in which there is paradoxical thrombosis and hemorrhage. What is the effects of DIC on PT, PTT, platelets and FSPs? - ANSWERSPT prolonged, PTT prolonged, Platelets decreased. FSPs increased. What drug is used in the treatment of DIC? - ANSWERSHeparin Name four nursing interventions to prevent interventions to prevent injury in clients with DIC. - ANSWERSGently provide oral care with mouth swabs. Minimize needle sticks ans use the smallest gauge needle possible when injections are necessary. Eliminate pressure by turning the client frequently. Minimize the number of BP measurements taken by cuff. Use gentle suction to prevent trauma to mucosa. Apply pressure to any oozing site. Early signs of shock - ANSWERSAgitation and restlessness resulting from cerebral hypoxia. What is the first priority when a client with an unwitnessed cardiac arrest is found? - ANSWERSBegin CPRq Myocardial infarction - ANSWERSNecrosis of the heart muscle due to poor perfusion to the heart. What criteria should alert a client with known angina who takes nitro subliminally to call EMS? - ANSWERSUnrelieved chest pain after 3 nitroglycerin. After calling out for help and asking someone to dial for emergency services, what is the next action in CPR? - ANSWERSFor adults check carotid pulse and if no pulse deliver C-A-B. In feeling for presence of a carotid pulse, no more than 5 seconds should be used. - ANSWERSFalse, palpate for no more than 10 seconds, recognizing that arrhythmias or bradycardia could be occurring. During one rescuer CPR, what is the ratio of compressions to ventilations for an adult? - ANSWERS30:2 During one rescuer CPR what is the ratio of compression to ventilations for a child? - ANSWERS15:2 for a child or neonate with two rescuers and 30:2 for 1 rescuer. What is the first drug most likely to be used for an in hospital cardiac arrest? - ANSWERSEpinephrine A client in cardiac arrest is noted on bedside monitor to be in pulse-less ventricular tachycardia. What is the first action that should be taken? - ANSWERSDefibrillation How would the nurse assess the adequacy of compression during CPR? - ANSWERSCheck for a carotid or femoral pulse. How would the nurse assess the adequacy of ventilations during CPR? - ANSWERSWatch for chest excursion and auscultate bilaterally for breath sounds. If a person is chocking when should the rescuer intervene? - ANSWERSWhen the person points to his or her throat and can no longer cough, talk, or make sounds. One should never make blind sweeps into the mouth of a choking child or infant, Why? - ANSWERSBecause the object might be pushed farther down into the throat. List four common causes of fluid volume deficit. - ANSWERSGastrointestinal causes, vomiting or diarrhea. GI suctioning decrease in fluid intake, increase in fluid output such as sweating, massive edema, or ascites List four common causes of fluid volume overload. - ANSWERSHeart failure, renal failure, cirrhosis, excess ingestion of table salt or over hydration with sodium containing fluids. Identify two examples of isotonic IV fluids - ANSWERSLactated ringers and normal saline. List 3 systems that maintain acid base balance. - ANSWERSLungs, kidneys, and chemical buffers. Normal value for pH - ANSWERS7.32-7.45 Normal value for Pco2 - ANSWERS35 to 45 mm Hg Normal value for HCO3 - ANSWERS21 to 28 mEq/L Acid base disorder pH 7.50, Pco2 30, HCO3 28 - ANSWERSRespiratory alkalosis Acid base disorder pH 7.30, Pco2 42, HCO3 20 - ANSWERSMetabolic acidosis Acid base disorder pH 7.48, Pco2 42, HCO3 32 - ANSWERSMetabolic alkalosis Acid base disorder pH 7.29, Pco2 55, HCO3 28 - ANSWERSRespiratory acidosis Identify the waveform found in a normal ECG - ANSWERSP wave, QRS complex, T wave, ST segment and PR interval. In an ECG reading, which wave represents depolarization of the atrium? - ANSWERSRepresented by a P wave. In an ECG reading, what complex represents depolarization of the ventricle? - ANSWERSQRS complex What does the PR interval represent? - ANSWERSThe time required for the impulse to travel from the atria through the AV node. If the U wave is most prominent, what condition might the nurse suspect? - ANSWERSHypokalemia Describe the calculation of the heart rate using an ECG rhythm strip. - ANSWERSCount the number of RR intervals in the 30 large squares and multiply by 10 to determine the heart rate for 1 minute. What is the most important assessment data for the nurse to obtain in a client with an arrhythmia? - ANSWERSThe ability of the client to tolerate the arrhythmia. List five variables that increase surgical risk. - ANSWERSAge. Very young and very old, obesity and malnutrition, preoperative dehydration/hypovolemia, preoperative infection, use of anticoagulants pre-operatively. Why is a client with liver disease at increased risk for operative complications? - ANSWERSImpairs ability to detoxify medications used during surgery. Impairs ability to produce prothrombin to reduce hemorrhage Preoperative teaching should include demonstration and explanation of expected postoperative client activities. What activities should be included? - ANSWERSRespiratory activities, range of motion exercises, pain management, NPO evolving to progressive diet, dressings and drains, orientation to recovery room environment. What items should the nurse assist the client in removing before surgery? - ANSWERSContact lenses, glasses, dentures, partial plates, wigs, jewelry, prostheses, and nail polish. How is the client positioned in the immediate postoperative period and why? - ANSWERSUsually on the side or with head to side to prevent aspiration of any emesis. List 3 nursing actions that prevent postoperative wound dehiscence and evisceration. - ANSWERSTeaching client to splint incision when coughing, encouraging coughing and deep breathing in early postoperative period when sutures are strong, monitoring for signs f infection, malnutrition, and dehydration. Encouraging high protein diet. Identify 3 nursing interventions that prevent postoperative urinary tract infection. - ANSWERSAvoiding postoperative catheterization, increasing oral fluid intake, emptying bladder every 4 to 6 hours, early ambulation. Identify nursing/medical interventions that prevent postoperative paralytic ileus. - ANSWERSEarly ambulation, limiting use of narcotic analgesics, and NG tube decompression. List four nursing interventions that prevent postoperative thrombophlebitits. - ANSWERSTeaching in bed leg exercises, encouraging early ambulation, applying antiembolus stockings, teaching avoidance of positions and pressures that obstruct venous flow. During the intraoperative period, what activities should the OR nurse perform to ensure safety during surgery? - ANSWERSAscertain correct sponge, needle, and instrument count, position client to avoid injury, apply ground during electrocautery use, apply strict use of surgical asepsis. HIV clients with TB - ANSWERSRequires respiratory isolation. Identify the ways HIV is transmitted - ANSWERSBlood and body fluids. Unprotected sex, sharing needles, infected blood products, breast milk and needle sticks. Vertical transmission from mother to fetus occurs how often if the mother is not treated during pregnancy? - ANSWERSVertical transmission occurs 30%-50% of the time. What are the side effects of amphotericin B - ANSWERSAnorexia, cramping muscle, and joint pain, and circulatory problems. They can be quite severe. What does the CD4 T-cell count describe? - ANSWERSDescribes the number of infection-fighting lymphocytes the person has. Why does the CD4 T-cell count drop in HIV infections? - ANSWERSIt drops because the virus destroys CD-4 T-cells as it invades them and replicates. Describe the ways a pediatric client might acquire HIV infection. - ANSWERSPediatric acquisition may occur through infected blood products, through sexual abuse and through breast milk. What modalities are associated with the gate control pain theory? - ANSWERSMassage, heart and cold, acupuncture, and TENS. How does past experience with pain influence current pain experience? - ANSWERSThe more pain experienced in childhood, the greater is the perception of pain in adulthood or with current pain. What modalities are thought to increase the production of endogenous opiates? - ANSWERSAcupuncture, administration of placebos, and TENS. What 6 factors should the nurse include when assessing the pain experience? - ANSWERSLocation, intensity, comfort measures, quality, chronology, and subjective view of pain. If narcotic agonist/antagonist drugs are administered to a client already taking narcotic drugs, what may be the result? - ANSWERSInitiation of withdrawal symptoms. List four side effects of narcotic medications. - ANSWERSNausea, vomiting, constipation, CNS depression and respiratory depression. What is the antidote fro narcotic-induced respiratory depression? - ANSWERSNarcan. naloxone What is the first sign of tolerance to pain analgesics? - ANSWERSDecreased duration of drug effectiveness. Which route of administration for pain medications has the quickest onset and the shortest duration? - ANSWERSIV push or bolus. List the 6 modalities that are considered noninvasive, nonpharmacologic pain relief measures. - ANSWERSHeat and cold applications, TENS, massage, distraction, relaxation techniques, and biofeedback techniques. Identify the 5 stage of grief associated with dying. - ANSWERSDenial, anger, bargaining, depression, and acceptance. A client has been told of a positive breast biopsy report. She asks no questions and leaves the health care provider's office. She is overhead telling her husband, "The doctor didn't find anything." What coping style is operating at this stage of grief? - ANSWERSDenial. Your client, an incest survivor, is speaking of her deceased father, the perpetrator. "he was a wonderful man, so good and kind. Everyone thought so." What would be he most useful intervention at this time? - ANSWERSGently point out both the positive and negative aspects of her relationship with her father. Try to minimize the idealization of the deceased. Your client feels responsible for his sister's death because he took her to the hospital where she died. "If I hadn't taken her there, they couldn't have killed her." It has been 1 month since her death. Is this response indicative of a normal or a complicated grief process? - ANSWERSThis is a normal expression of the anger and guilt that occur. Try to minimize rumination on these thoughts. Mrs. Green lost her husband 3 years ago. She has not disturbed any of his belongings and continues to set a place at the table for him nightly. Is this response indicative of a normal or a complicated grief reaction? - ANSWERSThis is a dysfunctional grief reaction. Mrs. Green has never moved out of the denial stage of her grief work. Pink puffer - ANSWERSBarrel chest is indicative of emphysema and is caused by use of accessory muscles to breathe. Works hard to breath but the amount of OX taken in is adequate to oxygenate the tissues. Blue bloater - ANSWERSInsufficient oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right sided heart failure. Cor pulmonale. Cancer of the larynx - ANSWERSThe tongue and mouth often appear white, gray, dark brown, or black and may appear patchy. Look and listen - ANSWERSIf breath sounds are clear but the client is cyanotic and lethargic, adequate oxygenation is not occurring. O2 delivery in adults - ANSWERSO2 must bubble through some type of water solution. If given at 4 L/min or delivered directly to the trachea. If given at 1 to 4 L/min or by mask or nasal prongs, the oropharynx and nasal pharynx provide adequate humidification. Laryngectomy Tube - ANSWERSHas a larger lumen and is shorter than the tracheostomy tube. Observe client for any signs of bleeding or occlusion within first 24 hrs post op. Positive TB skin test - ANSWERSExhibited by an induration 10 mm or greater in diameter 48 to 72 hrs after the skin test. Anyone who receives a bacillus Calmette-Guerin BCG vaccine - ANSWERSWill have a positive skin test and must be evaluated with an initial chest radiograph. TB drug therapy - ANSWERSis usually long term 6 months or longer. Rifampin - ANSWERSReduces effectiveness of oral contraceptives, client should use other birth control methods during treatment, gives body fluids orange tinge, and stains soft contact lenses. Isonaizid INH - ANSWERSIncreased phenytoin (dilantin) levels. Esthambutol - ANSWERSVision check before starting therapy and monthly thereafter, may have to take for 1 to 2 years. Rationale for combination drug therapy - ANSWERSResistance develops more slowly if several anti-TB drugs given, instead of one drug at a time. Large lung tumor removal - ANSWERSChest tubes are not usually used with these clients because it is helpful if the mediastinal cavity where the lung used to be fills up with fluid. Helps to prevent the shift of the remaining chest organs to fill the empty space If chest tube becomes disconnected - ANSWERSDo not Clamp! Disconnected chest tube - ANSWERSImmediately place the end of the tube in a container of sterile saline or water until a new drainage system can be connected. Chest tube accidentally removed - ANSWERSThe nurse should cover with a dry sterile dressing. If an air leak is noted - ANSWERSTape the dressing on 3 sides only, this allows air to escape and prevents the formation of a tension pneumothorax. Notify health care provider. Fluctuating tidaling int he fluid - ANSWERSOccurs if there is no external suction. Fluctuating movements - ANSWERSare a good indicator that the system is intact. They should move upward with each inspiration and downward with an expiration. Fluctuations cease - ANSWERSCheck for kinked tubing, accumulation of fluid in tubing, Four common symptoms of pneumonia noted on physical examination - ANSWERSTaychpnea, fever with chills, productive cough, bronchial breath sounds 4 nursing interventions for assisting the client to cough productively - ANSWERSEncourage deep breathing, increase fluid intake to 3 l/day, use humidity to loosen secretions, suction airway to stimulate coughing. What symptoms of pneumonia might be expected to be seen in an older adult? - ANSWERSConfusion, lethargy, anorexia, rapid respiratory rate. How does the nurse prevent hypoxia during suctioning? - ANSWERSDeliver 100% O2 hyper-inflating before and after each endotracheal suctioning. During mechanical ventilation, what are 3 major nursing interventions? - ANSWERSMonitor client's respiratory status ans secure connections, establish a communication mechanism with the client, keep airway clear by coughing and suctioning. When examining a client with emphysema, what physical findings is the nurse likely to see? - ANSWERSBarrel chest , dry or productive cough, decreased breath sounds, dyspnea, crackles in lung fields. What is the most common risk factor associated with lung cancer? - ANSWERSSmoking Describe the preoperative nursing care for a client undergoing a laryngectomy. - ANSWERSTeach family & client to manipulate tracheostomy equipment, plan acceptable communication methods, refer speech pathologist, discuss rehab. List 5 nursing interventions after chest tube insertion. - ANSWERSMaintain a dry occlusive dressing on chest tube. Keep all tubing connections tight and taped. Monitor client's clinical status. Encourage the client to breathe deeply periodically. Monitor the fluid drainage, and mark the time of measurement and the fluid level. What immediate action should the nurse take when a chest tube becomes dis connected from a bottle or suction apparatus? what should the nurse do if a chest tube is accidentally removed from the client. - ANSWERSPlace the end of the tube in a sterile water container at a 2 cm level. Apply an occlusive dressing, and notify health care provider stat. What instructions should be given to a client with TB when placed on respiratory isolation? - ANSWERSA mask for anyone entering the room; private room; client must wear mask if leaving the room. What instructions should be given to a client following radiation therapy? - ANSWERSDo not wash off the lines; wear soft cotton garments; avoid use of powders and cream on radiation site. List 4 components of teaching for the client with TB - ANSWERSCough into tissues and dispose immediately in special bags. Long term need for daily meds. Good hand-washing. Report symptoms of deterioration ie blood secretions. Acute renal failure - ANSWERSOften reversible, abrupt deterioration of kidney function. Chronic renal failure - ANSWERSIrreversible slow deterioration of kidney function characterized by increasing BUN and creatinine. Eventually dialysis. During the oliguric phase of renal failure why is protein restricted? - ANSWERSToxic metabolites that accumulate in the blood are derived mainly from protein catabolism. Identify 2 nursing interventions for the client on Hemodialysis - ANSWERSDo not take BP or perform venipuncture on the arm with the AV shunt, fistula, or graft. Assess access site for thrill and bruit What is the highest priority nursing diagnosis for clients in any type of renal failure? - ANSWERSRisk for imbalanced fluid volume. A client in renal failure asks why he is being given antacids. - ANSWERSCalcium and aluminum antacids bind phosphates and help to keep phosphates from being absorbed into bloodstream, therefore preventing rising phosphate levels. Must be taken with meals. List 4 essential elements of a teaching plan for clients with frequent UTIs - ANSWERSFluid intake 3 l/day, good hand washing, void every 2 to 3 hrs during waking hours, take all prescribed medications, wear cotton undergarments. What are the most important nursing interventions for clients with possible renal calculi? - ANSWERSStraining all urine is the most important intervention. Accurate I & O documentation What discharge instructions should be given to a client who has had urinary calculi? - ANSWERSMaintain high fluid intake of 3 to 4 l day. Pursue followup care. Follow prescribed diet based on calculi content. Avoid supine position. Following a TURP, hematuria should subside by what postoperative day? - ANSWERSThe 4th day. After the urinary catheter is removed in the TURP client, what are 3 priority nursing actions? - ANSWERSContinue strict I & O. Continue to observe for hematuria. Inform client burning and frequencies may last for a week. After kidney surgery, what are the primary assessments the nurse should make? - ANSWERSRespiratory status, circulatory status, pain assessment, urinary assessment. How do clients experiencing angina describe that pain? - ANSWERSAs squeezing, heavy, burning, radiates to left arm or should, transient or prolonged. Develop a teaching plan for a client taking nitro - ANSWERSTake at first sign of anginal pain. Take no more than 3, 5 minutes apart. Call for emergency attention if no relief in 10 minutes. List the parameters of BP for diagnosing hypertension - ANSWERS140/90 Essential hypertension - ANSWERSHas no cause secondary hypertension - ANSWERSDevelops as a response to an identifiable mechanism. Teaching plan for a client taking anti hypertensive medications. - ANSWERSExplain medication administration, reason for medication, necessity of compliance, need for followup visits, lab work and vital sign parameters. Intermittent claudication - ANSWERSPain related to PVD, the pain occurs with exercise and disappears with rest. Discharge instructions to a client with venous PVD - ANSWERSKeep extremities elevated when sitting, rest at fist sign of pain, keep extremities warm, no hearing pad, change position often, avoid crossing legs, and wear unrestrictive clothing. What is often the underlying cause of an abdominal aortic aneurysm? - ANSWERSAtherosclerosis What lab values should be monitored daily in a client with thrombophlebitis who is undergoing anticoagulant therapy? - ANSWERSPTT PT, Hgb, Hct, and platelets. When do PVCs present a grave danger? - ANSWERSWhen they begin to occur more often than once in 10 beats, occur in 2 or 3, land near the T wave or take on multiple configurations. Symptoms of left sided cardiac failure - ANSWERSResults in pulmonary congestion due to backup of circulation in the left ventricle. Symptoms of right sided cardiac failure - ANSWERSResults in peripheral congestion due to backup of circulation in the right ventricle. 3 symptoms of digitalis toxicity - ANSWERSDysrhythmias, headache, nausea, and vomiting What condition increases the likelihood that digitalis toxicity will occur? - ANSWERSHypokalemia What lifestyle changes can the client who is at risk for hypertension initiate to reduce the becoming hypertensive? - ANSWERSStop smoking, control weight, exercise regularly, and maintain a low fat low cholesterol diet. What immediate actions should the nurse implement when a client is having an MI? - ANSWERSStrict bed rest to lower 02 demand, administer 02 by nasal cannula at 2 to 5 L/min, alleviate pain and anxiety. What symptoms should the nurse expect to find in a client with hypokalemia? - ANSWERSDry mouth and thirst, drowsiness and lethargy, muscle weakness and aches, tachycardia. Bradycardia - ANSWERSA heart rate below 60 bpm. Tachycardia - ANSWERSA heart rate above 100 bpm.