Exam 3 V1: NUR170 / NUR 170 (Latest 2026/2027 Update) Concepts of Medical-Surgical Nursing | Questions & Answers | 100% Correct | Galen

Exam 3 V1: NUR170 / NUR 170 (Latest 2026/2027 Update) Concepts of Medical-Surgical Nursing | Questions & Answers | 100% Correct | Galen Q: A client recently admitted with new-onset type 2 diabetes will be discharged with a meter for self-monitoring of blood glucose (SMBG) levels. When is the best time for the nurse to explain to the client the proper use of the glucose monitor? Answer While performing the test in the hospital Q: An intensive care client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. When the cardiac monitor shows ventricular ectopy, which assessment will the nurse make? Answer Potassium level Q: A client with type 2 diabetes who is taking metformin (Glucophage) is seen in the diabetic clinic. The fasting blood glucose is 108 mg/dL (6.0 mmol/L), and the glycosylated hemoglobin (HbA1C) is 8.2%. Which action will the nurse take next? Answer Ask the client about current dietary intake and medication use. Q: The nurse is providing discharge teaching to a client with type 2 diabetes and peripheral neuropathy. Which statement by the client indicates a need for further teaching about injury prevention? Answer "I can break in my shoes by wearing them all day." Q: A client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." The client's vital signs are: T 98.4°F (36.9°C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air. Which action will the nurse take first? Answer Check the blood glucose. Q: The clinic nurse is providing teaching to a client with newly diagnosed diabetes. Which statement by the client indicates a correct understanding about the need to wear a MedicAlert bracelet? Answer "If I become hypoglycemic, I could become unconscious." Q: The nurse in the endocrine clinic is reviewing type 1 and type 2 diabetes with a group of nursing students. Which explanation by the students indicates their understanding of the types of diabetes? Answer Those with type 2 diabetes make insulin, but in inadequate amounts. Q: Which nursing action will the home health nurse delegate to a home health aide who is making daily visits to a client with newly diagnosed type 2 diabetes? Answer Assist the client with washing the feet and applying moisturizing lotion. Q: The nurse has just taken change-of-shift report on a group of clients on the medical surgical unit. Which client does the nurse assess first? Answer Answer Client taking glyburide (Diabeta) who is dizzy and sweaty Q: Which is the best referral that the community health nurse can suggest to a client who has been newly diagnosed with diabetes? Answer American Diabetes Association (ADA) Q: A client expresses fear and anxiety over the life changes associated with diabetes, stating, "I am scared I can't do it all and I will get sick and be a burden on my family." What is the nurse's best response? Answer "Let's tackle it piece by piece. What is most scary to you?" Q: A client with type 2 diabetes controlled with Metformin is recovering from surgery. The primary health care provider has placed the client on insulin in addition to the metformin. What is the nurse's best response about why the client needs to take insulin? Answer Stress, such as surgery, increases blood glucose levels. You'll need insulin to control your blood glucose temporarily." Q: A client newly diagnosed with diabetes is not ready to learn diabetes control during the hospital stay. Which information is the priority for the nurse to teach the client and the client's family? Answer Causes and treatment of hypoglycemia Insulin administration Q: The nurse is teaching a client with newly diagnosed type 2 diabetes about the importance of weight control. Which comment by the client indicates a need for further teaching? Answer "I will begin exercising for at least an hour a day." Q: Which of these clients with diabetes will the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit? Answer A client who needs blood glucose monitoring and insulin before each meal Q: The nurse working on a medical surgical endocrine unit has just received change-of-shift report. Which client will the nurse see first? Answer Client with type 1 diabetes whose insulin pump is beeping "occlusion" Q: The nurse is teaching a client about the manifestations and emergency management of hypoglycemia. Which response by the client indicates a correct understanding of what to do if the client feels hungry and shaky? Answer "I will eat three graham crackers." Q: The nurse caring for four clients with diabetes has these activities to perform. Which activity is appropriate to delegate to unlicensed assistive personnel (UAP)? Answer Perform a blood glucose check on a client who requires insulin. Q: A client with typically well controlled diabetes has a glycosylated hemoglobin (HbA1C) level of 9.4%. Which response by the nurse is most appropriate? Answer "Have you been doing something differently? Q: The nurse is performing an admission assessment on a 52-year-old client admitted with type 2 diabetes.Physical AssessmentDiagnostic FindingsProvider PrescriptionsLungs clearGlucose 179 mg/dL (9.9 mmol/L)Regular insulin 8 units if blood glucose 250 to 275 mg/dL (13.9 to 15.3 mmol/L)Right great toe mottled and cold to touchHemoglobin A1c 6.9%Regular insulin 10 units if glucose 275 to 300 mg/dL (15.3 to 16.7 mmol/L)Client states wears eyeglasses to readAfter completing the above assessment, which complication of diabetes does the nurse report to the primary health care provider? Answer Decreased peripheral perfusion Q: A client with type 1 diabetes mellitus received regular insulin at 7:00 a.m. The client will need to be monitored for hypoglycemia at which time? Answer 11:00 a.m. Q: The nurse in the endocrine clinic is providing education for a client who has just been diagnosed with diabetes. Which factor is most important for the nurse to assess before providing instruction to the client about the disease and its management? Answer Educational and literacy level Q: The intensive care nurse is caring for a client admitted in a hyperglycemic-hyperosmolar state. Which of these prescriptions made by the primary health care provider will the nurse question? Answer 1 ampule Sodium Bicarbonate IV now Q: The nurse is teaching a client with diabetes about proper foot care. Which statement by the client indicates that teaching was effective? Answer "I must inspect my shoes for foreign objects before putting them on." Q: A client diagnosed with exacerbation of systemic sclerosis (SSc) asks the nurse why a foot board and a bed cradle have been placed on the bed. The nurse explains that they are used for what purpose? Answer Promote comfort from Raynaud's phenomenon Q: The home health nurse conducts a community presentation on Lyme disease for the residents of an assisted-living facility. Which statement from the audience indicates to the home health nurse that further instruction is needed? Answer "I will gently remove the tick with tissue and then burn it to prevent the spread of the disease." Q: The nurse is caring for a middle-aged client diagnosed with rheumatoid arthritis. Which client statement requires further assessment for unproductive coping strategies? Answer "My husband is getting used to having sex only once a month." Q: Which statement indicates to the nurse that a client with fibromyalgia syndrome is using a complementary therapy to help relieve symptoms? Answer "Focusing on the slow stretching movements and my breathing in tai chi helps me relax." Q: In teaching a client with acute secondary gout, which instruction about preventing recurrence is most important for the nurse to include? Answer "Weight Watchers has healthy meal plans." A client diagnosed with rheumatoid arthritis (RA) is started on methotrexate (Rheumatrex). Which statement made by the client indicates to the nurse that further teaching is needed regarding drug therapy? Answer "Any side effects of this drug will be mild." Which factor indicates to the nurse the only similarity between discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE)? Answer Disfiguring and embarrassing rash The nurse is teaching a client about the difference between rheumatoid arthritis (RA) and osteoarthritis (OA). Which statement by the client indicates a need for further teaching? Answer "The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints." Which element is a risk factor for osteoarthritis (OA)? Answer Obesity A client has symptoms of rheumatoid arthritis (RA). Which laboratory finding indicates to the nurse that the client may have RA? Answer Positive total antinuclear antibody (ANA) The nurse assesses a client diagnosed with Sjögren's syndrome. The nurse anticipates that the client will also have which common condition? Answer Dry eyes Assessment findings reveal that an older adult client with severe osteoarthritis of the left hip can no longer perform activities of daily living (ADLs) and has had several falls in the home over the past month. To which community resource does the nurse refer the client? Answer Home health care agency Before administering low-molecular-weight heparin (LMWH) to an older adult client after total knee arthroplasty, the nurse notes that the client's platelet count is 50,000/mm3 (50 x 109/L). What action is most important for the nurse to take? Answer Notify the health care provider of the platelet count. An alert client who recently underwent total hip arthroplasty and is on anticoagulants is preparing for discharge from the hospital. Which information is most important for the nurse to provide to the client and caregiver? Answer Avoid using a straight razor. The nurse is caring for a postoperative client with total joint arthroplasty. What actions does the nurse take to prevent venous thromboembolism (VTE) postoperatively? Answer Apply elastic stockings. Administer anticoagulants. The nurse is reviewing the medication history for a client diagnosed with rheumatoid arthritis (RA) who has been ordered to start sulfasalazine (Azulfidine) therapy. The nurse plans to contact the health care provider if the client has which condition? Answer Sulfa allergy Before administering prednisone IV push to a middle-aged adult with rheumatoid arthritis (RA), the nurse notes that the client's random blood glucose level is 139 mg/dl (7.7 mmol/L). Which action is most important for the nurse to take? Answer Administer the prescribed prednisone on schedule. Which instructions for joint protection does the nurse recommend for a client with a connective tissue disease? Answer Use long-handled devices such as a reacher. Use adaptive devices such as Velcro closures. The nurse is developing a teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan? Answer Wear supportive shoes. The nurse is caring for an older, alert adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? Answer "The bus is coming to pick me up from the senior center three times a week so I can play cards." The nurse is reviewing the laboratory test results for a client with a possible pituitary disorder. Which information requires immediate intervention by the nurse? Answer Serum sodium 110 mEq/L (110 mmol/L) The charge nurse on the medical-surgical unit is making client assignments for the shift. Which client is the most appropriate to assign to an LPN/LVN? Answer Client with Cushing's syndrome who requires orthostatic vital signs assessments A client with an endocrine disorder says, "I can't, you know, satisfy my wife anymore." What is the nurse's best response? Answer "Can you please tell me more?" The nurse is teaching a client about proper nutrition to prevent an endocrine disorder. Which food does the nurse suggest adding to the diet when the client indicates a dislike of fish? Answer Iodized salt A client is hospitalized for pituitary function testing. Which nursing action included in the client's plan of care will be most appropriate for the RN to delegate to the LPN/LVN? Administer regular insulin for the growth hormone stimulation test. When caring for the older adult with decreased antidiuretic hormone (ADH) production, the nurse would include which of these in the plan of care? Encourage fluids every 2 hours. The nurse is caring for a client who has frequent episodes of hypoglycemia with loss of consciousness. During interdisciplinary rounds, which of these does the nurse suggest the client's family learn to use? Glucagon The nurse is instructing a client who will undergo an adrenal suppression test. Which statement by the client indicates that teaching was effective? "I am being tested to see whether my hormone glands are hyperactive." A client is hospitalized with a possible disorder of the adrenal cortex. Which nursing activity is best for the charge nurse to delegate to an experienced nursing assistant? Check the client's blood glucose levels every 4 hours. The nurse is teaching a client about the correct procedure for a 24-hour urine test for a hormone level. Which statement by the client indicates a need for further teaching? "I will not eat any protein when I am collecting urine for this test." The client tells the visiting nurse his blood glucose values over the last week have been excellent. Which of these resources does the nurse evaluate to verify the client's statement? Glycosylated hemoglobin (HbA1c) The nurse is caring for a client with a parathyroid dysfunction. Which comment by the client indicates a need for further assessment? "Lately, I lose my temper more quickly." After a cardiac catheterization, the client needs to increase his or her fluid intake for which reason? The dye causes an osmotic diuresis. A client who is suffering from dyspnea on exertion and congestive heart failure (CHF) will most likely report which symptom during the health history? Fatigue Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial? "I don't need to change. It hasn't killed me yet." Which client has the highest risk for cardiovascular disease? Man who smokes and whose father died at 49 of myocardial infarction (MI) Which client would the charge nurse assign to a graduate RN who has completed 2 months of orientation to the coronary care unit? Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes Which of these factors contribute to the risk for cardiovascular disease? Elevated C-reactive protein levels Smoking Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider? Client with pressure in the mid-abdomen and profound diaphoresis A client with heart failure reports a 7.6-pound (3.4 kg) weight gain in the past week. What intervention does the nurse anticipate from the primary health care provider? Daily weight monitoring The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs? Mean arterial pressure (MAP) is 58 mm Hg. Which signs and symptoms are seen with suspected pericarditis? Chest pain relieved by sitting upright Sudden-onset chest pain relieved by anti-inflammatory agents Pain in the chest described as sharp or stabbing The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action would be taken by he nurse? Collaborate with the primary health care provider to administer a positive inotropic agent. The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 8 mm Hg. The nurse anticipates which request by the primary health care provider? Intravenous furosemide Which action does the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory? Obtain client vital signs and a resting electrocardiogram (ECG). A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and must be communicated immediately to the primary health care provider? Serum troponin I level The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information would be included? Women may experience extreme fatigue and dizziness as sole symptoms. Which statement about diagnostic cardiovascular testing is correct? An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the primary health care provider by the nurse for further instructions? Potassium 3.0 mEq/L (3.0 mmol/L) All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the primary care provider before the procedure begins? The client develops wheezes and dyspnea after eating crab or lobster. A client recovering from cardiac angiography develops slurred speech. What does the nurse do first? Performs a complete neurologic assessment and notifies the primary care provider Which statement reflects correct cardiac physical assessment technique? Auscultate the aortic valve in the second intercostal space at the right sternal border. The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential? Validate that the client has remained NPO. An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client is most appropriate for the RN to assign to the LPN/LVN? A client who was admitted with peripheral vascular disease and needs assessment of the ankle brachial index The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching? "This test evaluates you for potentially fatal cardiac rhythms." A client who is to undergo cardiac catheterization must be taught which essential information by the nurse? "Keep your affected leg straight for 2 to 6 hours." Which laboratory finding is consistent with acute coronary syndrome (ACS)? Troponin 3.2 ng/mL (3.2 mcg/L) A client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction (MI)? Troponin of 5.2 ng/mL (5.2 mcg/L) Which statement best reflects correct client education for a client with a blood pressure (BP) of 136/86 mm Hg? This blood pressure increases the workload of the heart; the client must consider modifying his or her lifestyle The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol (Toprol). Which monitoring is essential when administering the medication? Heart rate What teaching does the nurse include for a patient with atrial fibrillation who has a new prescription for warfarin? "Report nosebleeds to your provider immediately." How does the nurse recognize that atropine has produced a positive outcome for the patient with bradycardia? The monitor shows an increase in heart rate. The nurse is caring for a patient on a telemetry unit who has a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 second. Additional vital signs are as follows: blood pressure 118/68 mm Hg, respiratory rate 16 breaths/min, and temperature 98.8°F (37°C). All of these medications are available on the medication record. What action does the nurse take? Continue to monitor. A patient's rhythm strip shows a heart rate of 116 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.16 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip? Sinus tachycardia The nurse is caring for a patient with atrial fibrillation (AF). In addition to an antidysrhythmic, what medication does the nurse plan to administer? Heparin The nurse receives a report that a patient with a pacemaker has experienced loss of capture. Which situation is consistent with this? Pacemaker spikes are noted, but no P wave or QRS complex follows. Which teaching is essential for a patient who has had a permanent pacemaker inserted? Avoid operating electrical appliances over the pacemaker. The nurse is teaching a patient with a new permanent pacemaker. Which statement by the patient indicates a need for further discharge education? "I no longer need my heart pills." The nurse is caring for a patient with heart rate of 143 beats/min. For which manifestations does the nurse observe? Palpitations Chest discomfort Hypotension A patient admitted after using crack cocaine develops ventricular fibrillation. After determining unresponsiveness, which action does the nurse take next? Prepare for defibrillation. Which waveform indicates proper function of the sinoatrial (SA) node? A P wave precedes every QRS complex. A patient with atrial fibrillation (AF) with rapid ventricular response has received medication to slow the ventricular rate. The pulse is now 88 beats/min. For which additional therapy does the nurse plan? Anticoagulation The nurse is caring for a patient who has developed a bradycardia. Which possible causes does the nurse investigate? Bearing down for a bowel movement Possible inferior wall myocardial infarction (MI) Diltiazem (Cardizem) administered 1 hour ago In teaching patients at risk for bradydysrhythmias, what information does the nurse include? "Use a stool softener." The nurse is caring for a patient with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first? Check the patient for a pulse. Which risk factors are known to contribute to atrial fibrillation? Excessive alcohol use Advancing age High blood pressure The nurse administers amiodarone (Cordarone) to a patient with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? QT interval Heart rate Heart rhythm The professional nurse is supervising a nursing student performing a 12-lead electrocardiogram (ECG). Under which circumstance does the nurse correct the student? The patient is instructed to breathe deeply through the mouth. The nurse is caring for a patient with advanced heart failure who develops asystole. The nurse corrects the graduate nurse when the graduate offers to perform which intervention? Defibrillation Which patient is appropriate for the cardiac care unit charge nurse to assign to the float RN from the medical-surgical unit? The 64-year-old patient admitted for weakness who has a sinus bradycardia with a heart rate of 58 beats/min Which intervention provides safety during cardioversion? Setting the defibrillator to the synchronized mode Which nursing action may be delegated to an unlicensed assistive personnel (UAP) working on the medical unit? Obtain daily weights for several clients with class IV heart failure. Which medication, when given in heart failure, may improve morbidity and mortality? Carvedilol (Coreg) The home health nurse visits a client with heart failure who has gained 5 pounds (2.3 kg) in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? Auscultate the client's posterior breath sounds. Which client is best to assign to an LPN/LVN working on the telemetry unit? Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? B-type natriuretic peptide (BNP) of 760 pg/mL (760 ng/dL) A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? The risk for hypotension The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? Splinter hemorrhages Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? The nurse obtains a bedside commode before administering furosemide. How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? Client states that she is able to sleep on one pillow. The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? Chest discomfort or pain Tachycardia Fatigue Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? Place the client in high-Fowler's position with the legs down. The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? "This may be caused by a genetic trait." The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? Positions the client to alleviate dyspnea A client who has been admitted for the third time this year for heart failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? Considers further assessment for depression A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription? Serum potassium level of 2.8 mEq/L (2.8 mmol/L) The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8°F (37.7°C), Pulse: 48 beats/min and irregular, Respirations: 20 breaths/min, Potassium level: 3.2 mEq/L (3.2 mmol/L). What action does the nurse take? Hold the digoxin, and obtain a prescription for a potassium supplement. A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective? The client's weight decreases by 2.5 kg. When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? Weight loss of 6 pounds (2.7 kg) since the last visit The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Blurred vision Fatigue Anorexia The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea, with pink, frothy sputum, and crackles throughout the lung fields. The nurse reviews the medical record, which contains the following information: Physical Assessment Findings Diagnostic Findings Provider Prescriptions Crackles in all fieldsS3 presentOliguriaEjection fraction 30%BNP 560Sodium 130 mEq/L (130 mmol/L)Diagnosis: heart failureEnalapril 10 mg orally dailyHeparin 5000 units subcutaneously every 12 hoursFurosemide 40 mg IV dailyStrict I & O Furosemide The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching? "I will call the provider if I have a cough lasting 3 or more days." The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client's HF? Ibuprofen (Motrin) After receiving change-of-shift report about these four clients, which client would the nurse assess first? CORRECT A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions (PVCs) The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching? "I need to avoid eating hamburgers." Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation? A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic The nurse is caring for a client who is being treated for hypertensive emergency. Which medication prescribed for the client would the nurse question? Dopamine (Intropin) Which vascular assessment by the student nurse requires intervention by the supervising nurse? Simultaneously palpating the bilateral carotids A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? Pedal pulses A client is receiving unfractionated heparin (UFH) by infusion. Of which finding does the nurse notify the primary health care provider (PCP)? Platelets 32,000/mm3 (32 × 109/L) When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? "I just started to feel a tearing pain in my belly." The nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding? Urine output of 20 mL over 2 hours Which symptom reported by a client who has had a total hip replacement requires emergency action? Shortness of breath and chest pain The nurse is teaching a client the precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective? "Eating foods like green beans won't interfere with my Coumadin therapy." The nurse is caring for a client with dark-colored toe ulcers and blood pressure (BP) of 190/100 mm Hg. Which nursing action does the nurse delegate to the LPN/LVN? Administer a clonidine patch for hypertension. The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective? Has maintained a low-sodium, no-added-salt diet Has lost 3 pounds (1.4 kg) since last seen in the clinic Has cut down on caffeine A client has undergone an embolectomy for acute arterial occlusion after creation of a lower arm arteriovenous fistula for dialysis. Which finding does the nurse report to the primary health care provider (PCP) immediately? Swelling and tenseness in the affected area Which sign/symptom is essential for the nurse to report to the primary health care provider (PCP) when caring for a client with Raynaud's phenomenon? The affected extremity becomes purple and cold. For a client with an 8-cm abdominal aortic aneurysm, which problem must be addressed immediately to prevent rupture? Blood pressure (BP) 192/102 mm Hg The nurse is teaching a young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching? "If I wear pantyhose, I won't have to wear the stockings the hospital gives me." A client with hypertension is started on verapamil (Calan). What teaching does the nurse provide for this client? "Avoid grapefruit juice." The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic? "Your concerns are valid; we can review some steps to limit disease progression." Which finding in the history of a client with an abdominal aortic aneurysm (AAA) is a risk factor for aneurysm formation? Marfan syndrome The nurse is assigned to all of these clients. Which client would be assessed first? The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago The nurse teaches a client who has had a myocardial infarction (MI) which information regarding diet? Use canola oil rather than palm oil. A client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care? "My leg might turn very white after the surgery." Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)? "Walk to the point of leg pain, then rest, resuming when pain stops." When administering furosemide (Lasix) to a client who does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels? Consume melons and baked potatoes. A client's medical record shows these data:Physical Assessment FindingsDiagnostic Findings Provider PrescriptionsCrackles at basesPTT 55 secondsLovenox 40 mg twice dailyRight leg swellingPOSITIVE, D-dimerElevate right legRight calf painhCG negativeDoppler study right leg Positive D-dimer (0.5mg/L) The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? Cold right foot Numbness and tingling of right foot Mottling of right foot and lower leg Which are risk factors that are known to contribute to atherosclerosis-related diseases? Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL (4.14 mmol/L) Smoking Type 2 diabetes The professional nurse and the nursing student are caring for a group of clients with hypertension. Which problem identified by the nursing student correctly identifies the client at risk for secondary hypertension? Kidney disease While caring for a client who has received recombinant tissue plasminogen activator (t-PA) for a large deep vein thrombus, the nurse becomes most concerned when the client develops which condition? Client stating that the year is 1967 The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess? Reproducible leg pain with exercise All of these client assignments have been made by the charge nurse. Which assignment is questionable? The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure (BP) is 210/150 mm Hg A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated primary health care provider's prescription? Intravenous infusion of normal saline An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus boxes The client can administer a nan