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A nurse is caring for a client following insertion of a permanent pacemaker. Which of the
following client statements indicates a potential complication of insertion procedure?
"I can't get rid of these hiccups."
A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should identify
that an increase in which of the following values is diagnostic of a myocardial infarction?
Creatine kinase-MB
A nurse is assessing a client who has pulmonary edema related to heart failure. Which of the
following findings indicates effective treatment of the client's condition?
Absence of adventitious breath sounds
A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings
should the nurse expect?
Dyspnea on exertion
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?
INR 2.0
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,A nurse is caring for a client who is being treated for heart failure and has a prescription for
furosemide. The nurse should plan to monitor for which of the following adverse effects of the
medication?
Lightheadedness
A nurse is caring for a client who was admitted for treatment of left-sided heart failure and is
receiving intravenous loop diuretics and digitals therapy. The client is experiencing weakness
and an irregular heart rate. Which of the following actions should the nurse take first?
Review serum electrolyte values
A nurse is providing teaching to a client who is 2 days postoperative following a heart
transplant. Which of the following statements should the nurse include in the teaching?
"You might no longer be able to feel chest pain."
A nurse in an emergency department is caring for a client who has an anterior MI. The client's
history reveals they are 1 week postoperative following an open cholecystectomy. The nurse
should identify that which of the following interventions is contraindicated?
Assisting with thrombolytic therapy
A nurse is reviewing the laboratory results of several male clients who have peripheral arterial
disease. The nurse should plan to provide dietary teaching for the client who has which of the
following laboratory values?
Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL
A nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hr.
Which of the following client statements indicates a need for further clarification by the nurse?
"I took my warfarin last night according to my usual schedule."
A nurse is providing health teaching to a group of clients. Which of the following clients is at risk
for developing peripheral arterial disease?
A client who has diabetes mellitus
A nurse is monitoring a client's ECG monitor and notes the client's rhythm has changed from
normal sinus rhythm to supraventricular tachycardia. The nurse should prepare to assist with
which of the following interventions?
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, Vagal stimulation
A nurse in an emergency department is assessing a client who has a bradydysrhythmina. Which
of the following findings should the nurse monitor for?
Confusion
A nurse is caring for a client who is 8 hr postoperative following a coronary artery bypass graft
(CABG). Which of the following findings should the nurse report?
Blood pressure 160/80 mmHg
A nurse is caring for a client who has HF and is experiencing atrial fibrillation. Which of the
following findings should the nurse plan to monitor for and report to the provider immediately?
Slurred speech
A nurse is assessing a client who has left-sided HF. Which of the following manifestations should
the nurse expect to find?
Weak peripheral pulses
A nurse is performing a cardiac assessment on a client. Identify the area the nurse should
inspect when evaluating the point of maximal impulse.
Apical pulse
A nurse is preparing a client for coronary angiography. Which of the following findings should
the nurse report to the provider prior to the procedure?
Previous allergic reaction to shellfish
A nurse is providing discharge teaching to a client who has a prescription for transdermal
nitroglycerin patches. Which of the following instructions should the nurse include in the
teaching?
Place the patch on an area of skin away from skin folds and joints.
A nurse in an emergency department is caring for a client who has a blood pressure of 254/139
mmHg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following
actions should the nurse take first?
Elevate the head of the client's bed.
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