vasc
The client has just returned from a cardiac catheterization. Which assessment data warrants immediate intervention from the nurse?
The client's blood pressure is 110/70 and pulse is 90.
The clients groin dressing is dry and intact.
The client refuses to keep the legs straight.
The client denies any numbness and tingling
The client refuses to keep the legs straight.
A nurse is assessing a client with hyperthyroidism. What findings should the nurse expect?
Weight gain, constipation, and lethargy
Weight loss, nervousness, and tachycardia
Exophthalmos, diarrhea, and cold intolerance
Diaphoresis, fever, and decreased sweating
Weight loss, nervousness, and tachycardia
When the postcardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects which electrolyte imbalance?
Hypermagnesemia
Hypokalemia
Hypomagnesemia
Hyperkalemia
Hypermagnesemia
Which is a true statement regarding regional enteritis (Crohn's disease)?
It is characterized by pain in the lower left abdominal quadrant.
It has a progressive disease pattern.
The clusters of ulcers take on a cobblestone appearance.
The lesions are in continuous contact with one another.
The clusters of ulcers take on a cobblestone appearance.
The nurse is caring for a client diagnosed with rule out acute renal failure. Which condition predisposes the client to developing prerenal failure?
Diabetes mellitus.
Hypotension.
Renal calculi.
Benign prostatic hypertrophy.
Hypotension.
Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve?
Pulmonary embolus.
Cerebrovascular accident.
Hemoptysis.
Deep vein thrombosis.
Cerebrovascular accident.
The nurse is caring for a patient with Graves disease. Which characteristics support this diagnosis?
Fatigue, weight loss, and renal stones
Buffalo hump, hirsutism, hyperglycemia
Hypoglycemia, bronze skin, fatigue
Increased appetite, weight loss, tachycardia
Increased appetite, weight loss, tachycardia
The nurse recognizes that the treatment for a non-ST-elevation myocardial infarction (NSTEMI) differs from that for a STEMI, in that a STEMI is more frequently treated with
IV nitroglycerin.
percutaneous coronary intervention (PCI).
IV heparin.
thrombolytics
Daily double: What are NSTEMIs treated with?
percutaneous coronary intervention (PCI).
IV nitroglycerin and IV heparin
A client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and board-like. What complication does the nurse determine may be occurring at this time?
Constipation
Accumulation of gas
Paralytic ileus
Peritonitis
Peritonitis
The client diagnosed with chronic kidney disease is receiving peritoneal dialysis. Which assessment data warrants immediate intervention by the nurse?
Inability to auscultate a bruit over the fistula.
The clients abdomen is soft, nontender, and bowel sounds are present.
The dialysate being removed from the clients abdomen is clear.
The dialysate instilled was 1,500mL and removed was 1,500mL.
The dialysate instilled was 1,500mL and removed was 1,500mL.
The nurse is developing a discharge teaching plan for the client diagnosed with heart failure. which intervention should be included in the plan? Select all that apply.
Notify the health care provider of a weight gain of more than 1 pound in a day.
Teach the client the importance of recording his/her intake/output.
Instruct the client to remove the salt shaker from the dinner table.
Encourage the client to drink 3 liters of water per day.
Discuss the importance of taking the loop diuretic Furosemide at bedtime.
Teach the client the importance of recording his/her intake/output.
Instruct the client to remove the salt shaker from the dinner table.
Hypophysectomy is the treatment of choice for which endocrine disorder?
Addison's Disease
Cushing syndrome
Hyperthyroidism
Pheochromocytoma
Cushing syndrome
The nurse is caring for a client presenting to the emergency department (ED) reporting chest pain. Which electrocardiographic (ECG) finding would be most concerning to the nurse?
ST elevation
Isolated premature ventricular contractions (PVCs)
Sinus tachycardia
Frequent premature atrial contractions (PACs)
ST elevation
A 70 year old client is admitted to the medical unit diagnosed with acute diverticulitis. Which interventions should the nurse implement? Select all that apply.
Tell the client not to eat or drink.
Start an intravenous line.
Assess the client, for abdominal tenderness.
Have the dietitian consult for a low residue diet.
Place the client on bed rest with bathroom privileges.
Tell the client not to eat or drink.
Start an intravenous line.
Assess the client, for abdominal tenderness.
Place the client on bed rest with bathroom privileges.
The client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first?
Monitor the clients urinary output.
Assess the clients pain and rule out complications.
Increase the clients oral fluid intake.
Use a safety gait belt when ambulating the client.
Assess the clients pain and rule out complications.
A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?
Trauma
Arterial insufficiency
Neither venous nor arterial insufficiency
Venous insufficiency
Venous insufficiency
Before discharge, what should a nurse instruct a client with Addison's disease to do when exposed to periods of stress?
Administer hydrocortisone I.M.
Drink 8 oz of fluids.
Perform capillary blood glucose monitoring four times daily.
Continue to take his usual dose of hydrocortisone.
Administer hydrocortisone I.M.
A client was chopping firewood and experienced a heaviness in the chest and dyspnea. The client arrives in the emergency department four hours after the heaviness and the health care provider diagnoses an anterior myocardial infarction (MI). What orders will the nurse anticipate?
streptokinase, aspirin, and morphine administration
morphine administration, stress testing, and admission to the cardiac care unit
sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry
serial liver enzyme testing, telemetry, and a lidocaine infusion
sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry
The nurse is caring for a client diagnosed with hemorrhaging duodenal ulcer. Which collaborative interventions should the nurse implement? Select all that apply.
Perform a complete pain assessment.
Assess the client's vital signs frequently.
Administer a proton pump inhibitor intravenously.
Obtain permission and administer blood products.
Monitor the intake of a soft, bland diet.
Administer a proton pump inhibitor intravenously.
Obtain permission and administer blood products.
A nurse receives her client care assignment. Following the report, she should give priority assessment to the client:
who, following a kidney transplant, has returned from hemodialysis with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L.
who has a sodium level of 135 mEq/L and a potassium level of 3.7 mEq/L 7 days after a kidney transplant.
with pinkish mucus discharge in the appliance bag 2 days after an ileal conduit.
who is experiencing mild pain from urolithiasis.
who, following a kidney transplant, has returned from hemodialysis with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L.
A client with a history of aching leg pain seeks medical attention for the development of a leg wound. Which assessment findings indicate to the nurse that the client is experiencing a venous ulcer? Select all that apply.
Thick, tough skin around the ankles
Darkened skin around the lower extremities
Wound has an irregular border
Wound is superficial
Wound base is pale in color
Thick, tough skin around the ankles
Darkened skin around the lower extremities
Wound has an irregular border
Wound is superficial
The nurse is caring for a patient with hyperparathyroidism and observes a calcium level of 16.2 mg/dL. What interventions does the nurse prepare to provide to reduce the calcium level? Select all that apply.
Administration of calcitonin
Administration of calcium carbonate
Intravenous isotonic saline solution in large quantities
Monitoring the patient for fluid overload
Administration of a bronchodilator
Administration of calcitonin
Intravenous isotonic saline solution in large quantities
Monitoring the patient for fluid overload
The nurse is caring for a client presenting to the emergency department (ED) reporting chest pain. Which electrocardiographic (ECG) finding would be most concerning to the nurse?
ST elevation
Isolated premature ventricular contractions (PVCs)
Sinus tachycardia
Frequent premature atrial contractions (PACs)
ST elevation
The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and a temp of 102°F. Which intervention should the nurse implement?
Notify the health care provider.
Prepare to administer a Fleet's enema.
Administer an antipyretic suppository.
Continue to monitor the client closely.
Notify the health care provider.
The nurse is reviewingthe potassium level of a patient with kidney disease. The results of the test are 6.5 mEq/L, and the nurse observes peaked T waves on the ECG. What priority intervention does the nurse anticipate the physician will order to reduce the potassium level?
Administration of an insulin drip
Administration of a loop diuretic
Administration of sodium bicarbonate
Administration of sodium polystyrene sulfonate [Kayexalate])
Administration of sodium polystyrene sulfonate [Kayexalate])