NUR202: Ch. 31, Ch. 32, & Ch. 33

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification would the nurse suggest to avoid further slowing of the heart rate?

• • “Make certain that your bath water is warm.”

• • “Avoid straining while having a bowel movement.”

• • “Limit your intake of caffeinated drinks to one a day.”

• • “Avoid strenuous exercise such as running.”

A nurse is assessing clients on a medical-surgical unit. Which client would the nurse identify as being at greatest risk for atrial fibrillation?

• • A 45-year-old who takes an aspirin daily.

• • A 50-year-old who is post coronary artery bypass graft surgery.

• • A 78-year-old who had a carotid endarterectomy.

• • An 80-year-old with chronic obstructive pulmonary disease.

A telemetry nurse assesses a client who has a heart rate of 35 beats/min on the cardiac monitor. Which assessment would the nurse complete next?

• • Pulmonary auscultation

• • Pulse strength and amplitude

• • Level of consciousness

• • Mobility and gait stability

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. What action would the nurse take prior to the cardioversion?

• • Administer intravenous adenosine.

• • Turn off oxygen therapy.

• • Ensure that a tongue blade is available.

• • Position the client on the left side.

A nurse is teaching a client who has premature ectopic beats. Which education would the nurse include in this client’s teaching? (Select all that apply.)

• • Smoking cessation

• • Stress reduction and management

• • Avoiding vagal stimulation

• • Adverse effects of medications

• • Foods high in potassium

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure?

• • “I sleep with four pillows at night.”

• • “My shoes fit really tight lately.”

• • “I wake up coughing every night.”

• • “I have trouble catching my breath.”

A nurse is teaching a client with heart failure who has been prescribed enalapril. Which statement would the nurse include in this client’s teaching?

• • “Avoid using salt substitutes.”

• • “Take your medication with food.”

• • “Avoid using aspirin-containing products.”

• • “Check your pulse daily.”

After administering the first dose of captopril to a client with heart failure, the nurse implements interventions to decrease complications. Which intervention is most important for the nurse to implement?

• • Provide food to decrease nausea and aid in absorption.

• • Instruct the client to ask for assistance when rising from bed.

• • Collaborate with assistive personnel to bathe the client.

• • Monitor potassium levels and check for symptoms of hypokalemia.

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client’s understanding. Which client statement indicates a need for additional teaching?

• • “I’ll be able to carry heavy loads after 6 months of rest.”

• • “I will have my teeth cleaned by my dentist in 2 weeks.”

• • “I must avoid eating foods high in vitamin K, like spinach.”

• • “I must use an electric razor instead of a straight razor to shave.”

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations would the nurse assess? (Select all that apply.)

• • Pulmonary crackles

• • Confusion

• • Pulmonary hypertension

• • Dependent edema

• • Cough that worsens at night