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WorksheetsPerfusion2
Total questions: 50
Worksheet time: 3hrs 30mins
A client is admitted to the emergency department after reporting acute chest pain radiating down the left arm. The client appears anxious, dyspneic, and diaphoretic. Which laboratory studies would the nurse anticipate? Select all that apply.
Hemoglobin and hematocrit (HCT)
Serum glucose
Creatine kinase (CK)
Troponin T and troponin I
Myoglobin
10. A client is prescribed lisinopril for the treatment of hypertension. The client asks a nurse about possible adverse effects. Which common adverse effects of angiotensin-converting enzyme (ACE) inhibitors would the nurse include in the teaching? Select all that apply.
Constipation
Dry cough
Headache
Hyperglycemia
Hypotension
A nurse is counseling a client about risk factors for hypertension. While reviewing the client’s history, which information is consistent with the diagnosis of primary hypertension? Select all that apply.
Obesity
High intake of sodium or saturated fat
Glomerulonephritis
Stress
Hormonal contraceptive use
A nurse is caring for a client with a new prescription of digoxin. Which client statement would require further teaching about digoxin? Select all that apply.
“I will take the digoxin at 9 AM daily.”
“I will take the digoxin with my antacids at night.”
“I will take my pulse before each dose of digoxin.”
“If I forget a dose, I will catch up by doubling the next dose.”
“I will notify my doctor if experiencing increased fatigue or muscle weakness.”
A client at high risk for coronary artery disease (CAD) is receiving instructions for a 2,000-Kcalorie heart-healthy diet. Which statements are likely to be made by a nurse during the teaching session? Select all that apply.
Limit your intake of foods that are high in omega-3 fatty acids.
Keep colorful foods such as carrots, grapes, blueberries, and melon in the refrigerator.
Use lean ground turkey instead of ground beef
Limit meat, fish, and poultry servings to a maximum of 3 ounces per day.
Add unsalted nuts to meals to increase monounsaturated fat intake
A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client.
Monitor maternal vital signs every 2 hours
Notify the physician if respirations are less than 18 per minute.
Monitor renal function and cardiac function closely
Keep calcium gluconate on hand in case of a magnesium sulfate overdose
Monitor deep tendon reflexes hourly
When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply.
Reflects electrical impulse beginning at the SA node
Indicated electrical impulse beginning at the AV node
Reflects atrial muscle depolarization
Identifies ventricular muscle depolarization
Has duration of normally 0.11 seconds or less.
A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for the signs and symptoms associated with heart failure. Select all that apply.
Weight loss
Unusual fatigue
Dependent edema
Nocturnal dyspnea
Increased urinary output
the nurse tells a student nurse that the normal constituents of urine are the following.
Protein
sodium chloride
ketones
urea
epithelial cell
The nurse is conducting a focused assessment for a client with heart failure who is being admitted to the hospital with shortness of breath. Which of the following questions initially would be most helpful for planning care? Select all that apply:
When did you first notice feeling short of breath?
Do you have a cough?
How long have you had chest pain?
How much caffeine have you had today?
Do you ever wake up during the night feeling short of breath?
The nurse is preparing to measure a patient for orthostatic hypotension. Which action should the nurse take to obtain this information? (Select all that apply.)
Use the correct size blood pressure cuff for the patient.
Instruct the patient not to eat or drink for 30 minutes prior to the test.
Have the patient refrain from smoking for at least 4 hours prior to the test.
Take pulse and blood pressure readings immediately upon assisting the patient to stand.
Assist the patient to a sitting position, wait 3 minutes, and take the pulse and blood pressure.
The nurse is reviewing the role of atrial natriuretic peptide (ANP) in blood pressure regulation for a patient with hypertension. What should the nurse include in this discussion? (Select all that apply.)
It decreases blood volume.
It increases cardiac output.
It inhibits aldosterone secretion.
It causes an increase in the baseline heart rate.
It causes vasoconstriction throughout the body.
The nurse is contributing to the teaching plan for a patient taking antihypertensives to control blood pressure who is on a 2000-calorie DASH diet. What should be included in the teaching about this diet? (Select all that apply.)
Eat four or five servings of vegetables a day.
Include four to five servings of grains each day.
Consume four or five servings of fruit each day.
Eat four or five servings of nuts, seeds, and legumes each day.
Eat two or fewer servings of lean meat, poultry, or fish each day.
The nurse is preparing to measure a patient’s blood pressure. What should the nurse do to ensure that the reading obtained is accurate? (Select all that apply.)
The patient is seated.
The patient’s arm is at the level of the heart.
The patient’s arm is lowered towards the floor.
The patient’s arm is elevated towards the head.
The patient is standing against the examination table.
A patient is being considered for medication therapy to treat high blood pressure. Prior to beginning medication, the nurse should prepare to schedule the patient for which diagnostic tests? (Select all that apply.)
Hematocrit
Electrocardiogram
Liver function tests
Blood glucose level
Cholesterol and triglycerides
The nurse is participating in the preparation of a seminar on coronary heart disease for a group of community members. What should modifiable risk factors for atherosclerosis should the nurse include in this presentation? (Select all that apply.)
Ethnic group
Hypertension
Diabetes mellitus
Familial hyperlipidemia
Increased serum iron levels
The nurse is contributing to a patient’s teaching plan. What should be included when teaching a patient about the use of nitroglycerin? (Select all that apply.)
Take tablet every morning.
Place tablet under the tongue.
Rise slowly after taking tablet.
Sit or lie down when taking tablet.
Take before activity known to cause angina.
As part of discharge teaching, the nurse is instructing a patient on the use of digoxin. What should be included in the teaching? (Select all that apply.)
Report if a persistent cough occurs.
Change position quickly to avoid orthostatic hypotension.
Take medication exactly as directed at the same time each day.
Report blurred vision, photophobia, or seeing yellowish green halos.
Take pulse before taking medication and if below 60 or above 100, call the physician.
A patient with heart failure is prescribed an angiotensin-converting enzyme inhibitor (ACEI). What should the nurse teach the patient about this medication? (Select all that apply.)
Prevents remodeling
Reduces fluid volume
Lowers blood pressure
Reduces workload on the heart
Decrease pulmonary venous pressure
Which assessment findings suggest probable fetal distress? (Select all that apply.)
Fetal heart rate (FHR) of 120
Meconium-stained amniotic fluid
Decreased FHR during contractions
Strong contractions 10 seconds apart
Slow return of FHR to baseline
The baseline FHR is the average rate during a 10-minute segment. Changes in FHR are categorized as periodic or episodic. These patterns include both accelerations and decelerations. The labor nurse is evaluating the client’s most recent 10-minute segment on the monitor strip and notes a late deceleration. Which is likely to have caused this change? (Select all that apply.)
Spontaneous fetal movement
Compression of the fetal head
Placental abruption
Cord around the baby’s neck
Maternal supine hypotension
Which patient teaching would help to prevent venous stasis? (Select all that apply.)
Dangle legs when sitting
Avoid crossing legs at the knee
Elevate legs when lying in bed or sitting
Massage extremities to help maintain blood flow
Wear elastic stockings when ambulating
The nurse examines the complete blood count (CBC) to assess (select all that apply):
hematocrit.
red cell count.
differential white cell count.
hemoglobin.
plasma level.
The nurse outlines behaviors that aid in the prevention of cardiovascular disease, which are: (Select all that apply.)
regular physical activity at least 30 minutes a day.
maintain high-density lipoprotein (HDL) greater than 50 mg/dL.
refrain from smoking.
obtain and maintain healthy weight.
maintain triglycerides above 150 mg/dL.
Cardiac output is dependent on: (Select all that apply.)
heart rate.
peripheral pulses.
venous return.
viscosity of the blood.
strength of contraction.
The nurse cautions the patient with uncontrolled hypertension that the consequences of the disease will include: (Select all that apply.)
threat of a stroke.
possible kidney failure.
risk for heart attack.
probability of congestive heart failure.
development of DVT.
The nurse in a long-term care facility designs a teaching program for the residents to help prevent peripheral vascular disease (PVD) caused by age-related changes, which include: (Select all that apply.)
decreasing blood viscosity.
loss of elasticity in vessel walls.
atherosclerotic vessels.
sedentary practices.
weakened leg muscles.
The nurse plans to enhance blood flow in the 80-year-old long-term care facility resident by interventions such as: (Select all that apply.)
using lap throws or light blankets over legs while sitting.
elevating legs with knee gatch.
encouraging walking.
coaching isometric exercises.
keeping environment warm.
The nurse monitoring a patient who is receiving a transfusion will stop the transfusion in the event of the patient complaining of: (Select all that apply.)
feeling cold.
a headache.
back pain.
a rash.
urticaria.
The physician has ordered the collection of a 24-hour urine specimen. The nurse’s instructions to the patient for proper collection of the urine specimen include: (Select all that apply.)
keep the container refrigerated as needed.
empty the bladder into the toilet and begin timing the collection.
void a small amount of urine after external genitalia are cleansed.
keep the container on ice if instructed to do so.
save only the first voiding in the morning.
Which of the following are signs of digoxin (Lanoxin) toxicity? (Select all that apply.)
Ringing in the ears
Bradycardia
Headache
Visual disturbance
Hematuria
The nurse is notified by the cardiac monitoring technician that a patient on continuous cardiac monitoring is having frequent alarms. When the nurse enters the patient’s room, the patient is in no apparent distress, sitting in the chair and eating. Which are appropriate nursing interventions? Select all that apply.
Confirm that lead wires are properly connected.
Assess the placement of electrodes.
Remove and reapply new electrodes if nonadherent.
Assess skin sites and move an electrode if the skin appears irritated.
Call for assistance.
Which actions are correct when the nurse is performing the Allen’s test? Select all that apply.
Occlude the radial artery and, after 15 seconds, occlude the ulnar artery.
Ask the patient to hold the hand below waist level for 30 seconds before beginning the test.
Release pressure over the ulnar artery first.
Hold pressure on the radial artery for 30 seconds before assessing the hand.
Consider color return to the hand in 20 seconds as a negative test.
The nurse, caring for an elderly patient, realizes that aging adults are at higher risk for development of heart failure because of which changes? Select all that apply.
Impaired diastolic filling
Increased cardiac reserve
Increased maximal heart rate
Reduced ventricular compliance
High responsiveness to sympathetic nervous system stimulation
A 68-year-old patient is prescribed furosemide (Lasix) for treatment of heart failure. The patient is diabetic, hypertensive, and had hip replacement surgery last year. Which laboratory results should be closely monitored due to the addition of this drug? Select all that apply.
Potassium
Glucose
Magnesium
Bleeding times
Thyroid function test
Which explanation of diastolic dysfunction by the nurse would help clarify the physiological process for the patient? Select all that apply.
“Your heart does not relax as well or as quickly as it should between beats.”
“You have a stiff, noncompliant heart.”
“The muscle of your heart does not stretch as well as it needs to.”
“Your irregular heartbeat keeps your heart from working as efficiently as it should.”
“Your obesity has caused your heart muscle to be infiltrated with fat.”
Which statements by the patient would the nurse evaluate as indicating a need for additional teaching about hypertension? Select all that apply.
“Hypertension affects my blood vessels only if I have other underlying health problems.”
“Hypertension causes my blood vessels to become inflamed and reduces the blood supply to my organs if left untreated.”
“Hypertension damages my blood vessels even if I don’t have any symptoms.”
“I will be more prone to heart disease and eye problems if I discontinue my blood pressure medications.”
“As long as I take my medications, I am cured of hypertension.”
A patient has been prescribed 3 units of packed red blood cells. How should the nurse proceed? Select all that apply.
Start an IV site with an 18-gauge catheter.
Obtain special Y-type tubing.
Attach D5NS to the selected tubing and prime the line.
Warm the blood for at least one hour before beginning the transfusion.
Stay with the patient for the first 15 minutes of the transfusion.
A nurse is planning to teach a senior citizens group heart-healthy lifestyle choices. Which should be included? (Select all that apply.)
Smoking cessation tips
Low-carbohydrate food choices
Stress management techniques
Regular blood pressure monitoring
Strategies to include exercise into daily routine
A 77-year-old patient is being treated for cardiac arrhythmia. The nurse determines that the patient’s cardiac output is adequate with which assessments? (Select all that apply.)
Urine output of 140 mL over 4 hours
Systolic blood pressure that remains within 20 mm of baseline
Denial of substernal pain
Recollection of the birthdays of all of her grandchildren
Absence of rales and crackles
The nurse is preparing a client for a non–stress test (NST). Which interventions should the nurse plan to implement? (Select all that apply.)
Ensure that the client has a full bladder.
Plan approximately 15 minutes for the test.
Have the client sit in a recliner with the head elevated 45 degrees.
Apply electronic monitoring equipment to the client’s abdomen.
Instruct the client to press an event marker every time she feels fetal movement.
The nurse is monitoring a client with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.)
Cool, clammy skin
Altered sensorium
Pulse oximeter reading of 95%
Respiratory rate of less than 12 breaths/min
Absence of deep tendon reflexes
When blood pressure and other signs indicate that the preeclampsia is worsening, hospitalization is necessary to monitor the woman’s condition closely. At that time, which of the following should be assessed? Select all that apply.
Fetal heart rate
Blood pressure
Temperature
Urine color
Pulse and respirations
Women with heart disease often present with which symptom? (Select all that apply.)
Chest pain
Dyspnea
Fatigue
Nausea
Palpitations
Important health promotion measures a nurse could teach a client in order to avoid another episode of DVT include (Select all that apply)
avoiding prolonged sitting.
elevating the legs when sitting.
maintaining an ideal body weight.
remaining hydrated.
What findings does the nurse expect when assessing the cardiovascular system of a healthy adult? Select all that apply.
Heart rate of 102 beats/min
S1 and S2 present with regular rhythm
Capillary refill greater than 3 seconds
Blood pressure of 124/86
Warm, elastic turgor
A nurse is providing care to a patient diagnosed with essential hypertension. What should the nurse know is included in a first-line therapeutic approach to lowering this patient’s blood pressure? (Select all that apply.)
Smoking cessation
Beta-blockers
Exercise programs
Weight loss
Decreased sodium intake
When reviewing a client’s laboratory results, which findings alert the nurse to the possibility of atherosclerosis? (Select all that apply.)
Total cholesterol of 280 mg/dL
High-density cholesterol of 50 mg/dL
Triglycerides of 200 mg/dL
Serum albumin of 4 g/dL
Low-density cholesterol of 160 mg/dL
A client has a consistently regular heart rate of 128 beats/min. Which related physiologic alterations does the nurse assess for? (Select all that apply.)
Decrease in cardiac output
Increase in cardiac output
Increase in blood pressure
Decrease in blood pressure
Increase in urine output
The nurse is assessing a client with left-sided heart failure. What conditions does the nurse assess for? (Select all that apply.)
Pulmonary crackles
Confusion, restlessness
Pulmonary hypertension
Dependent edema
S3/S4 summation gallop
