A client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse should assess for which finding as the best indicator of adequate ongoing respiratory status?

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?

The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included?

Which of the following is an expected outcome when a client is receiving an IV administration of furosemide?

The nurse makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has

Which term does the nurse document to best describe a client experiencing shortness of breath when lying down who must assume an upright or sitting position to breathe more comfortably and effectively?

A client's serum lipids are cholesterol 197mg/dl, low-density lipoprotein (LDL) 110 mg/dl, and high-density lipoprotein (HDL) 35 mg/dl. The nurse knows what about these values?

The nurse is working on a respiratory care unit in the hospital. On entering the room of a patient with emphysema, it is noted that the patient is experiencing respiratory distress. The nurse should first:

A patient has been diagnosed with Right-Sided Congestive Heart Failure, and is confused about return of deoxygenated blood from the tissue. To clarify the confusion, which chamber of the heart receives blood from systemic circulation?

An elderly client is being monitored for evidence of congestive heart failure. To detect early signs of heart failure, the nurse would instruct the certified nursing attendant (CNA) to do which of the following during care of the patient?

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best?

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?

A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?

You hear a repetitious pattern of respiration that begin shallow, gradually increase in depth and frequency to a peak, then begin to decrease in depth and frequency until slow and shallow, followed by a period of apnea lasting from 10 to 60 seconds. What type of respiration are you hearing?

You hear respirations increase in rate and depth, with long, strong, blowing or grunting exhalations. What type of respiration are you hearing?

After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108/minute. What should the nurse suspect is happening?

A70-year-old woman with chronic heart failure and atrial fibrillation asks the nurse why warfarin (Coumadin) has been prescribed for her to continue at home. Which response by the nurse is accurate?

Patients with heart failure can experience episodes of exacerbation. All of the patients below have a history of heart failure. Which of the following patients are at MOST risk for heart failure exacerbation?

A 56-year-old client is being seen at the primary care clinic for follow-up after having chest pain. The client tells the nurse, “I think I had a heart attack yesterday but it could have just been chest pain. It still hurts some, though.” The provider orders a troponin level and an ECG. Which response from the nurse is most appropriate?

The nurse is caring for a female client who is having an acute myocardial infarction. Which of the following symptoms is specific to females who are experiencing an MI?

The nurse prepares a discharge teaching plan for a 44-yr-old male patient who has recently been diagnosed with coronary artery disease (CAD). Which risk factor should the nurse plan to focus on during the teaching session?

A 74-yr-old man with a history of prostate cancer and hypertension is admitted to the emergency department with substernal chest pain. Which action will the nurse complete before administering sublingual nitroglycerin?

A nurse is caring for a client who had a percutaneous insertion of an inferior

vena cava filter and was on heparin therapy before surgery. The nurse would

inspect the surgical site most closely for signs of:

When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which food?

A nurse is assessing a client with an abdominal aortic aneurysm. Which of the

following assessment findings by the nurse is probably unrelated to an

aneurysm?

which nursing interventions appropriate for preventing atelectasis assists in the post up patient?

The nurse assesses a client and detects the following findings: difficulty

breathing, increased respiratory and pulse rates, and pale skin with regions of

cyanosis. What condition would the nurse suspect as causing these respiratory

alterations?

A nurse is caring for a client who breathes very shallowly and has been

reporting severe back pain. What suggestion could the nurse make to

help the client breathe efficiently?

The nurse determines that the student who has been instructed about lung

function and smoking requires additional teaching when the student says

A client with chronic obstructive pulmonary disease (COPD) requires

low flow oxygen. How will the oxygen be administered?

Nurses can best help older clients prevent hypertension by teaching

A client with myocardial infarction has been transferred from a

coronary care unit to a general medical unit with cardiac monitoring via

telemetry. A nurse plans to allow for which of the following client

activities?

A 60-year-old male client comes into the emergency department with

complaints of crushing chest pain that radiates to his shoulder and left

arm. The admitting diagnosis is acute myocardial infarction. Immediate

admission orders include oxygen by NC at 4L/minute, blood work, chest

×-ray, an ECG, and 2mg of morphine given intravenously. The nurse

should first:

A patient with COPD has carbon dioxide retention and is ordered oxygen therapy. The nurse anticipates the use of which oxygen delivery system?

A patient with a tracheostomy tube has an order for oxygen. Which action by the nurse is appropriate?

The nurse is caring for patient on a mechanical ventilation. The nurse determines that the endotracheal tube is properly placed by which assessment.

A patient with COPD is unable to perform activities of daily living (ADLs) without becoming exhausted. Which nursing diagnosis best describes this alteration in oxygenation as the etiology?

The home health nurse has developed a teaching guide for a client with cardiovascular risk factors that focuses on the importance of regular physical activity with gradually increasing activity levels. This teaching guide specifically promotes which topic?

Which would most likely be included in the evaluation of the client goal of "Demonstrate adequate tissue perfusion"?

The surgeon ordered sequential compression devices (SCDs)to be applied postoperatively. The client asks why the SCDs are needed. Which is the best response by the nurse when teaching the client about the purpose of SCDs?

The spouse of a client is recalling the modifiable risk factors for coronary heart disease. Which statement by the client's spouse indicates a need for further teaching?

Which of the following would be a sign of heart failure?

The nurse is discussing nutrition with a patient that has been diagnosed with hypertension. Which of the following, if stated by the patient, would show a correct understanding of the types of food that this patient can eat for lunch?

During an assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change?

Which position is most appropriate for the nurse to place a patient experiencing an asthma exacerbation?

The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with COPD are successful based on which finding?

Which of the following is marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea?