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Worksheets212 Exam 2 OT 1
Total questions: 100
Worksheet time: 50mins
A nurse is teaching a client who has stable angina and a new prescription for sublingual nitroglycerin. The client reports taking sildenafil last night. Which instruction is the nurse’s priority?
“Do not take nitroglycerin and notify your provider immediately.”
“Take nitroglycerin only if your systolic blood pressure is above 140 mm Hg.”
“Take nitroglycerin after you eat to reduce stomach upset.”
“Chew the tablet to make it work faster.”
A nurse assesses a client with chest discomfort. Which finding most strongly indicates decreased tissue perfusion requiring immediate escalation of care?
Warm, flushed skin with bounding pulses
Cool, clammy skin with pallor and decreased level of consciousness
Blood pressure 148/86 mm Hg with a regular pulse
Pain rated 3/10 that improves when lying flat
A client is scheduled for a cardiac catheterization with contrast. Which action is the nurse’s priority before the procedure?
Encourage oral fluids 2–3 L the morning of the procedure
Administer an antacid 30 min before transport
Assess for sensitivity to iodine/shellfish and review BUN/creatinine results
Teach the client to keep the affected extremity straight for 6 hr after the procedure
A client returns to the unit after coronary angiography via femoral access. Which assessment is the nurse’s priority?
Ask about a metallic taste in the mouth
Encourage the client to ambulate to prevent clots
Offer a snack if the client reports hunger
Check the insertion site and distal pulses for bleeding/hematoma and perfusion
A client with angina takes 1 sublingual nitroglycerin tablet and reports no relief after 5 minutes. Which instruction should the nurse reinforce?
“Take another tablet every 5 minutes, up to a total of 3 tablets.”
“Wait 30 minutes before taking a second dose.”
“Take an extra tablet daily to prevent future pain.”
“Swallow the next tablet with water for better absorption.”
A nurse is assessing a client for cardiac output and tissue perfusion concerns. Which finding most directly signals organ under-perfusion?
Urine output 40 mL/hr
Oliguria with altered mental status
Capillary refill 1 second with warm extremities
Heart rate 72/min with regular rhythm
A nurse is preparing a client for a cardiac catheterization. Which action should the nurse plan to complete before transport?
Teach the client to increase fluids 2–3 L/day immediately after returning
Have the client sit upright for 2 hours prior to the procedure
Verify the client has remained NPO for at least 8 hr
Apply a pressure device to the wrist access site
A nurse is monitoring a client after coronary angiography. Which finding requires immediate action?
Client reports a “warm burning sensation” during contrast injection earlier
Mild soreness at the insertion site
New swelling and firmness at the access site with decreasing distal pulses
Client requests to drink water
A nurse teaches a client prescribed sublingual nitroglycerin for angina. Which statement by the client indicates the need for further teaching?
“I’ll sit down before I take it.”
“If the pain isn’t relieved after the first dose, I’ll take another in 5 minutes.”
“If my chest pain is not relieved after 3 doses, I’ll seek emergency care.”
“I’ll take it whenever I feel dizzy so my blood pressure goes back up.”
A client has findings consistent with impaired perfusion in a lower extremity. Which assessment finding best matches impaired arterial flow and reduced tissue perfusion?
Brown discoloration at the ankle with warmth and edema
Decreased capillary refill of toes (>3 seconds) with cool, cyanotic extremity
Moist skin with strong palpable pedal pulses
Pain that improves with leg elevation and rest
A nurse is reviewing pre-procedure orders for a client scheduled for coronary catheterization. Which pre-procedure item is most important for client safety?
Place the client supine for 6 hours before the procedure
Obtain baseline blood glucose immediately before transport for all clients
Obtain informed consent and ensure allergies/renal function have been reviewed
Give a full meal to prevent hypoglycemia during the procedure
A nurse provides discharge teaching after coronary angiography. Which instruction is most important for preventing complications at the access site?
“Exercise the affected extremity hourly.”
“Take a hot bath if you notice bruising.”
“Limit fluid intake for 24 hours.”
“Keep the affected extremity straight and maintain bedrest for the ordered time.”
A client with angina asks how to take sublingual nitroglycerin. Which instruction should the nurse include?
“Place the tablet under your tongue and allow it to dissolve.”
“Crush the tablet and mix it with food.”
“Swallow the tablet whole with water.”
“Take it only after activity, never during symptoms.”
A nurse assesses a client with suspected decreased cardiac output. Which cluster of findings best supports poor tissue perfusion?
Hypertension, bounding pulses, warm dry skin
Tachycardia, cool extremities with weak pulses, hypotension
Bradycardia with flushed skin and increased urine output
Slow respirations with warm extremities and strong pulses
A nurse is completing pre-cath teaching for a client scheduled for coronary angiography with contrast. Which statement by the nurse is most appropriate?
“You should drink 2–3 liters of fluid before the procedure.”
“You’ll be walking immediately after the procedure to prevent bleeding.”
“We’ll avoid checking pulses after the procedure to prevent discomfort.”
“You may feel a warm burning sensation when the dye is injected.”
A client returns from coronary angiography and asks why so many pulse checks are being done. Which response by the nurse is best?
“It’s just routine; it doesn’t mean anything.”
“Pulse checks help us know your heart rhythm is normal.”
“We are checking pulses to see if the dye affected your lungs.”
“We are monitoring circulation beyond the access site to detect decreased perfusion early.”
A nurse is reinforcing nitroglycerin teaching. Which client report is most concerning and requires follow-up before the client self-administers nitroglycerin?
“I took tadalafil earlier today.”
“I sometimes get headaches.”
“I have occasional heartburn.”
“I ate a salty meal.”
A nurse suspects inadequate tissue perfusion in a client with cardiovascular compromise. Which finding is the best indicator of worsening perfusion?
Mild chest discomfort that improves with rest
Capillary refill less than 2 seconds
Clear lung sounds with oxygen saturation 98%
Altered mental status with decreasing urine output
A nurse is preparing a client for cardiac catheterization. Which baseline assessment is most important to obtain prior to the procedure to support post-procedure comparison?
Baseline bowel sounds
Baseline hearing screening
Baseline peripheral pulses in the extremity likely used for access
Baseline visual acuity
A nurse is caring for a client after coronary angiography. Which instruction should the nurse include to support recovery and reduce complications related to contrast?
“Restrict oral fluids for 24 hours.”
“Avoid all urination for 6 hours to prevent bleeding.”
“Ambulate immediately to improve circulation.”
“Increase fluid intake to about 2–3 liters per day, if not contraindicated.”
A client reports substernal chest pressure that starts when climbing stairs and goes away after sitting for 5 minutes. The client denies nausea, shortness of breath, and sweating. Which interpretation is most consistent with the client’s findings?
Stable angina
Unstable angina
Myocardial infarction (MI)
Gastroesophageal reflux (GERD)
A nurse in a provider’s office is preparing a client for blood work after the client reports episodic chest pain. Which set of tests should the nurse anticipate to evaluate angina risk and possible cardiac muscle injury?
BNP and serum potassium
Cardiac enzymes and a lipid profile
WBC count and PT/INR
Amylase and lipase
A client arrives to the ED with chest pain that began 3 hours ago. The provider suspects myocardial injury and wants the lab that becomes detectable within a few hours and indicates cardiac tissue damage when positive. Which lab is the best priority?
BNP
Total cholesterol
Troponin (I or T)
HDL
A client’s chest pain started yesterday afternoon and improved overnight. The nurse is reviewing labs to determine whether myocardial injury occurred within the last 1–2 days. Which lab is expected to be elevated and commonly peaks around 24 hours after onset of chest pain?
HDL
Total cholesterol
BNP
CK-MB (creatine kinase-MB)
A client reports chest tightness that occurs with emotional stress and is relieved by rest and sublingual nitroglycerin. Episodes last about 10 minutes and the client denies diaphoresis or nausea. Which finding best supports the nurse’s interpretation?
Symptoms are precipitated by exertion/stress and last less than 15 minutes
Symptoms occur at rest in the morning and are relieved only by opioids
Symptoms are associated with nausea, epigastric distress, and diaphoresis
Symptoms persist longer than 30 minutes despite nitroglycerin
A nurse is teaching a client scheduled for a lipid profile as part of angina evaluation. Which instruction is most important to include?
“Eat a high-protein snack 1 hour before the test.”
“Plan to fast 12 to 14 hours before the lipid sample is drawn.”
“Drink at least 2 liters of water immediately before the test.”
“Take your morning medications with a full breakfast.”
A client had chest pain 9 days ago and did not seek care. Today, the provider wants to know whether there may have been cardiac tissue damage that could still be detectable on labs. Which test is most useful for this timing?
CK-MB
Myoglobin
Troponin (I or T)
Total cholesterol
A nurse is trending cardiac enzymes for a client who had suspected myocardial injury 36 hours ago. Which trend is most expected if the injury occurred, based on typical timing?
Troponin should already be absent by 24 hours
CK-MB should be elevated and may remain elevated for a few days
HDL should rise within 2–3 hours and stay high for 10 days
Total cholesterol should peak at 24 hours after chest pain
A client reports chest discomfort that happens “out of nowhere” early in the morning after resting. The nurse notes the client also has nausea and diaphoresis and states the pain has lasted 40 minutes. Which interpretation is the priority concern?
Stable angina
Anxiety-related chest pain
Musculoskeletal pain
Myocardial infarction (MI) pattern rather than stable angina
A client is being evaluated for angina and the nurse is reviewing which labs were ordered. Which results would be used specifically to assess cholesterol-related risk for heart disease as part of a lipid profile?
Troponin I and troponin T
CK-MB and myoglobin
BNP and potassium
Total cholesterol, LDL, HDL, triglycerides
A nurse is reviewing an order set for a client with chest pain to determine which lab is the earliest marker that rises with injury to cardiac or skeletal muscle and then is no longer evident after about 24 hours. Which lab matches this description?
BNP
Troponin T
CK-MB
Myoglobin
A client is being monitored for possible myocardial injury, and the nurse wants the lab that can rise within a few hours and remains elevated for several days but is no longer evident after about 3 days. Which lab fits best?
CK-MB
Troponin I
Troponin T
HDL
A nurse is caring for a client with long-standing hyperlipidemia and hypertension. Which underlying change most directly contributes to the development of coronary artery disease in this client?
Acute vasospasm of coronary arteries
Progressive narrowing of coronary arteries from atherosclerotic plaque
Increased myocardial oxygen extraction
Sudden rupture of ventricular myocardium
A client with coronary artery disease develops chest pain during mild exertion. Which pathophysiologic mechanism is the primary cause of the pain?
Reduced preload leading to hypotension
Decreased coronary blood flow resulting in myocardial ischemia
Impaired pulmonary gas exchange
Increased parasympathetic nervous system stimulation
A nurse is monitoring a client with acute left-sided heart failure. Which finding best reflects impaired pulmonary circulation?
Jugular vein distention
Crackles in bilateral lung bases
Bounding peripheral pulses
Decreased urine output
A client with coronary artery disease experiences a sudden drop in cardiac output. Which vital sign change should the nurse anticipate first as a compensatory response?
Increased heart rate
Decreased respiratory rate
Increased oxygen saturation
Widened pulse pressure
A nurse is assessing a client with worsening pulmonary congestion due to left ventricular dysfunction. Which pathophysiologic event is responsible for the client’s dyspnea?
Decreased systemic vascular resistance
Increased pulmonary capillary pressure causing fluid leakage into alveoli
Reduced red blood cell production
Bronchial smooth muscle constriction
A client with coronary artery disease has a heart rate of 112/min and blood pressure of 88/54 mm Hg. Which explanation best accounts for these findings?
Decreased myocardial contractility leading to compensatory tachycardia
Excess parasympathetic stimulation
Increased preload due to fluid retention
Primary pulmonary pathology
A nurse is caring for a client with severe coronary artery disease and impaired pulmonary circulation. Which assessment finding indicates worsening tissue perfusion?
Oxygen saturation of 96%
Warm, flushed skin
Delayed capillary refill
Increased urine output
A client with advanced coronary artery disease develops pulmonary edema. Which vital sign abnormality should the nurse anticipate?
Bradycardia with widened pulse pressure
Tachypnea with decreased oxygen saturation
Hypertension with bounding pulses
Slow, shallow respirations
A nurse is monitoring a client with coronary artery disease who suddenly develops hypotension. Which pathophysiologic process is the most likely cause?
Increased coronary artery perfusion
Reduced cardiac output from impaired myocardial oxygen delivery
Increased pulmonary circulation efficiency
Enhanced renal blood flow
A nurse is assessing a client with known left-sided heart failure who suddenly reports severe dyspnea. Assessment shows pink frothy sputum and bibasilar crackles. Which action is the nurse’s priority?
Place the client in high-Fowler’s position and apply oxygen
Encourage oral fluids to thin secretions
Obtain a daily weight and document intake/output
Apply warm blankets and reassess in 30 min
A client with left-sided heart failure is receiving IV fluids post-procedure. Which finding is most concerning for worsening pulmonary edema related to left-sided heart failure?
Dependent edema in both ankles
New onset crackles and worsening dyspnea when lying flat
Abdominal distention after meals
Jugular vein distention when supine
A nurse is teaching a client about left-sided heart failure. Which explanation best describes why pulmonary congestion happens?
Increased left ventricular end-diastolic pressure raises left atrial and pulmonary venous pressures, causing fluid to move into the alveoli
Right ventricular failure causes systemic venous congestion that backs up into the lungs
Coronary artery vasospasm increases bronchial secretions and airway obstruction
Increased systemic vascular resistance shunts blood away from the lungs, leading to fluid accumulation
A client with left-sided heart failure has oliguria and new confusion. Which interpretation is best?
These findings indicate dehydration from diuretic therapy
These findings suggest poor tissue perfusion from decreased cardiac output
These findings are expected and do not require action
These findings confirm the client has right-sided failure only
A nurse is prioritizing assessments for a client suspected of worsening left-sided heart failure. Which finding is the best indicator of pulmonary congestion?
Jugular vein distention
Bibasilar crackles on lung auscultation
Abdominal ascites
Hepatomegaly with tenderness
A client with heart failure reports waking up at night “gasping for air” and needing extra pillows to breathe. Which manifestation does the nurse suspect is most consistent with left-sided heart failure?
Abdominal distention and ascites
Orthopnea and nocturnal dyspnea
Dependent edema and weight gain
Jugular vein distention
A nurse is reviewing findings for a client with suspected left-sided heart failure. Which cluster most strongly supports left-sided failure with pulmonary congestion?
Dependent edema + ascites + hepatomegaly
JVD + weight gain + abdominal distention
Dyspnea + cough + bibasilar crackles
Anorexia + nausea + fatigue
A client with heart failure has pink frothy sputum. Which interpretation should the nurse make?
This is an expected effect of diuretics
This suggests pulmonary edema from right-sided failure
This indicates dehydration from fluid restriction
This is a high-risk sign of acute pulmonary edema and requires rapid intervention
A nurse is assessing a client with right-sided heart failure. Which finding should the nurse expect?
Jugular vein distention
Bibasilar crackles
Pink frothy sputum
Severe orthopnea as the only symptom
A client has right-sided heart failure and new abdominal distention. Which explanation is best?
Fluid is backing up into the lungs because the left ventricle is weak
Fluid is backing up into the systemic veins, causing swelling in the abdomen and legs
The body is producing too much insulin, causing abdominal swelling
The kidneys are filtering too much blood, causing fluid to shift into the belly
A nurse is comparing right-sided vs. left-sided heart failure findings. Which finding is most specific to right-sided heart failure?
Bibasilar crackles
Pink frothy sputum
Ascending dependent edema (ankles/sacrum)
Dyspnea with exertion
A client with right-sided heart failure has hepatomegaly and reports nausea and anorexia. What is the nurse’s best reasoning?
Pulmonary congestion is irritating the stomach lining
Liver congestion from systemic venous backup can cause GI fullness and decreased appetite
The client is hyperventilating, which causes nausea
This confirms the client has only left-sided failure
A nurse is caring for a client with suspected pericardial effusion. Which diagnostic procedure should the nurse anticipate as the priority to evaluate the presence/amount of pericardial fluid?
Echocardiogram
Colonoscopy
Spirometry
EEG
A provider suspects a large pericardial effusion with hemodynamic compromise. Which procedure should the nurse anticipate to remove fluid and improve cardiac filling?
Stress test
Pericardiocentesis
Bronchoscopy
Endoscopy
A client is being prepared for pericardiocentesis. Which nursing action is most important to anticipate for safety during the procedure?
Keep the client NPO for 24 hr
Apply cold packs to the chest
Continuous ECG monitoring during the procedure
Place the client prone
A nurse is reviewing orders for a client with pericardial effusion. Which set of diagnostic studies is most consistent with what the nurse should anticipate?
Echocardiogram, ECG, chest x-ray
Upper GI series, barium enema, colonoscopy
EEG, lumbar puncture, MRI brain
Bone scan, DEXA scan, joint aspiration
A nurse is reviewing laboratory orders for a client with pericardial effusion. Which lab set is most appropriate to monitor based on the condition and possible complications?
CBC and cardiac enzymes
Thyroid panel only (TSH, T3, T4)
Lipase and amylase only
HgbA1c only
A client with suspected pericardial effusion is at risk for impaired oxygenation. Which laboratory test should the nurse expect to evaluate oxygenation/ventilation status?
INR
ABGs
Creatinine
Magnesium
A nurse is caring for a client with pericardial effusion who may require an invasive procedure. Which lab is most important to review to reduce bleeding risk?
Troponin
Potassium
Coagulation studies (PT/INR, aPTT)
Vitamin D level
A nurse receives lab results for a client with pericardial effusion: electrolytes are abnormal after diuretic therapy. Why are electrolytes important to trend in this client?
Electrolytes don’t matter in cardiac conditions
Electrolyte imbalances can contribute to dysrhythmias and worsen cardiac instability
Electrolytes only affect blood sugar control
Electrolytes only affect liver enlargement
A nurse is caring for a client diagnosed with dilated cardiomyopathy. Which assessment finding should the nurse expect?
Cardiomegaly with decreased cardiac output
Sudden episodes of bradycardia triggered by exercise
Bounding peripheral pulses with widened pulse pressure
Increased right-sided filling pressures with absent lung findings
A client with dilated cardiomyopathy reports worsening fatigue and dyspnea with minimal activity. Which assessment finding best supports decreased cardiac output as the cause?
Warm, flushed skin
Delayed capillary refill and weak peripheral pulses
Increased urine output
Hyperactive bowel sounds
A client with dilated cardiomyopathy is admitted with acute shortness of breath. Which provider prescription should the nurse anticipate to improve symptoms related to fluid overload?
Increase isotonic IV fluids
Encourage high-sodium diet
Administer a diuretic as prescribed
Restrict oxygen therapy
A nurse is evaluating teaching for a client with dilated cardiomyopathy. Which statement by the client indicates the highest risk for worsening cardiac workload?
“I will track my weight daily.”
“I will pace my activities with rest periods.”
“I will notify the provider if I have swelling.”
“I will take over-the-counter decongestants when I’m congested.”
A nurse is assessing a client with restrictive cardiomyopathy. Which manifestation is most expected?
Crushing substernal chest pain with exertion relieved by nitroglycerin
Right-sided heart failure manifestations
Large, bounding pulses with headache
Acute wheezing relieved by bronchodilators
A client has restrictive cardiomyopathy and reports increasing abdominal fullness. Which assessment finding best supports progression of the disorder?
Productive cough with pink frothy sputum
Ascites and dependent edema
Sharp pleuritic chest pain relieved by leaning forward
Severe calf pain with walking that improves with rest
A nurse is planning care for a client with restrictive cardiomyopathy. Which finding is the most important to report to the provider as a potential complication?
Mild headache after medication administration
Occasional dry cough
Rapid weight gain with worsening peripheral edema
Heart rate of 88/min after ambulation
A nurse is providing discharge teaching to a client with restrictive cardiomyopathy. Which instruction is the priority to reduce complications related to fluid retention?
“Increase fluid intake during the day.”
“Use a heating pad for chest discomfort.”
“Avoid potassium-rich foods.”
“Report rapid weight gain and swelling promptly.”
A nurse is reviewing findings for a client diagnosed with hypertrophic cardiomyopathy. Which manifestation should the nurse expect?
Angina
Pitting edema with brown skin discoloration of the lower legs
Persistent productive cough with fever
Severe hypotension that improves when lying flat
A client with hypertrophic cardiomyopathy reports chest pain and shortness of breath during exercise. Which nursing interpretation best explains why symptoms increase with exertion?
Exercise decreases venous return, improving ventricular filling
Exercise increases the heart’s workload and oxygen demand
Exercise prevents tachycardia, reducing myocardial oxygen use
Exercise causes systemic vasodilation, reversing cardiac strain
A nurse is caring for a client with hypertrophic cardiomyopathy who reports new chest tightness. Which action is the nurse’s priority?
Encourage the client to ambulate to improve circulation
Place the client in Trendelenburg position
Assess vital signs and oxygenation status immediately
Provide a high-carbohydrate snack
A nurse is teaching a client with hypertrophic cardiomyopathy. Which statement by the client indicates a need for further teaching?
“I’ll report chest pain that doesn’t go away.”
“I’ll pace my activities if I feel short of breath.”
“I’ll keep follow-up appointments.”
A nurse is teaching a class about rheumatic fever prevention. Which statement is most accurate?
Early treatment of streptococcal infections can prevent rheumatic fever
Rheumatic fever is prevented by restricting physical activity in children
Rheumatic fever is prevented by avoiding dairy products during illness
Rheumatic fever is prevented by taking aspirin at the first sign of fever
A nurse is assessing a school-aged child with suspected rheumatic fever. Which history finding is most consistent with this condition?
Recent viral gastroenteritis 24 hr ago
Untreated or partially treated strep throat 2 to 6 weeks ago
Long-standing asthma with nightly wheezing
Recent exposure to poison ivy
A nurse is reviewing labs for a child suspected of rheumatic fever. Which result is described as the most reliable diagnostic test in the study material?
Decreased erythrocyte sedimentation rate
Low C-reactive protein
Elevated or rising antistreptolysin O (ASO) titer
Decreased white blood cell count
A nurse is assessing a child who might meet Jones criteria for rheumatic fever. Which set of findings best supports the diagnosis?
One major criterion only following sore throat
Two minor criteria without evidence of streptococcal infection
One major and one minor criterion after GABHS infection
Two major criteria following acute GABHS infection
A nurse is providing teaching to a client who has a new prescription for lisinopril. Which finding should the nurse instruct the client to report immediately as a potential adverse reaction?
Tongue swelling
Increased appetite
Mild constipation
Nasal congestion
A client took the first dose of lisinopril 2 hours ago and now reports dizziness when standing. Which action is the nurse’s priority?
Encourage the client to ambulate to build tolerance
Place the client in a supine position and recheck blood pressure
Instruct the client to take the next dose with an energy drink
Ask the client to increase sodium intake immediately
A nurse is reviewing labs for a client taking lisinopril. Which laboratory value is the priority for the nurse to report?
Sodium 138 mEq/L
Potassium 5.8 mEq/L
Chloride 101 mEq/L
Magnesium 1.9 mEq/L
A nurse is caring for a client who takes lisinopril and spironolactone. Which finding is the nurse most concerned about?
Blood glucose 110 mg/dL
Calcium 9.4 mg/dL
Potassium 6.1 mEq/L
Hemoglobin 12.8 g/dL
A client taking lisinopril reports “my lips feel tingly and my heart feels like it’s skipping.” Which complication is the nurse most concerned about first?
Hypokalemia
Hyperkalemia
Hypernatremia
Hypocalcemia
A nurse is reinforcing teaching for a client prescribed lisinopril. Which statement by the client indicates a need for further teaching related to potassium?
“I’ll avoid salt substitutes unless my provider says it’s okay.”
“I’ll have my potassium checked as ordered.”
“I’ll report muscle weakness or palpitations.”
“I’ll increase bananas and orange juice every day to help my heart.”
A nurse is preparing to administer IV furosemide to a client with acute pulmonary edema. Which action is the nurse’s priority to reduce the risk of an adverse effect?
Administer the dose rapidly to relieve dyspnea
Administer the dose slowly as an IV push per protocol
Dilute the medication in dextrose and infuse over 1 hr
Give the medication IM to prevent vein irritation
A nurse is providing discharge teaching to a client taking oral furosemide. Which finding should the nurse instruct the client to report immediately as a potential adverse effect?
Increased appetite
Tinnitus
Mild headache
Occasional hiccups
A nurse is evaluating a client taking furosemide. Which assessment finding is most concerning and suggests a complication requiring immediate provider notification?
Potassium 3.0 mEq/L
Sodium 142 mEq/L
Glucose 118 mg/dL
Hemoglobin 13.2 g/dL
A nurse is about to administer furosemide to a client with heart failure. Which finding requires the nurse to hold the medication and notify the provider?
Crackles at the lung bases
Blood pressure 86/52 mm Hg
2+ ankle edema
Weight gain of 1.4 kg (3 lb) in 2 days
A client prescribed furosemide reports new dizziness and “really dry mouth” after several days of therapy. Which additional finding is most consistent with the adverse effect the nurse suspects?
Bounding pulse and hypertension
Decreased urine specific gravity
Orthostatic hypotension with a weak, thready pulse
New crackles and rapid weight gain
A nurse is caring for an older adult receiving furosemide and digoxin. Which finding is the priority for the nurse to assess that would indicate the client’s medication should be held and the provider notified?
Apical pulse 58/min
Potassium 3.1 mEq/L
Urine output 45 mL/hr
Blood pressure 138/84 mm Hg
A nurse is preparing to administer digoxin to a client with heart failure. Which finding is the priority for the nurse to report to the provider before giving the medication?
Apical pulse 54/min
Blood pressure 148/86 mm Hg
Potassium 4.2 mEq/L
Respiratory rate 22/min
A client taking digoxin and furosemide reports nausea and “my vision looks weird.” Which action should the nurse take first?
Administer an antiemetic PRN
Hold the digoxin and obtain a digoxin level and potassium level
Give the scheduled dose with food
Encourage the client to rest and reassess in 1 hr
A nurse is caring for a client receiving digoxin. Which set of findings most strongly suggests digoxin toxicity?
Dry cough, ankle swelling, potassium 5.8 mEq/L
Bradycardia, confusion, yellow-green halos around lights
Hypertension, headache, flushed skin
Tachycardia, fever, elevated WBC count
A nurse is reviewing labs for a client who takes digoxin for heart failure. Which lab result places the client at the highest risk for developing digoxin toxicity?
Potassium 2.9 mEq/L
Sodium 140 mEq/L
Calcium 8.9 mg/dL
Magnesium 2.0 mg/dL
A client with heart failure is prescribed digoxin. Which new medication order is the nurse most concerned about because it can increase the risk of digoxin toxicity through electrolyte changes?
Furosemide
Acetaminophen
Docusate sodium
Famotidine
A nurse is assessing a client with suspected digoxin toxicity. Which finding requires immediate action due to risk of life-threatening complication?
Anorexia and mild nausea
Blurred vision and fatigue
Ventricular dysrhythmias on telemetry
Resting heart rate 64/min
A nurse is reviewing laboratory results for a client with chronic kidney disease who is taking spironolactone. Which potassium level requires the priority nursing intervention?
4.8 mEq/L
5.2 mEq/L
5.9 mEq/L
4.1 mEq/L
A client admitted with hyperkalemia has peaked T waves on the ECG. Which intervention should the nurse anticipate as the most immediate action to reduce the risk of dysrhythmias?
Administer sodium polystyrene sulfonate
Administer IV calcium gluconate
Encourage oral fluid intake
Restrict dietary potassium
A nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement indicates the need for further teaching?
“I will avoid salt substitutes.”
“I will report muscle weakness.”
“I will eat bananas daily to stay healthy.”
“I will have my blood tested regularly.”
A nurse is evaluating medications for a client with hyperkalemia. Which prescribed medication should the nurse question due to its effect on potassium levels?
Furosemide
Spironolactone
Regular insulin
Sodium bicarbonate
A client with hyperkalemia is prescribed insulin with dextrose IV. Which outcome indicates the treatment was effective?
Increased urinary potassium excretion
Shift of potassium from extracellular to intracellular space
Binding of potassium in the intestines
Increased renal potassium reabsorption
