Exam Review

A nurse is caring for a client who has an irregular heart rate. Which of the following actions should the nurse take?
A)Palpate the client's pulse at the third intercostal space.
B)Auscultate the client's apical pulse.
C)Check the clients heart rate for 30 sec.
D)Ask the client to perform the Valsalva maneuver.
Which clinical manifestations are most commonly associated with left-sided heart failure? (Select all that apply)(SATA)
A)Crackles in the lungs
B)Jugular vein distension
C)Ascites
D)Shortness of breath
E)Pulmonary congestion
F)Wet, phlegmy cough
G)Peripheral edema
A nurse is preparing to administer atenolol 25 mg PO every 12 hr. The amount available is atenolol 50 mg/tab. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take?
A)Place the blood pressure cuff 5 cm (2 in) above the client's antecubital space.
B)Elevate the client's arm above the level of the heart.
C)Select a cuff that covers 50% of the client's upper arm.
D)Align the artery indicator on the blood pressure cuff with the client's brachial artery.

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A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg PO daily. Available is digoxin PO 0.25 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?
A)Dry, hacking cough
B)Crackles in the lungs
C)Hepatomegaly
D)Dizziness
Which interventions are most appropriate for managing fluid retention in a patient with right-sided heart failure? (Select all that apply)(SATA)
A)Restricting sodium in the diet
B)Positioning the patient in Trendelenburg
C)Administering calcium channel blockers
D)Elevating the legs
E)Performing thoracentesis
F)Assessing jugular vein distension
G)Administering furosemide
H)Monitoring intake and output
I)Compression stockings
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?
A)Alteration in body image
B)Impaired tissue perfusion
C)Impaired skin integrity
D)Alteration in activity tolerance

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A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe?
A)Aspartate aminotransferase (AST)
B)Troponin I
C)Lipase
D)B-type natriuretic peptide (BNP)
While auscultating a client's heart sounds, the nurse hears turbulence between the S, and S2 heart sounds. The nurse should document this finding as which of the following?
A)A systolic murmur
B)A third heart sound (S3)
C)An expected heart sound
D)A fourth heart sound (S4)
A nurse in an outpatient clinic is assessing a middle adult client as part of a routine physical examination. The client's BP is 142/88 mm Hg, his body mass index (BMI) is 31, and he is a current smoker. The nurse should identify that this client has multiple risk factors for which of the following disorders?
A)Cardiovascular disease
B)Depression
C)Thyroid disease
D)Testicular cancer
Which cardiac enzymes are most useful in diagnosing an acute myocardial infarction? (Select all that apply)(SATA)
A)Myoglobin
B)Aspartate transaminase (AST)
C)C-reactive protein (CRP)
D)Troponin I
E)Lactate dehydrogenase (LDH)
F)Creatine kinase-MB (CK-MB)
G)Brain natriuretic peptide (BNP)

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A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for the client?
A)Peripherally inserted central catheter
B)Implanted infusion port
C)Arteriovenous fistula
D)Short peripheral catheter
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)(SATA)
A)Increased temperature
B)Increased respiratory rate
C)Increased heart rate
D)Increased blood pressure
E)Increase hematocrit
A nurse is assessing a client who is a professional athlete. Which of the following findings should the nurse expect?
A)Hypothermia
B)Bradycardia
C)Hypertension
D)Decreased oxygen saturation
A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity?
A)Ataxia
B)Anorexia
C)Jaundice
D)Photosensitivity

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A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflects the client's understanding of these dietary instructions?
A)Beans
B)Eggs
C)Liver
D)Milk
A patient with peripheral vascular disease is at risk for amputation due to ischemia. What is a critical assessment the nurse should perform regularly?
A)Checking blood glucose levels
B)Monitoring capillary refill time
C)Assessing for neurological deficits
D)Evaluating dietary intake
A nurse is obtaining a health history from a child who has suspected acute rheumatic fever. Which of the following questions should the nurse ask?
A)"Has your son had a sore throat recently?"
B)"Has your child had any injuries recently?"
C)"Have you given your child aspirin in the past 2 weeks?"
D)"Was your son born with this cardiac defect?"
A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?
A)Different apical and radial pulses.
B)Differences in upper and lower lung sounds.
C)Different blood pressures in the upper limbs.
D)Differences between oral and axillary temperatures.

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A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication?
A)Improved sexual function
B)Prevention of bipolar manic episodes
C)Increase of HDL cholesterol
D)Decreased blood pressure
A nurse is assessing a client who has a heart rate of 56/min. Which of the following findings should the nurse expect?
A)History of cigarette smoking
B)Hypoglycemia
C)Report of dizziness
D)Temperature of 39° C (102.2° F).
A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.)(SATA)
A)Have the client remain in bed up to 6 hr.
B)Keep the client's hip and leg extended.
C)Check peripheral pulses in the affected extremity.
D)Measure the client's vital signs every 4 hr.
E)Place the client in high-Fowler's position.
A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?
A)The fourth heart sound (S4)
B)The third heart sound (S3)
C)A friction rub
D)A split-second heart sound S2

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