Perfusion

The client is admitted to the telemetry unit diagnosed with left-sided heart failure. Which clinical manifestations would the nurse expect to find when assessing this client?

• Apical pulse rate of 110 and crackles on auscultation.

• Jugular vein distention and 4+ pitting edema of feet.

• The client sleeping with no pillow and eupnea.

• Radial pulse rate of 90 and CRT less than 3 seconds.

The nurse is developing a nursing care plan for a client diagnosed with left-sided heart failure. A nursing diagnosis of “decreased cardiac output related to the inability of the heart to pump effectively” is written. Which short-term goal would be best for the client?

• The client will be able to ambulate in the hall by date of discharge.

• The client will have an audible S1 and S2 with no S3 heard by the end of shift.

• The client will turn, cough, and deep breathe every 2 hours.

• The client will have a Sao2 reading of 98% by day 2 of care.

The nurse enters the client’s room and notes an unconscious client with an absence of respirations and no pulse or blood pressure. The concept of perfusion is identified by the nurse. Which should the nurse implement first?

• Notify the HCP.

• Call a rapid response team (RRT).

• Determine the telemetry monitor reading.

• Activate the code blue system.

The nurse is caring for a client diagnosed with CAD. Which should the nurse teach the client about their nitroglycerin before discharge? Select all that apply.

• Carry your nitroglycerin tablets in a brown bottle.

• Swallow a nitroglycerin tablet at the first sign of angina.

• If one nitroglycerin tablet does not work in 10 minutes, take another.

• Nitroglycerin tablets have a fruity odor if they are potent.

• Replace your nitroglycerin tablets after 6 months.

The telemetry monitor tech notifies the nurse of the strip shown here. Which should the RN implement first?

• Instruct the UAP (unlicensed assistive personnel) to check the client.

• Go to the client’s room and assess the client personally.

• Have the monitor tech check the client using a different lead.

• Call for the code blue team and perform CPR.

The client comes to the emergency department, saying, “I am having a heart attack.” Which question is a priority when assessing the client?

• “Can you describe your chest pain?”

• “What were you doing when the pain started?”

• “Did you have a high-fat meal today?”

• “Does the pain get worse when you lie down?”

The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first?

• Administer amiodarone IVP.

• Prepare to defibrillate the client.

• Assess the client’s apical pulse and blood pressure.

• Start basic CPR.

The nurse identifies the concept of clotting for a client diagnosed with a DVT. Which clinical manifestations support the diagnosis?

• Brown-purple discoloration on the calf.

• Bright red skin on the lower legs.

• Swelling in the calf, warmth, and tenderness.

• Pain after walking for short distances that resolve with rest.

The client diagnosed with a DVT is prescribed heparin via continuous infusion. The client’s laboratory data are listed in the table. Based on the laboratory results, which intervention should the nurse implement?

• Request a change of medication to a subcutaneous anticoagulant.

• Administer vitamin K IM.

• Have the dietary department remove all green, leafy vegetables from the trays.

• Administer the IV as ordered.

The nurse is planning care for a client diagnosed with peripheral arterial disease. Which exercise instructions would the nurse teach the client?

• Have the client perform isometric exercises 30 minutes each day.

• Tell the client to start exercising on a stair stepper for 15 minutes.

• Inform the client that warm-up exercises are not necessary.

• Teach the client to walk in well-fitting shoes on level ground.