A 68-year-old client on day 2 after hip 1
surgery has no cardiac history but
reports having chest heaviness. The first
nursing action should be to:
1. Inquire about the onset, duration,
severity, and precipitating factors of the
heaviness.
2. Administer oxygen via nasal cannula.
3. Offer pain medication for the chest
heaviness.
4. Inform the physician of the chest
heaviness.
,. A client is scheduled to have an 2
arteriogram. During the arteriogram, the
client
reports having nausea, tingling, and
dyspnea. The nurse's immediate action
should be
to:
1. Administer epinephrine.
2. Inform the physician.
3. Administer oxygen.
4. Inform the client that the procedure is
almost over.
,. A client with heart failure has bilateral +4 1
edema of the right ankle that extends
up to midcalf. The client is sitting in a chair
with the legs in a dependent position.
Which of the following goals is the
priority?
1. Decrease venous congestion.
2. Maintain normal respirations.
3. Maintain body temperature.
4. Prevent injury to lower extremities.
, After a myocardial infarction, the 3
hospitalized client is taught to move the
legs
while resting in bed. The expected
outcome of this exercise is to:
1. Prepare the client for ambulation.
2. Promote urinary and intestinal
elimination.
3. Prevent thrombophlebitis and blood
clot formation.
4. Decrease the likelihood of pressure
ulcer formation.
After the administration of t-PA, the 1
nurse should:
1. Observe the client for chest pain.
2. Monitor for fever.
3. Review the 12-lead electrocardiogram
(ECG).
4. Auscultate breath sounds.
surgery has no cardiac history but
reports having chest heaviness. The first
nursing action should be to:
1. Inquire about the onset, duration,
severity, and precipitating factors of the
heaviness.
2. Administer oxygen via nasal cannula.
3. Offer pain medication for the chest
heaviness.
4. Inform the physician of the chest
heaviness.
,. A client is scheduled to have an 2
arteriogram. During the arteriogram, the
client
reports having nausea, tingling, and
dyspnea. The nurse's immediate action
should be
to:
1. Administer epinephrine.
2. Inform the physician.
3. Administer oxygen.
4. Inform the client that the procedure is
almost over.
,. A client with heart failure has bilateral +4 1
edema of the right ankle that extends
up to midcalf. The client is sitting in a chair
with the legs in a dependent position.
Which of the following goals is the
priority?
1. Decrease venous congestion.
2. Maintain normal respirations.
3. Maintain body temperature.
4. Prevent injury to lower extremities.
, After a myocardial infarction, the 3
hospitalized client is taught to move the
legs
while resting in bed. The expected
outcome of this exercise is to:
1. Prepare the client for ambulation.
2. Promote urinary and intestinal
elimination.
3. Prevent thrombophlebitis and blood
clot formation.
4. Decrease the likelihood of pressure
ulcer formation.
After the administration of t-PA, the 1
nurse should:
1. Observe the client for chest pain.
2. Monitor for fever.
3. Review the 12-lead electrocardiogram
(ECG).
4. Auscultate breath sounds.
