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The nurse is caring for a client who is diagnosed with mitral stenosis. The nurse
expects the client to exhibit which of the following clinical manifestations?
a. A considerably widened pulse pressure with a characteristic water hammer
(Corrigan's) pulse.
b. High-pitched, blowing, and diastolic murmur at the third intercostal space, left
sternal border.
c. Dyspnea on exertion (DOE) due to pulmonary venous hypertension.
d. Marked arterial pulsations visible and palpable at the carotid and temporal
areas. -ANSWERS-c. Dyspnea on exertion (DOE) due to pulmonary venous
hypertension.
The nurse is caring for a client who is diagnosed with pericarditis and reports
chest pain of 6 on a painscale of 0 (no pain) to 10 (severe pain). Which of the
following interventions should the nurse implement first?
a. Encourage the client to restrict activities until pain subsides.
b. Position the client in an upright chair leaning forward.
c. Administer analgesic or non-steroidal anti-inflammatory drug (NSAID).
,d. Reassure the client the pain is not due to a heart attack. -ANSWERS-b. Position
the client in an upright chair leaning forward.
The nurse is caring for a client who is diagnosed with sarcoidosis and is taking
long-term corticosteroids. Which of the following laboratory values is most
important for the nurse to report to theprimary health care provider (PHCP)?
a. Cholesterol < 200 mg/dL.
b. Hemoglobin (Hgb) 11.6 g/dL.
c. Platelet count 390 mm³.
d. Glucose 153 mg/dL. -ANSWERS-d. Glucose 153 mg/dL.
The nurse is caring for a client who is on heparin for a deep vein thrombosis (DVT)
and develops epistaxis. The nurse is unable to stop the bleed and notifies the
primary health care provider (PHCP). Which of the following prescriptions does
the nurse expect the PHCP to order?
a. Protamine sulfate.
b. Vitamin K.
c. Andexanet alfa.
d. Fondaparinux. -ANSWERS-a. Protamine sulfate.
The nurse is caring for a client who presents to the emergency department (ED)
for an exacerbation of chronic obstructive pulmonary disease (COPD). Which of
the following admission findings requires immediate follow-up by the nurse?
, a. The client fails to read the paperwork without reading glasses.
b. The client's chest is observed to symmetrically rise with each breath.
c. The client leans forward with hands on upper thighs during inspiration with
respirations of 26.
d. The client's blood pressure is 143/56 mm Hg and pulse is 92. -ANSWERS-c. The
client leans forward with hands on upper thighs during inspiration with
respirations of 26.
The nurse is caring for a client who was admitted to the emergency department
(ED) with reports of substernal chest pain. Twenty-four hours after presentation,
the client's laboratory results demonstratenormal levels of creatine kinase
isoenzymes. Which of the following actions should the nurse take next?
a. Administer nitroglycerin to prevent further myocardial cell death.
b. Assess the client to identify another potential cause of the chest pain.
c. Notify the client's next-of-kin of impending cardiac surgery.
d. Provide client education related to complications of myocardial infarction (MI).
-ANSWERS-b. Assess the client to identify another potential cause of the chest
pain.
The nurse is caring for a client with right ventricular hypertrophy resulting in
decreased right ventricular function. Which of the following disorders may have
contributed to this client's diagnosis?