NUR 2502 / NUR2502 Final Exam Multidimensional Care III / MDC 3 - Rasmussen

NUR 2502 / NUR2502 Final Exam Multidimensional Care III / MDC 3 - Rasmussen 1. A nurse is performing discharge teaching for a client who was recently diagnosed with heart failure. Which of the following should be included in the client and family teaching? (Select all that apply) A. Low sodium diet B. Weekly weights (it has to be daily) C. Symptoms to report to the provider D. Medication teaching E. Fluid restriction 2. Which of the following assessment findings is a priority during blood transfusion? A. Chest pain B. Fatigue C. Joint pain D. Headache 3. The nurse is caring for a client with mitral regurgitation. Which of the following would the nurse anticipate the client to develop if left untreated? A. Left-sided heart failure B. Right-sided heart failure C. Renal failure D. Myocardial ischemia 4. Which of the following procedures are performed for a client with a pericardial effusion? A. Thoracotomy B. Pericardiocentesis C. Coronary artery bypass graft D. Thoracentesis 5. Which of the following medications are appropriate for the treatment of heart failure? (Select all that apply) A. Digoxin B. Bronchodilators C. Antibiotics D. Diuretics E. Angiotensin-converting enzyme (ACE) inhibitors 6. A hospitalized client has a platelet count of 58,000/mm3 (58 x 109/L). What action by the nurse is best? A. Implement fall precautions. B. Encourage high-protein foods. C. Limit visitors to healthy adults. D. Institute neutropenic precautions. 7. Which of the following assessment findings are consistent with aortic stenosis? A. Systolic clickB. Pitting edema C. Harsh systolic crescendo decrescendo murmurD. Atrial fibrillation 8. 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 the priority in the client’s care? A. Ineffective peripheral tissue perfusion B. Alteration in body image C. Impaired skin integrity D. Alteration in activity tolerance 9. A client is receiving treatment for the diagnosis of hemophilia A. which of the following is the most appropriate to include in the assessment of this client? A. Cranial nerves B. Appetite C. Joint pain and bruising D. Urine output 10. Which of the following is a treatment option for a client with infective endocarditis? A. Bedrest B. Antimicrobials C. Diet modification D. Antihypertensive 11. A client admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best? A. “Both you and the father are equally responsible for passing it on.” B. “There are many good treatments for sickle cell disease these days.” C. “It’s not your fault; there is no way to know who will have this disease.” D. “It’s understandable that you are upset about this news. Would you like to talk about what you’re feeling?” 12. A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client should the nurse see first? A. A client with a swollen and painful left great toe B. Client who reports dyspnea C. Client with a blood pressure of 180/98 mm Hg D. Client who reports calf tenderness and swelling 13. A nurse reviews the arterial blood gas (ABG) values of a client admitted with end-stage kidney disease; PH 7.26; PaCO2 37 mm Hg ; PaO2 94 mm Hg and HCO3 15 mEq/L. what do these values indicate? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis 14. Which of the following interventions should be included in the nutrition care plan of the client with atherosclerosis?A. Limit sodium intake to 6 g per day B. Increase full-fat dairy products C. Increase saturated fats D. Increase daily intake of vegetables, fruits, and whole grains 15. Which of the following clients is most at risk for developing endocarditis? A. A client who recently had a valve replacement and had dental work recently performed B. A client who recently underwent a valve replacement C. A client with Marfan’s syndrome D. A client recently diagnosed with mitral stenosis 16. The nurse is caring for a client who presented to the emergency department with pulmonary edema. The client is hypotensive with a pulse oximeter reading of 85% on room air. Which of the following is a nursing priority? A. Administer IV fluids B. Obtain a chest x-ray C. Administer diuretics D. Administer oxygen 17. A 65-year-old male client is brought via EMS to the emergency department with chest pain. He rates the pain as a “10” on a scale from 0-10; the pain is located mid-sternum and radiates to his left arm. His heart rate is 126 beats/minute and blood pressure are 96/60 mm Hg. A 12-lead electrocardiogram is performed and reveals ST-segment elevation. Which of the following interventions does the nurse anticipate performing immediately? (Select all that apply.) A. Administer oxygen B. Administer morphine C. Administer a statin D. Administer a beta-blocker E. Administer nitroglycerin 18. A nurse is caring for a client who has recently diagnosed with left ventricular heart failure. What is an early sign the client is most likely to report? A. Dyspnea on exertion B. Abdominal distention C. Swollen legs D. Weight gain 19. Which of the following is the surgical treatment of choice for end-stage heart failure? A. Cardiac resynchronization therapy (CRT) B. Percutaneous angiogram C. Genetic counseling D. Ventricular assist devices (VADs) 20. A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first? A. Client who had two bloody diarrhea stools this morningB. Client who has been premedicated for nausea prior to chemotherapy C. Client who is crying and feeling lonely D. Client with an unchanged lesion to the lower right lateral malleolus 21. A nurse is caring for a client diagnosed with peripheral artery disease. Which of the following is a common assessment finding? A. 4+ pedal pulses B. 3+ pedal pulses C. Bounding pulses in all 4 extremities D. 1+ pedal pulses 3+, Increased, full, bounding 2+, Normal 1+, Weak 0, Absent 22. A nurse is caring for a client diagnosed with polycythemia vera. Which of the following should the nurse include in the client and family education? A. Resume normal activity B. Wear support hose while awake C. Decrease fluid intake to no more than 1 liter per day D. Diet high in vitamin K intake 23. A nurse is caring for a client who recently underwent a heart transplant. Which of the following postoperative nursing interventions is the priority? A. Maintain strict bedrest B. Advance diet as tolerated C. Educated the client on medication D. Ensure strict adherence to aseptic techniques 24. Which of the following is the most common assessment finding related to autoimmune thrombocytopenic purpura? A. A reddish-purple fine petechial rash B. Confusion in the elderly C. Fever greater than 102.0 degrees F D. Extreme fatigue 25. A 75-year-old female presented to the emergency department with shortness of breath. The client’s daughter is at the bedside and shares that the client has a history of heart failure. The nurse places the client on the cardiac monitor and finds that the client is in atrial fibrillation at a rate of 180 beats per minute. Which is a likely finding? A. Bounding pulses B. Lethargy C. Hypotension D. Edema26. The nurse is caring for a 65-year-old female who presented to the emergency department with shortness of breath and chest discomfort. The client has not been feeling well for the past few days and complains of a productive cough of blood-tinged sputum. Laboratory tests reveal an elevated brain natriuretic peptide (BNP), and chest x-ray reveals pulmonary congestion. Based on the assessment findings, which of the following diagnosis are consistent with these findings? A. Heart failure (left-sided) B. Lung cancer C. Heart failure (right-sided) D. Pulmonary embolism 27. The nurse is providing care to a client with pericarditis. If left untreated, which of the following is the client at risk of developing? A. Pneumonia B. Pulmonary embolism C. Deep vein thrombosis D. Cardiac tamponade 28. A male client is presenting with radiating chest pain. Which of the following would the nurse recognize as indicators that an acute myocardial infarction may be occurring? (Select all that apply.) A. Positive troponin markers B. ST elevation on EKG on two contiguous leads C. Pain relieved with rest D. Diaphoresis E. Pain radiating in jaw, back, shoulder, or abdomen 29. The nurse is caring for a client who was recently diagnosed with hemophilia. Which of the following laboratory tests is consistent with that diagnosis? A. Prolonged activated partial thromboplastin time (with normal PT) B. Prolonged prothrombin time C. Decreased platelet count D. Decreased bleeding time 30. The nurse educates the client that besides an echocardiogram, which of the following tests is the best tool for diagnosing heart failure? A. Pulmonary artery catheter B. Multigated angiographic (MUGA) scan C. B-type natriuretic peptide (BNP) D. Radionuclide studies 31. The nurse is working in the emergency department and has four clients arrive at the same time. Which client should the nurse see first? A. A client requesting antibiotics for a cough B. A client who has a facial fracture with severe facial and oral swelling C. A client who states she has not urinated in 8 hours D. A client with a history of chronic obstructive pulmonary disease reporting increased dyspnea32. The nurse is discharging home a client at risk for venous thromboembolism on enoxaparin sodium. What instruction is a priority for the nurse to provide to this client? A. “Notify your health care provider if your stools appear dark or tarry.” B. “You must have your prothrombin time (PT)/international normalized ratio (INR) checked every 2 weeks.” C. “Massage the injection site after the heparin is injected.” D. “You must have your activated partial thromboplastin time (aPTT) checked every 72 hours.” 33. A nurse is caring for a client who presented to the emergency department with complaints of fatigue, palpitations, and chest pains. Upon assessment, the provider notes an s3 and s4 gallop, weak peripheral pulses, and tachycardia. The provider orders a chest x-ray and echocardiogram, which reveals left ventricular dilation. Which of the following disorder is consistent with these findings? A. Cardiac tamponade B. Dilated cardiomyopathy C. Pericarditis D. Restrictive cardiomyopathy 34. Which of the following would predispose a client to mitral stenosis? A. Obesity B. Rheumatic fever C. Intravenous drug use D. Diabetes 35. The nurse is arriving at the beginning of her shift and has taken report on four clients on a medical surgical unit. Which client should the nurse see first? A. A client with pain that is two days post-operative from a prostatectomy B. A client ready for discharge education after treatment of an acute kidney injury C. A client with hypertension with a blood pressure of 172/92mm Hg D. A client with a history of asthma complaining of increased dyspnea 36. The nurse assesses a client and documents the following findings: “edema 2+ bilateral ankles, brown pigmentation of lower extremity skin, aching pain of lower extremities when standing that resolves with elevation, and 2+ pedal pulses.” What condition does the client likely have? A. Deep vein thrombosis B. Raynaud’s disease C. Venous insufficiency D. Peripheral arterial disease 37. A nurse sets an infusion pump to infuse 1 L of DSNS at the rate of 100 mL/hr. How many hours will it take to complete the infusion? hours. (Record answer as a whole number. Do not use a trailing zero. Answer numerically, do not label.) 1000ml divided by 100 = 10 hours 1038. A client suffering from a narcotic overdose is seen in the Emergency Department. The client is confused, with warm, flushed skin, headache, and weakness. Vital signs of noted are temperature 102.6 F, heart rate 128 beats/minute, respirations 24 breaths/minute, and blood pressure 130/86 mm Hg. A blood gas analysis sample was drawn on room air, and the results are as follows: Ph 7.33 PaCO2 53 mm Hg, PaO2 72 mm Hg. HCO3 24 mEq/L. this client is at risk for which of the following? A. Metabolic alkalosis B. Respiratory alkalosis C. Respiratory acidosis D. Metabolic acidosis 39. The family of a neutropenic client reports that the client is confused and “is not acting right.” What action by the nurse is the priority? A. Delegate taking a set of vital signs. B. Ask the client about pain. C. Look at today’s laboratory results D. Assess the client for a urinary tract infection 40. A nurse is caring for a client recently diagnosed with leukemia. Which of the following signs and symptoms are consistent with this diagnosis? (Select all that apply.) A. Bone pain B. Bleeding gums C. Weight gain D. Bruising E. Increased urination 41. A female client is being treated for a deep-vein thrombus she developed post-operatively about one week ago and was treated with unfractionated heparin. Today she presents to the clinic with petechiae on bilateral hands and feet. Laboratory results show a platelet count of 42,000/mm3 (42x109/L). the nurse is concerned about a drug reaction and anticipates the client has which of the following? A. Heparin-induced thrombocytopenia (HIT) B. Hemophilia A (classic hemophilia) C. Thrombotic thrombocytopenic purpura (TTP) D. Sickle cell crisis 42. A nurse is caring for a client with a history of an abdominal aortic aneurism. Which of the following assessment findings requires immediate intervention? A. Back pain B. Absent peripheral pulses C. Decreased urine output D. Nausea and vomiting 43. The client is admitted for heart failure and has edema, neck vein distension, and ascites. What is the most accurate way to monitor fluid gain or loss in this client? A. Auscultate the lungs for crackles or wheezing. B. Weigh the client daily at the same time with the same scale.C. Check for pitting edema in the dependent body parts. D. Asses skin turgor and the condition of mucus membranes. 44. A client states that their legs have pain with walking that decreases with rest. The nurse observes absence of hair on the client’s lower extremities and the client has a thread, weakened posterior tibial pulse. What would be the best position to have the client’s legs? A. Elevated above the heart B. Slightly bent with three pillows under the knees. C. Crossed at the knee D. Hanging down. 45. A nurse is caring for a client diagnosed with atherosclerosis. Which of the following is considered a risk factor for the development of this disorder? A. Diet high in vitamin K B. Low HDL-C/High LDL-C C. High HDL-C/Low LDL-C D. Vegan diet. 46. The nurse is assessing a client with severe anemia. Which clinical manifestation does the nurse expect to see in this client? A. Bradycardia B. Hypertension C. Pale, cool skin D. Warm, flushed skin. 47. A nurse is caring for a 19-year-old male recently diagnosed with leukemia. Which of the following nursing interventions is appropriate for the care of this client? A. Fluid restriction B. Low residual diet C. Therapeutic phlebotomy D. Strict hand hygiene to prevent infection 48. Which of the following clients would not be a candidate for thrombolytic therapy? A. Client with a pulse of 102 beats/minute B. Client with a blood pressure of 100/60 mm Hg C. Client with a history of hemorrhagic stroke one month ago D. Client age 65 years. 49. A nurse is caring for a client who was received in the emergency department with a heart rate of 220 beats per minute. The client’s cardiac monitor displays supraventricular tachycardia (SVT). Which of the following interventions should the nurse anticipate? A. Apply compression stockings B. Perform Valsalva maneuver (Vagal maneuvers) C. Draw labs D. Check blood glucose.50. The nurse Questions which order for a client with thrombocytopenia? A. Apply ice to areas of trauma B. Administer intramuscular (IM) medication C. Test all urine and stool for the presence of occult blood D. Avoid enemas 51. Which of the following is a possible treatment plan for a client diagnosed with leukemia? A. Dialysis B. Therapeutic phlebotomy C. Splenectomy D. Stem cell transplant 52. A 65-year-old female presented to the emergency room with complaint of progressively worsening fatigue, shortness of breath, and palpitations. Upon assessment, heart rate is 130 beats per minute and irregular, and there is positive jugular vein distention. Heart tones reveal a high- pitched holosystolic murmur. Which of the following disorders are consistent with these findings? A. Mitral regurgitation B. Mitral stenosis C. Mitral valve prolapse D. Aortic regurgitation 53. A nurse is caring for a client recently diagnosed with hypertension. Which of the following should be included in the discharge teaching? A. Decrease physical activity to avoid spikes in blood pressure B. Diet changes are not recommended C. Only check blood pressure at a clinic or pharmacy D. Adherence to sodium restrictions 54. A nurse is caring for a client recently diagnosed with pericarditis. Which of the following is a common assessment finding with this disorder? A. Elevated troponin B. Pericardial friction rub C. Heart failure D. ST-segment depression 55. A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan? A. Yogurt B. Leafy green vegetables C. Oranges D. Cashews 56. Which of the following is the priority nursing intervention for a client experiencing a transfusion reaction? A. Stop transfusion immediately B. Check vital signs C. Notify the providerD. Flush the intravenous line. 57. The nurse knows which of the following is the most common problem for a client with valvular heart disease? A. Altered body image B. Difficulty coping C. Bradycardia D. Decreased cardiac output 58. A nurse is caring for a 65-year-old male who recently underwent an aortic valve replacement. Which of the following is a post-operative nursing care priority? A. Temperature monitoring B. Assess for bleeding C. Advance diet as tolerated D. Dressing change 59. When educating a female client on the signs and symptoms of myocardial infarction, the nurse recognizes which of the following should be included in the teaching? A. Pain usually resolves with rest and relaxation B. Older adults and women often present with atypical signs and symptoms C. Women experience intermittent claudication D. Substernal chest pain is the most common symptom in women 60. Which of the following medication are utilized to treat peripheral artery disease (PAD)? A. Antiplatelet drugs B. Diuretics C. Antibiotics D. Nitroglycerin 61. The nurse knows that hemolytic to blood transfusions occur most often when the first milliliters of the infusion. A. 125 B. 50 C. 100 D. 75 62. Which of the following is a treatment option for a client with sickle cell disease? A. NPO diet B. Blood product administration C. Pain management with nonsteroidal anti-inflammatory drugs (NSAIDs) only D. Arthrocentesis 63. A nurse is providing discharge teaching to a client who recently underwent a mechanical valve replacement. Which of the following statements by the client indicates the clients correct understanding of the discharge teaching regarding warfarin anticoagulant therapy? A. “I may need to modify my diet while on this medication.”B. “I do not need to take my prescribed medication for the rest of my life.” C. “Additional monitoring is not required while on the anticoagulant.” D. “I can lead a normal life while on anticoagulants; no restrictions are required.” 64. A nurse is caring for a client who has heart failure and a prescription for digoxin 125mcg PO daily. Available is digoxin PO 0.25mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth, or one decimal place. Use a leading zero if it applies. Do not use a trailing zero. Answer numerically only, do not label.) 0.5 65. The nurse receives an order to infuse heparin 1200 units/hr IV. The IV bag contains 25.000 units heparin in 500ml DSW. Calculate the IV rate in Ml/hr. (Record answer as a whole number. Do not include trailing zero. Answer numerically, do not label.) 24 66. The nurse is caring for a 55-year-old male who presented to this primary physician’s office for his yearly check-up. Upon the physical assessment, the provider noted enlarged lymph nodes in the groin and neck region. The provider Questioned Joe regarding the possible causes of the finding. Which of the following diagnosis are consistent with this finding? A. Leukemia B. Lymphoma C. Sickle cell anemia D. Polycythemia vera 67. A client diagnosed with stable angina is complaining of substernal chest pain, rating the pain 5 out of 10. What would be the priority action by the nurse? A. Administer the client’s prescribed beta-blocker B. Administer nitroglycerin intravenously immediately C. Administer morphine D. Administer 325 mg of chewable aspirin immediately 68. Which of the following is a priority nursing intervention for a client in atrial fibrillation with a rate of 180 beats per minute? A. Apply compression stockings B. Administer medications to slow the rate C. Administer anticoagulants D. Monitor urine output 69. Which of the following nursing interventions would be appropriate for a client with sickle cell disease? (Select all that apply.) (hydration, oxygen, pain medicine - opioid) HOP A. Prepare the client for surgery B. Encourage fluid intake C. Provide a warm environment D. Keep the client strictly NPO E. Administer intravenous morphine 70. The nurse is caring for four clients on a post-surgical unit. The nurse understands that monitoring the client for which posts-operative complication takes priority?A. Nausea B. Constipation C. Pneumonia D. Urinary retention 71. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication? A. “I’ve had a backache for several days.” B. “I feel nauseated and have no appetite.” C. “I can walk a mile a day.” D. “I am urinating more frequently.” 72. Which of the following is a pharmacologic treatment option for a client with dilated cardiomyopathy? (Select all that apply.) A. Phentermine B. Digoxin C. Anticholinergic D. Sodium tablets E. Diuretics 73. The nurse is arriving at the beginning of her shift and has taken report on four clients on a medical surgical unit. Which client should the nurse see first? A. A Client with pyelonephritis with nausea and vomiting B. A client with chronic obstructive pulmonary disease with an oxygen saturation of 90% on room air C. A client post vaginoplasty with bright red blood and clots in her catheter D. A client post-total abdominal hysterectomy with 9/10 pain. 74. The nurse is reviewing laboratory values for a client. Which of the following lab values should the nurse address immediately? A. Potassium 5.9 mmol/L B. Phosphorus 5.1 mg/Dl C. Creatinine 6.2 mg/Dl D. Sodium 147 mEq/L 75. During hourly rounding the nurse enters a room where the client is unresponsive without pulse. What is the nurse’s priority action? A. Begin ventilation at 1 breath every 6.8 seconds B. Start chest compressions at a rate of 100-120 compressions per minute C. Wait for the emergency response team for direction D. Call the family 3. The nurse is assessing a client with severe anemia. Which clinical manifestation does the nurse expect to see in this client? a. Dyspnea with activity b. Hypertensionc. Bradycardia d. Warm, flushed skin 10. The nurse questions which order for a client with thrombocytopenia a. Avoid IM injection b. Administer enemas c. Apply ice to areas of trauma d. Test all urine and stool for the presence of occult blood. 13. Which of the following is the treatment of choice for end-stage heart failure a. Heart transplant b. Coronary artery bypass c. Percutaneous angiogram d. Medications 14. A nurse is caring for a client who recently underwent a heart transplant. which of the following nursing interventions is the priority? a. Assess for signs and symptoms of rejection b. Advance diet as tolerated c. Auscultate bowel sounds d. Maintain strict bedrest 27. The nurse educates the client on which of the following tests as the best tool for diagnosis heart failure. a. echocardiography b. Pulmonary artery catheter c. Radionuclide studies d. Multigated angiographic ( MUGA) scan 28. A nurse is caring for a client with leukemia. Which of the following sign and symptoms are consistent with this diagnosis? ( select all that apply) a. Bleeding gums b. Bone pain c. Weight gain d. Increased urination e. Fatigue 35. A 78 year old female presented to the emergency department with shortness of breath. Her daughter is at the bedside and shares that the client has a history of heart failure. You place the client on the cardiac monitor and find that the client is in atrial fibrillation at a rate of 180 beats per minute. Which of the following are you concerns regarding this rhythm? ( select all that apply) a. Potential for embolic event b. Hypotension due to elevated heart rate c. Worsening heart failure d. Dizziness and light-headness e. Cerebral edema48. Which of the following assessment findings is consistent with mitral valve prolapse. a. Systolic click b. Urinary frequency c. Atrial fibrillation d. Claudication 57. A client states that their legs have pain with walking that decreases with rest. The nurse observes absence of hair on the client’s lower extremities and the client has a thready, walker posterior tibial pulse. What should be the best position to have the client’s legs? a. Elevated on pillows b. Crossed at the knee c. Slightly bent with a pillow under the knees d. Dependent position 58. A nurse is caring for a client recently diagnosed with hypertension. Which of the following should be included in the discharge teaching? a. Only check your blood pressure at a clinic or pharmacy b. Diet changes are not recommended c. Decrease physical activity to avoid spikes in blood pressure d. Adhere to prescribed medications 60. Which of the following is a treatment option for a client with sickle cell disease a. Pain management with NSaids only b. Arthrocentesis c. NPO diet d. IV fluid bolus 62. Which of the following is a common early assessment finding consistent with a diagnosis of hereditary hemochromatosis a. Flank pain b. Fever c. Hypoglycemia d. Liver dysfunction 66. Which of the following is the most common assessment related to autoimmune thrombocytopenic purpura a. Bruising b. Fatigue c. Confusion d. Fever 67. A male client is presenting with radiating chest pain. Which of the following would the nurse recognize as indicators that an acute myocardial infarction may be occurring? ( select all that apply) a. Positioning troponin markers b. ST-elevation on EKG on two contiguous leadsc. History of atherosclerosis d. Pain radiating in jaw,back,shoulder or abdomen. e. Pain relieved with rest. 69. A nurse is caring for a client who was recently diagnosed with left ventricular heart failure. what is an early sign the client is most likely to report? a. Abdominal distention b. Weight gain c. Swollen legs d. Nocturnal coughing From 1 to 18, just 13 the lab in the exam was not sodium, it was magnesium that was out of range. 1. A nurse is caring for a client with an elevated cardiac output, fatigue, shortness of breath, and a high fever caused by septicemia. Which diagnosis is consistent with these findings? a. Heart failure (right-sided) b. High output heart failure c. Pulmonary embolism d. Heart failure (left-sided) 2. Which assessment finding is associated with an abdominal aortic aneurism rupture? a. Hypertension b. Abdominal distention c. Difficulty swallowing d. Chest pain 3. A client is undergoing chimeric antigen receptor (car) t-cell therapy treatment for Non-Hodgkins lymphoma. The nurse assessment findings indicates the client has petechia and bleeding. Which acute side effect of this therapy is associated with these clinical manifestations a. Hemolytic anemia b. Pancytopenia c. Neutropenia d. Polycythemia vera 4. While performing an admission assessment for a client, the nurse notes the client has distended protruding veins that appear dark and tortuous with some mild edema to the ankle. Which is associated with these clinical manifestations? a. Thrombophlebitis b. Phlebothrombosis c. Varicose veins d. Venous thromboembolism (VTE) 5. The nurse is caring for four clients in a post-surgical unit. Which client should the nurse assess first. a. A client who needs pain medication prior to a dressing change of a surgical wound b. A hypertensive client with a blood pressure of 180/90 mm Hg c. A client who needs to use the bathroom 1 hour after receiving their first dose of captopril d. A client who needs a beta blocker, and has a blood pressure of 100/60 mm Hg6. A nurse is caring for a 65-year-old client brought to the emergency room with chest pain the client rates the pain at a 10 that radiates down the left arm. After receiving sublingual nitroglycerin, the client complains of feeling lightheaded and dizziness. Which nursing intervention are appropriate? (Select all that apply) a. Instruct the client to lie down b. Check the medications expiration date c. Maintain the clients airway d. Monitor blood pressure e. Assess for ringing in the ears 7. A nurse is caring for a post-operative heart transplant client. Which nursing intervention is the priority in the poste-operative phase? a. Assess the client’s pain b. Auscultate for cardiac dysrhythmias c. Educate the client on rejection symptoms d. Collaborate with physical therapy 8. Which assessment finding is associated with acute pericarditis a. Thickening of the pericardium is seen on echocardiography b. New ST-Elevation in all of the electrocardiogram (ECG) leads c. Elevated systemic venous pressure with jugular distention d. PR segment elevation on the 12-lead electrocardiogram (ECG) 9. An immunocompromised older adult client had recent dental work performed 2 weeks ago. The client present to the clinic with a fever of 102.0 Fahrenheit (38.9 Celsius), night sweats, malaise, and a newly developed cardiac murmur. Which of the following is associated with these clinical manifestations? a. Cardiomyopathy b. Pericarditis c. Rheumatic carditis d. Infective endocarditis 10. Which diagnostic test determines ejection fraction, cardiovascular valvular changes, pericardial effusion, chamber enlargement, ventricular hypertrophy and is the best tool when diagnosing heart failure? a. Echocardiogram b. Chest X-ray c. Radionuclide studies d. Multigated angiographic (MUGA) scan 11. A nurse is caring for a 70-year-old client in the emergency room with dyspnea, anginal pain and syncope upon exertion. The nursing assessment reveals a harsh systolic crescendo-decrescendo murmur. Which cardiovascular disorder is associated with these findings? a. Aortic stenosis b. Aortic regurgitation c. Mitral stenosis d. Mitral regurgitation 12. Which of the following would predispose a client to mitral valve prolapse? a. Intravenous drug abuse b. Marfan syndrome c. Diabetesd. Rheumatic fever 13. The nurse is reviewing laboratory values for a client. Which of the following lab values should the nurse address immediately? a. Magnesium 3.0 mEq/L b. Potassium 4.7 mmol/L c. Calcium 9.0 mg/dL d. Sodium 152 mEq/L 14. A nurse is caring for a client diagnosed with polycythemia vera. Which of the following should the nurse include in the client and family education. a. Take anticoagulants as prescribed b. Encourage fluid restriction to 1 liter per day c. Brush and floss teeth twice a day d. Exercise moderately for 40 minutes 4 times a week 15. Which clinical manifestation is associated with mitral valve stenosis? a. Blowing, decrescendo diastolic murmur b. High-pitched holosytolic murmur c. Harsh, systolic crescendo decrescendo murmur d. Rumbling, apical diastolic murmur 16. A nurse is caring for a client with right side heart failure. Which is associated with this diagnosis? a. Confusion b. Oliguria c. Breathlessness d. Hepatomegaly 17. A client with unstable angina is complaining of chest pain rated 8 out of 10, that is not relieved by rest. After obtaining a 12-lead electrocardiogram (ECG), applying 2 liters of oxygen via nasal cannula, and obtaining intravenous access, what nursing action is the nurses next priority? a. Administer sublingual nitroglycerine b. Reevaluate the clients pain level c. Position the client in semi-fowlers d. Review the clients medical history 18. A nurse is providing warfarin anticoagulant therapy discharge teaching for a client with a mechanical valve replacement. Which client statement indicates understanding of the teaching? a. I can lead a normal life while on this medication no restrictions. b. The therapeutic goal of my international normalized ratio (INR) is 2.0 and 3.0. c. Lifelong therapy is required with frequent international ratio (INR) monitoring d. Additional monitoring is not required while on this medication