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A nurse is assessing a client who has pulmonary edema related to heart failure.
Which of the following findings indicates effective treatment of the client's
condition?
A. Absence of adventitious breath sounds
B. Presence of a nonproductive cough
C. Decrease in respiratory rate at rest
D. SaO2 86% on room air - CORRECT ANSWERS A. Absence of adventitious
breath sounds
Adventitious breath sounds occur when there is fluid in the lungs. the absence
of these sounds means the edema is resolving.
A nurse is caring for a client following insertion of a permanent pacemaker.
Which of the following client statements indicates a potential complication of
the insertion procedure?
A. "I can't get rid of these hiccups."
B. "I feel dizzy when I stand."
C. "My incision site stings."
D. "I have a headache." - CORRECT ANSWERS A. "I can't get rid of these
hiccups."
hiccups can indicate the pacemaker is stimulating the chest wall or diaphragm
A nurse is caring for a postoperative client 1 hr following an aortic aneurysm
repair. Which of the following findings can indicate shock and should be
reported to the provider?
A. Serosanguineous drainage on dressing
B. Severe pain with coughing
C. Urine output of 20 mL/hr
D. Increase in temperature from 36.8° C (98.2° F) to 37.5° C (99.5° F) - CORRECT
ANSWERS C. Urine output of 20 mL/hr
, urine output < 30 ml/hr is a manifestation of shock
A nurse is assessing a client who has dilated cardiomyopathy. Which of the
following findings should the nurse expect?
A. Dyspnea on exertion
B. Tracheal deviation
C. Pericardial rub
D. Weight loss - CORRECT ANSWERS A. Dyspnea on exertion
the nurse should identify this as an expected manifestation of dilated
cardiomyopathy. Dyspnea is due to ventricular compromise and reduced
cardiac output
A nurse is providing health teaching for a group of clients. Which of the
following clients is at risk for developing peripheral arterial disease?
A. A client who has hypothyroidism
B. A client who has diabetes mellitus
C. A client whose daily caloric intake consists of 25% fat
D. A client who consumes two 12-oz bottles of beer a day - CORRECT
ANSWERS B. A client who has diabetes mellitus
A nurse in an emergency department is caring for a client who has a blood
pressure of 254/139 mm Hg. The nurse recognizes that the client is in a
hypertensive crisis. Which of the following actions should the nurse take first?
A. Initiate seizure precautions
B. Tell the client to report vision changes
C. Elevate the head of the client's bed
D. Start a peripheral IV - CORRECT ANSWERS C. Elevate the head of the client's
bed
the greatest risk to the client is organ injury due to severe HTN. elevating the
clients HOB reduces blood pressure and promotes oxygenation
A nurse is assessing a client who has a history of deep-vein thrombosis and is
receiving warfarin. The nurse should identify that which of the following
findings indicates the medication is effective?
A. Hemoglobin 14 g/dL
B. Minimal bruising of extremities
C. Decreased blood pressure
D. INR 2.0 - CORRECT ANSWERS D. INR 2.0