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A nurse is providing discharge teaching for a client who has a prescription for
the transdermal nitroglycerin patch. Which of the following instructions should
the nurse include in the teaching?
-Apply the new patch to the same site as the previous patch
-Place the patch on an area of skin away from skin folds and joints
-Keep the patch on 24 hr per day
-Replace the patch at the onset of angina - ✔✔ANSWER✔✔>>Place the patch on
an area of skin away from skin folds and joints
A nurse in an emergency room is assessing a client who has a
bradydysrhythmia. Which of the following findings should the nurse monitor for?
-Confusion
-Friction rub
-Hypertension
-Dry skin - ✔✔ANSWER✔✔>>Confusion
Bradydysrhythmia can cause decreased systemic perfusion, which can lead to
confusion.
A nurse is admitting a client who has a leg ulcer and a history of diabetes
mellitus. The nurse should use which of the following focused assessments to
help differentiate between an arterial ulcer and a venous stasis ulcer?
-Explore the client's family history of peripheral vascular disease
-Note the presence or absence of pain at the ulcer site
-Inquire about the presence or absence of claudication
-Ask if the client has had a recent infection - ✔✔ANSWER✔✔>>Inquire about the
presence or absence of claudication
, Clients who have arterial ulcers experience claudication, but those who have
venous ulcers do not.
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?
-"I can't get rid of these hiccups."
-"I feel dizzy when I stand."
-"My incision site stings."
-"I have a headache." - ✔✔ANSWER✔✔>>"I can't get rid of these hiccups."
Hiccups can indicate that the pacemaker is stimulating the chest wall or
diaphragm, which can occur as a result of a lead wire perforation.
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?
-Absence of adventitious breath sounds
-Presence of a nonproductive cough
-Decrease in respiratory rate at rest
-SaO2 86% on room air - ✔✔ANSWER✔✔>>Absence of adventitious breath
sounds
Adventitious breath sounds occur when there is fluid in the lungs. The absence
of adventitious breath sounds indicates that the pulmonary edema is resolving.
A nurse is caring for a client who is receiving heparin therapy and develops
hematuria. Which of the following actions should the nurse take if the client's
aPTT is 96 seconds?
-Increase the heparin infusion flow rate by 2 mL/hr
-Continue to monitor the heparin infusion as prescribed
-Request a prothrombin time (PT)
-Stop the heparin infusion - ✔✔ANSWER✔✔>>Stop the heparin infusion.
The nurse should identify that the client's aPTT is above the critical value and
the client is displaying manifestations of bleeding. Therefore, the nurse should
discontinue the heparin infusion immediately and notify the provider to reduce
the risk of client injury.
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?