COMPLETE STUDY NOTES AND EXAM REVIEW
A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins.
Which of the following actions should the nurse take? - (answers)Position the client supine with his legs
elevated when in bed.
Rationale: Elevating legs about the heart helps to promote venous return by gravity. ; Ambulate 5-10 min
every hour while awake ; discourage sitting or standing for a long duration ; wear graduated compression
stockings for up to 1 week after surgery.
A nurse is caring for a client who has heart failure and whose telemetry reading displays a flattening of
the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this
ECG change? - (answers)Potassium 2.8 mEq/L
Rationale: flattened T-wave indicates a low potassium level
A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh frozen plasma
(FFP). Which of the following laboratory results should the nurse review? - (answers)Prothrombin Time
Rationale: plasma rich in clotting factors. It is administered to treat acute clotting disorders. The desired
effect is a decrease in the prothrombin time.
A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which
of the following information should the nurse include in the teaching? - (answers)Hypertension is a
common adverse effect of this medication.
Rationale: Due to the rise in production of erythrocytes and other blood cell types. Used to treat anemia
associated with kidney disease or medication therapy.
, A nurse is completing an assessment for a client who has a history of unstable angina. Which of the
following findings should the nurse expect? - (answers)Chest pain lasts longer than 15 min
A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the
following manifestations should the nurse expect? (Select all that apply.) - (answers)JVD
Moist crackles
Increased HR
Rationale: excessive pressure causes all of the these. Fever occurs with dehydration. Hypertension and
tachycardia are also signs of fluid volume overload.
A nurse is monitoring a client who had a myocardial infarction. For which of the following complications
should the nurse monitor in the first 24 hrs? - (answers)Ventricular dysrhythmias
Rationale: After an MI, the conduction system is typically irritable and prone to dysrhythmias due to
most likely ischemic tissue. ; Pericarditis can occur 10 days to 2 months after an MI due to an infection,
tissue disorder, or trauma. ; Pulmonary emboli only occurs is HF follows an MI but more commonly with
valvular disorders, atrial fibrillation, or a DVT
A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following
ECG abnormalities should the nurse recognize as atrial flutter? - (answers)Atrial rate of 300/min with
QRS complex of 80/min
Rationale: Idicates a lack of conduction between the atria and ventricles - the additional beats are not
conducting.
A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following
manifestations should the nurse expect? - (answers)Lower back discomfort
Rationale: back and abdominal pain would be seen as well as a bruit over the location of the mass.