INR 2.0
A nurse is assessing a client who has a history of DVT and is receiving warfarin. The nurse should identify that thich of the following findings indicates teh medication is effective?Hemoglobin 14 g/dLMinimal bruising of extremitiesDecreased bp
INR 2.0Desired reference range
2.0 to 3.0 for a client who has a DVT and is receiving warfarin
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.Rotating the patch site can help prevent skin irritation.Place the patch on an area of skin away from skin folds and joints.The client should apply the patch to an area of skin that is not prone to movement or wrinkling.Keep the patch on 24 hr per day.INCORRECTThe client should have a patch-free interval of 10 to 12 hr per day to help prevent tolerance to the medication.Replace the patch at the onset of angina.INCORRECTThe nurse should emphasize that nitroglycerin patches offer ongoing prevention of angina attacks. The patches do not treat angina attacks because they do not take effect immediately.
Place the patch on an area of skin away from skin folds and joints.
The client should have a patch free interval of ________ to prevent tolerance to the medication.
The nurse should emphasize that nitroglycerin patches offer ongoing prevention of ________.
angina attacks (do not take effect immediately)
A nurse in the emergency department is caring for a client who had an anterior myocardial infarction. The client's history reveals she is 1 week postoperative open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated?Administering IV morphine sulfateAdministering oxygen at 2 L/min via nasal cannulaHelping the client to the bedside commode
Assisting with thrombolytic therapy
Assisting with thrombolytic therapy
*** the nurse should recognize the major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.
Using a bedside commode is less stressful than using _____, and most clients are allowed to use a commode following a MI.
A nurse is caring for a client who is being treated for heart failure and has prescriptions for digoxin and furosemide. The nurse should plan to monitor for which of the following as an adverse effect of these medications?SOBlightheadednessdry cough
metallic taste
lightheadedness***Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness.
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 diseaseNote 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.
Inquire about the presence or absence of claudication
***Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?Ventricular depolarizationGuillain-Barre syndromeMyelodyslastic syndrome
Valvular disease
Valvular disease**** Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.
A nurse is watching a client's ECG monitor and notes that the client's rhythm has changed from a normal sinus rhythm to supraventricular tachycardia. The client is conscious with a heart rate of 200 to 210/min and has a faint radial pulse. The nurse should anticipate assisting with which of the following interventions?Delivery of a precordial thumpVagal stimulationAdministration of atropine IV
Defibrillation
Vagal stimulationVagal stimulation can help the client's heart return to a normal sinus rhythm temporarily.
A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure?•Hemoglobin 14.4 g/dLHistory of peripheral arterial diseaseUrine output 200 mL/4 hr
Previous allergic reaction to shellfish
Previous allergic reaction to shellfish
The contrast medium used is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine.
A nurse is caring for a client in the first 8 hr following coronary artery bypass graft (CABG) surgery. Which of the following client findings should the nurse report to the provider?•Mediastinal drainage 100 mL/hrBlood pressure 160/80 mm HgTemperature 37.1° C (98.8° F)
Potassium 3.8 mEq/L
Blood pressure 160/80 mm Hg
The nurse should report an elevated blood pressure following a CABG procedure because increased vascular pressure can cause bleeding at the incision sites.
A nurse is providing discharge teaching for a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider?•Weight gain of 0.9 kg (2 lb) in 24 hrIncrease of 10 mm Hg in systolic blood pressureDyspnea with exertionDizziness when rising quickly
Weight gain of 2 lb in 24 hour
When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1 to 2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately.
A nurse is assessing a client who has left-sided heart failure. Which of the following manifestations should the nurse expect to find?Increased abdominal girthWeak peripheral pulsesJugular venous neck distentionDependent edema
Weak peripheral pulsesCORRECT
Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure.
A nurse is caring for a client who has a history of angina and is scheduled for a stress test at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling?•"I'm still hungry after the bowl of cereal I ate at 7 a.m.""I didn't take my heart pills this morning because the doctor told me not to.""I have had chest pain a couple of times since I saw my doctor in the office last week.""I smoked a cigarette this morning to calm my nerves about having this procedure."Smoking prior to the test can change the outcome and places the client at additional risk, so the test should be rescheduled....
"I smoked a cigarette this morning to calm my nerves about having this procedure."CORRECTSmoking prior to the test can change the outcome and places the client at additional risk, so the test should be rescheduled....
A nurse is caring for a client in the first hour following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider?•Serosanguineous drainage on dressingSevere pain with coughingUrine output of 20 mL/hr
Increase in temperature from 36.8° C (98.2° F) to 37.5° C (99.5° F)