and Lymphatic Systems
A nurse identifies that a client who had a myocardial infarction is struggling with
an alteration in self-concept’ The nurse intervenes to promote client autonomy’
The behavior that demonstrates an increase in client autonomy is when the
client: - correct answer 1’ Actively participates in providing self-care
The nurse recognizes that an early finding that indicates that a client is
hypertensive is: - correct answer A throbbing headache over the left eye when
arising in the morning
The spouse of a client who had emergency coronary artery bypass surgery asks
why there is a dressing on the client's left leg’ The nurse explains that: - correct
answer A vein in the leg was used to bypass the coronary artery
A client who had a femoropopliteal bypass graft is receiving clopidogrel (Plavix)
postoperatively’ What should the nurse teach the client related to the
medication? - correct answer Report multiple bruises on the extremities
,One week after admission to the cardiac care unit a client displays an outburst of
anger and tells the nurse to get out of the room’ Which is the most appropriate
nursing action? - correct answer Return when the client has calmed down
What should the nurse expect the health care provider to prescribe if a client
exhibits clinical indicators of warfarin (Coumadin) overdose? - correct answer
Vitamin K
When assessing a client with heart failure, the nurse asks when the client most
notices an increase in symptoms’ Which activity should the nurse expect will
cause the client the greatest distress? - correct answer Climbing a flight of stairs
to the bedroom
The nurse provides discharge teaching to a client who has received prescriptions
for digoxin (Lanoxin), furosemide (Lasix), and a 2-gram sodium diet’ The nurse
evaluates that further teaching is needed when the client states: - correct answer
"I can use a little table salt on my food as long as I do not use it when cooking’"
The nurse evaluates that the client understands the teaching regarding the use of
vitamin B12 injections to treat pernicious anemia when the client states, "I must
take the drug: - correct answer Monthly, for the rest of my life’"
, An ECG is performed before a client is to have a cardiac catheterization, and
hypokalemia is suspected’ To confirm the presence of hypokalemia, the nurse
expects the primary health care provider to prescribe: - correct answer A serum
electrolyte level
A client who is recovering from an acute myocardial infarction reports not being
happy about the lack of salt with meals’ Recognizing that adherence to a medical
regimen improves with understanding, the nurse explains that the salt must be
limited to: - correct answer Prevent further accumulation of fluid, which increases
the workload of the heart’
What client response indicates to the nurse that a vasodilator medication is
effective? - correct answer Blood pressure changes from 154/90 to 126/72
A nurse reviews the plan of care for a client who is recovering from the acute
phase of left ventricular failure’ The nurse expects which dietary restriction to be
included on the plan? - correct answer Sodium
A nurse is taking the blood pressure of a client with hypertension’ The first sound
is heard at 140 mm Hg, the second sound is a swishing sound heard at 130 mm
Hg, a tapping sound is heard at 100 mm Hg, a muffled sound is heard at 90 mm
Hg, and the sound disappears at 72 mm Hg’ When recording just the systolic and
diastolic readings, what is the diastolic pressure? - correct answer 72 mm Hg
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