1. Fetal heart rate tracing abnormalities are observed on the fetal monitor when a
client in active labor turns to the supine position. Which nursing
... [Show More] action is most
beneficial at this time? - Helping the client change her position
2. The nurse teaching a health awareness class identifies which situation as being
the highest risk factor for the development of a deep vein thrombosis (DVT)? -
Inactivity
3. A client is diagnosed with heart failure and is admitted for medical management.
Which statement made by the client may indicate worsening heart failure? - "I
wake up at night short of breath."
4. A client who is receiving atenolol for hypertension frequently reports feeling
dizzy. What effect of atenolol should the nurse consider may be responsible this
response? - Blocking the adrenergic response
5. A healthcare provider prescribes enalapril for a client. Which is the most
important nursing action? - Monitor the client's blood pressure during therapy.
6. A client who just returned from a cardiac catheterization reports to the nurse that
the pressure bandage on the right groin is tight. What action should the nurse
take? - Assess the pulses distal to the dressing
7. A nurse on the Code Blue/Arrest team responds to a code that is called for a
client with hyperkalemia who is experiencing cardiac standstill. What would an
appropriate immediate treatment plan include? - Sodium bicarbonate
8. A client with a coronary occlusion is experiencing chest pain and distress. Why
does the nurse administer oxygen? - To increase oxygen concentration to heart
cells
9. While assessing a client's vascular system, the nurse finds that pulse strength is
diminished or barely palpable. Which documentation is appropriate in this
situation? - 1+
10.A nurse is assessing an ECG rhythm strip. Which component of the tracing will
the nurse observe to determine ventricular depolarization? - QRS complex
11.A nurse is teaching Hands Only Basic Life Support for adults in the community.
What should the rescuer do first after determining that the person is not
responding and the emergency medical system has been activated? - Identify the
absence of a pulse12.A 2-month-old infant is being treated with sequential casts for bilateral clubfoot
(talipes equinovarus). New casts have just been applied. What should the nurse
evaluate to determine that circulation to the feet remains sufficient? - warmth of
the toes of both feet
13.A client is prescribed prolonged bed rest after surgery. Which complication does
the nurse expect to prevent by teaching this client to avoid pressure on the
popliteal space? - pulmonary embolism
14.The nurse develops a teaching plan for a client with diabetes who has been
diagnosed with lower extremity arterial disease (LEAD). What measures should
the nurse include to increase arterial blood flow to the extremities? - exercise that
promotes muscular activity
15.The parents of a child who is scheduled for open-heart surgery ask why their
child must be subjected to chest tubes after surgery. What should the nurse
consider before responding in language that the parents will understand? - chest
tubes facilitate drainage of air and fluid
16.A nurse is discussing discharge instructions with a patient who had a coronary
artery bypass graft (CABG). The client states, "My spouse is afraid to have sex
with me. When will it be safe to have sex again?" Which is the most appropriate
response by the nurse? - "You can resume sexual activity as soon as you can
climb one flight of stairs without fatigue or discomfort." [Show Less]