Nokea
The nurse assesses a client with acute left leg swelling and calf tenderness following a long car ride. The nurse anticipates that the primary healthcare provider (PHCP) will order which diagnostic test?
- A. D-dimer test
- B. Ankle-Brachial Index
- C. Radiograph (X-Ray)
- D. Venous Duplex Ultrasonography
Correct Answer: D
Rationale: Venous duplex ultrasonography is the gold standard for diagnosing deep vein thrombosis, indicated by swelling and tenderness.
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The nurse cares for a client with acute myocardial infarction (AMI). The nurse anticipates the physician will order an emergent
- A. exercise electrocardiography.
- B. computed tomography (CT) of the chest with contrast.
- C. percutaneous coronary intervention (PCI).
- D. echocardiogram.
Correct Answer: C
Rationale: PCI is the standard emergent treatment for AMI to restore coronary blood flow.
The nurse cares for a client with a complete (3rd-degree) heart block and hypotension. The nurse should take which appropriate action?
- A. prepare the client for temporary transcutaneous pacing
- B. obtain a prescription for an esmolol infusion
- C. begin chest compressions
- D. instruct the client to perform the Valsalva maneuver
Correct Answer: A
Rationale: Complete heart block with hypotension requires urgent pacing to restore adequate heart rate and cardiac output.
The nurse is caring for a client with cardiac tamponade. Which vital signs are expected?
- A. HR: 109 bpm; RR: 26; BP: 88/71 mmHg
- B. HR: 90 bpm; RR: 32; BP: 90/52 mmHg
- C. HR: 115 bpm; RR: 22; BP: 140/78 mmHg
- D. HR: 54 bpm; RR: 14; BP: 161/52 mmHg
Correct Answer: A
Rationale: Cardiac tamponade causes tachycardia (HR >100), increased respiratory rate, and hypotension due to restricted cardiac output.
The following scenario applies to the next 6 items
The client is a 72-year-old male who presents to the emergency department with increasing
shortness of breath over the past two days that gets worse when he is lying flat in bed at night.
Item 1 of 6
History And Physical Nurses' Notes Flow Sheet
0700: The client is a 72-year-old male who presents to the emergency department with increasing shortness of breath over the past two days that gets worse when he is lying flat in bed at night. He states, "I feel like I can't catch my breath," and he had to sleep in a recliner. He reports a 4 lb weight gain over the last week and increasing fatigue. The client is alert and oriented but is using his accessory muscles to breathe. He reports feeling short of breath, orthopnea, and paroxysmal nocturnal dyspnea. He has bilateral pedal edema (+2), bilateral crackles heard upon auscultation, and jugular vein distention noted on his assessment. The
the client has a medical history of hypertension, coronary artery disease, and a prior myocardial infarction. He was diagnosed with heart failure with reduced ejection fraction (HFrEF) two years ago. Current home medications include lisinopril, metoprolol succinate, furosemide, and atorvastatin.
The client reporting …………… and …………….would indicate improvement in their condition.
- A. Ambulation tolerance
- B. Edema after activity
- C. Weight loss
- D. Sleeping in bed
- E. High sodium intake
Correct Answer: A,D
Rationale: A: Improved ambulation tolerance indicates better functional capacity. D: Sleeping in bed (without orthopnea) suggests reduced pulmonary congestion. B, C, E: Edema, weight loss, and high sodium intake do not necessarily indicate improvement.
The nurse caring for a client with a history of atrial fibrillation is prescribed dofetilide to control the dysrhythmia. What assessment should the nurse prioritize before administering the medication?
- A. Daily weight
- B. Liver function tests
- C. QT interval on the electrocardiogram (ECG)
- D. Blood urea nitrogen (BUN) and creatinine levels
Correct Answer: C
Rationale: Dofetilide can prolong the QT interval, increasing the risk of torsades de pointes, so monitoring the ECG for QT prolongation is critical.