NURS Comprehensive Exam Questions with Answers 100% Completed Answers Best Rated Solution, Exams of Nursing

Download NURS Comprehensive Exam Questions with Answers 100% Completed Answers Best Rated Solution and more Exams Nursing in PDF only on Docsity! ,, NURS Comprehensive Exam Questions with Answers 100% Completed Answers Best Rated Solution A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? a.Assess the client's lung sounds. b.Notify the Rapid Response Team. c. Provide reassurance to the client. d.Take a full set of vital signs. b This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour. b.Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d.Tell the client that sometimes no cause for disease is found. c 1 ,, Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder should be referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature. A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best? a. "Breathing so rapidly interferes with oxygenation." b."Maybe the client has respiratory distress syndrome." c. "The blood clot interferes with perfusion in the lungs." d."The client needs immediate intubation and mechanical ventilation." c A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment. A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. 2 ,, near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client. A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? a. Ensure the client has adequate sedation. b.Find another provider to intubate. c. Interrupt the procedure to give oxygen. d.Monitor the client's oxygen saturation. c Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation during the procedure and monitor the client's oxygen saturation, but these do not take priority. Finding another provider is not appropriate at this time. An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b.Ensure all connections are patent. c. Listen to the client's lung sounds. d.Suction the endotracheal tube. c When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still 5 ,, correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction. A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? a.Assess the client for sedation needs. b.Get family permission for restraints. c. Provide frequent oral care per protocol. d.Use nonverbal pain assessment tools. c The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse. A nurse is caring for a client on mechanical ventilation. When double- checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? a.The client is able to initiate spontaneous breaths. b.The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d.The upper peak airway pressure limit alarm is on. d The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury. 6 ,, A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a.Assess the cause of the agitation. b.Reassure the client that he or she is safe. c. Restrain the client's hands. d.Sedate the client immediately. a The nurse needs to determine the cause of the agitation. A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority? a.Assessing that the ventilator settings are correct b.Ensuring there is a bag-valve-mask in the room c. Obtaining personal protective equipment d.Planning to suction the client upon arrival to the room b Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse should know and check the settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or may not need suctioning on arrival. A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best? a. "It will increase the motility of the gastrointestinal tract." b."It will keep the gastrointestinal tract functioning normally." c. "It will prepare the gastrointestinal tract for enteral feedings." 7 ,, Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have trouble maintaining this diet. The nurse should explore this possibility with the client. The other options are not related. A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse? a.Assessing the client's platelet count b.Choosing an 18-gauge, 2-inch needle c. Not aspirating prior to injection d.Swabbing the injection site with alcohol b Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions are appropriate A client in the emergency department has several broken ribs. What care measure will best promote comfort? a.Allowing the client to choose the position in bed b.Humidifying the supplemental oxygen c. Offering frequent, small drinks of water d.Providing warmed blankets a Allow the client with respiratory problems to assume a position of comfort if it does not interfere with care. Often the client will choose a more upright position, which also improves oxygenation. The other options are less effective comfort measures. A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? 10 ,, a.Alteplase (Activase) b.Enoxaparin (Lovenox) c. Unfractionated heparin d.Warfarin sodium (Coumadin) a Activase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting. A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority? a.Administer oxygen and reassess. b.Auscultate the client's lung sounds. c. Facilitate a portable chest x-ray. d.Prepare to assist with intubation. d This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated. A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best? a. "It is chronic hypoxemia that accompanies restrictive airway disease." b."It is hypoxemia from lung damage due to mechanical ventilation." c. "It is hypoxemia that continues even after the client is weaned from oxygen." 11 ,, d."It is hypoxemia that persists even with 100% oxygen administration." d Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute 12 ,, breath because this could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax; or drainage greater than 70 mL/hr because this could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention. A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.) a.Production of pink sputum b.Tracheal deviation c.Sudden onset of shortness of breath d.Pain at insertion site e.Drainage of 75 mL/hr ANS: B, C Tracheal deviation and sudden onset of shortness of breath are manifestations of a tension pneumothorax. The nurse must intervene immediately for this emergency situation. Pink sputum is associated with pulmonary edema and is not a complication of a chest tube. Pain at the insertion site and drainage of 75 mL/hr are normal findings with a chest tube. A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b.Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma d.Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur b, d, e Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, 15 ,, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE. When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a.Avoid drinking alcohol. b.Eat more omega-3 fatty acids. c. Exercise on a regular basis. d.Maintain a healthy weight. e.Stop smoking cigarettes. c, d, e Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart- healthy actions but do not relate to the prevention of PE. A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a.Acknowledge the frightening nature of the illness. b.Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. d.Request a prescription for antianxiety medication. e.Stay with the client and speak in a quiet, calm voice. a, b, c, e Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegate comfort measures, give simple explanations the 16 ,, client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the client's anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case. The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a.Adherence to proper hand hygiene b.Administering anti-ulcer medication c. Elevating the head of the bed d.Providing oral care per protocol e.Suctioning the client on a regular schedule a, b, c, d The "ventilator bundle" is a group of care measures to prevent ventilator- associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed. A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a.Allow visitors at the client's bedside. b.Ensure the client can communicate if awake. c. Keep the television tuned to a favorite channel. d.Provide back and hand massages when turning. e.Turn the client every 2 hours or more. a, b, d, e There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of 17 ,, A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? a.Administer prescribed anxiolytic medication. b.Ensure informed consent is on the chart. c. Reinforce any teaching done previously. d.Start the preoperative antibiotic infusion. ANS: B Since this is an operative procedure, the client must sign an informed consent, which must be on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy and the eyelids are swollen. What action by the nurse takes priority? a.Assess the client's oxygen saturation. b.Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d.Palpate the skin of the upper chest. ANS: A This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the client's oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Elevate the head of the client's bed. 20 ,, b.Measure and compare cuff pressures. c. Place the client on NPO status. d.Request that the client have a swallow study. ANS: B Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This can be manifested by food particles seen in secretions or by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated. The nurse should measure the pressures and compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not correct this situation. An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority? a.Assess the client's lung sounds. b.Assign a different UAP to the client. c. Report the UAP to the manager. d.Request thicker liquids for meals. ANS: A The priority is to check the client's oxygenation because he or she may have aspirated. Once the client has been assessed, the nurse can consult with the registered dietitian about appropriately thickened liquids. The UAP should have reported the incident immediately, but addressing that issue is not the immediate priority. A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? a. Holding the device securely when changing ties b.Suctioning the client first if secretions are present 21 ,, c. Tying a square knot at the back of the neck d.Using half-strength peroxide for cleansing ANS: C To prevent pressure ulcers and for client safety, when ties are used that must be knotted, the knot should be placed at the side of the client's neck, not in back. The other actions are appropriate. A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? a.Applying suction while inserting the catheter b.Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d.Suctioning for only 10 to 15 seconds each time ANS: A Suction should only be applied while withdrawing the catheter. The other actions are appropriate. A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met? a. 100% of meals being eaten by the client b. Intact skin behind the ears c. The client understanding the need for oxygen d.Unchanged weight for the past 3 days ANS: B Oxygen tubing can cause pressure ulcers, so clients using oxygen have the nursing diagnosis of Risk for Impaired Skin Integrity. Intact skin behind the ears indicates that goals for this diagnosis are being met. Nutrition and weight are not related to using oxygen. Understanding the need for oxygen is important but would not take priority over a physical problem. A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's 22 ,, d.Turn the client every 2 hours or as needed. ANS: A Oxygen can be drying, so the UAP can apply water-soluble lubricant to the client's lips and nares. The UAP should not adjust the oxygen flow rate or remove the tubing. Turning the client is not related to comfort measures for oxygen. A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? a.Assess the client's oxygen saturation and, if normal, turn off the oxygen. b.Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d.Turn the oxygen off while the client eats the meal and then restart it. ANS: B Oxygen is a drug that needs to be delivered constantly. The nurse should determine if the provider has approved switching to a nasal cannula during meals. If not, the nurse should consult with the provider about this issue. The oxygen should not be turned off. Lifting the mask to eat will alter the FiO2 delivered. The nurse assesses the client using the device pictured below to deliver 50% O2: The nurse finds the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best? a.Assess the client's oxygen saturation. b.Document these findings in the chart. c. Immediately increase the flow rate. 25 ,, d.Turn the flow rate down to 2 L/min. ANS: C For the Venturi mask to deliver high flow of oxygen, the flow rate must be set correctly, usually between 4 and 10 L/min. The client's flow rate is too low and the nurse should increase it. After increasing the flow rate, the nurse assesses the oxygen saturation and documents the findings A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.) a.The client does not allow smoking in the house. b.Electrical cords are in good working order. c. Flammable liquids are stored in the garage. d.Household light bulbs are the fluorescent type. e.The client does not have pets inside the home. ANS: A, B, C Oxygen is an accelerant, which means it enhances combustion, so precautions are needed whenever using it. The nurse should assess if the client allows smoking near the oxygen, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety. A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a.Applying water-soluble lip balm to the client's lips b.Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d.Reminding the client to cough and deep breathe often e.Suctioning excess secretions through the tracheostomy ANS: A, D 26 ,, The UAP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises. Oral care can be accomplished with normal saline, not products that dry the mouth. Ensuring the humidity is adequate and suctioning through the tracheostomy are nursing functions. A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self- esteem? (Select all that apply.) 27 ,, A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm." b."Avoid straining while having a bowel movement." c. "Limit your intake of caffeinated drinks to one a day." d."Avoid strenuous exercise such as running." ANS: B Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition. A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a.A 45-year-old who takes an aspirin daily b.A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d.An 80-year-old with chronic obstructive pulmonary disease ANS: B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation. A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b.Speech alterations c. Fatigue 30 ,, d.Dyspnea with activity ANS: B Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a 31 ,, nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance. A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b.Warfarin (Coumadin) c. Atropine (Sal-Tropine) d.Lidocaine (Xylocaine) ANS: B Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication. A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d.Hypertensive crisis ANS: C Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure. 32 ,, cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed medications. A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client's concerns? a.Administer oxygen therapy at 2 liters per nasal cannula. b.Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d.Ask unlicensed assistive personnel to help bathe the client. 35 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) ANS: C Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities. A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a.Administer intravenous adenosine. b.Turn off oxygen therapy. c. Ensure a tongue blade is available. d.Position the client on the left side. ANS: B For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position. A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? a. Medication reconciliation b. Immunization history c. Religious beliefs d.Nutrition preferences ANS: A The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client. A nurse assesses a client with 36 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) ANS: C tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d.P wave touching the T wave ANS: A Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death. A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this client's teaching? a. "Minimize or abstain from caffeine." b."Lie on your side until the attack subsides." c. "Use your oxygen when you experience PACs." d."Take amiodarone (Cordarone) daily to prevent PACs." ANS: A PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although 37 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) ANS: D Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization. Ventricular tachycardia and ventricular fibrillation rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization. A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first? a.Assess airway, breathing, and level of consciousness. b.Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d.Begin cardiopulmonary resuscitation (CPR). ANS: A Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action. A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The client's blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the client's rhythm on the cardiac monitor and observes the reading shown below: 40 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) Which action should the nurse take first? a. Begin external temporary pacing. b.Assess peripheral pulse strength. c. Ask the client what medications he or she takes. d.Administer 1 mg of atropine. ANS: C This client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse should assess the client's current medications first. The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d.Ask the client's family about code status. ANS: B The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client's code status should already be known by the nurse prior to this event. 41 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs Nursing Assessment Time: 0800 Temperature: 98° F Heart rate: 68 beats/min Blood pressure: 135/60 mm Hg Respiratory rate: 14 breaths/min Oxygen saturation: 96% Oxygen therapy: 2 L nasal cannula Time: 1000 Temperature: 98.2° F Heart rate: 50 beats/min Blood pressure: 132/57 mm Hg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2 L nasal cannula Time: 0800 Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Time: 1000 Client alert and oriented. Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. 42 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching? (Select all that apply.) a. Smoking cessation b.Stress reduction and management c. Avoiding vagal stimulation d.Adverse effects of medications e. Foods high in potassium ANS: A, B, D A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances. A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect? a. Heart rate of 120 beats/min b.Cool, clammy skin c. Oxygen saturation of 90% d.Respiratory rate of 8 breaths/min ANS: A When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the 45 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) low blood pressure and maintain oxygen saturations and perfusion. The client may not be able to compensate for long, and decreased oxygenation and cool, clammy skin will occur later. A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find? a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg b.Respiratory rate decreased from 25 breaths/min to 14 breaths/min c. Oxygen saturation increased from 88% to 96% d.Pulse decreased from 100 beats/min to 80 beats/min 46 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) ANS: D Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased HR. A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease? a.An 86-year-old man with a history of asthma b.A 32-year-old Asian-American man with colorectal cancer c. A 45-year-old American Indian woman with diabetes mellitus d.A 53-year-old postmenopausal woman who is on hormone therapy ANS: C The incidence of coronary artery disease and hypertension is higher in American Indians than in whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary artery disease in people of any race or ethnicity. Asthma, colorectal cancer, and hormone therapy do not increase risk for cardiovascular disease. A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. Which action should the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the client's medications. d.Administer 1 mg of atropine. ANS: C 47 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) to the distal portion of the leg. Increasing intravenous fluids will not address the client's problem. A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake 50 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) b.Bruising at the insertion site c. Slurred speech and confusion d.Discomfort in the left leg ANS: C A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are expected at the site. If intake decreases, a client can become dehydrated because of dye excretion. The second intervention would be to increase the client's fluid status. Neurologic changes would take priority. A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? a. Client's level of anxiety b.Ability to turn self in bed c. Cardiac rhythm and heart rate d.Allergies to iodine-based agents ANS: D Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life- threatening reaction, so it is a high priority. Second, it is important for the nurse to assess anxiety, mobility, and baseline cardiac status. A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take? a. Schedule an electrocardiogram just before the MRI. 51 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) b.Notify the health care provider before scheduling the MRI. c. Call the physician and request a laboratory draw for cardiac enzymes. d. Instruct the client to increase fluid intake the day before the MRI. ANS: B The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health care provider and report that the client has a pacemaker so the provider can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids. A nurse assesses a client who is recovering from a myocardial infarction. The client's pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first? a. Compare the results with previous pulmonary artery pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the health care provider of the elevated pressures. d.Document the finding in the client's chart as the only action. ANS: A Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15 mm Hg for diastolic. Although this client's readings are within normal limits, the nurse needs to assess any trends that may indicate a need for medical treatment to prevent complications. There is no need to increase intravenous fluids or notify the provider. A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery? a.Administration of IV furosemide (Lasix) b.Initiation of an external pacemaker 52 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea. A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I will need to stop eating so much chili to keep that indigestion pain from returning." How should the nurse respond? a. "Chili is high in fat and calories; it would be a good idea to stop eating it." b."The provider has prescribed an antacid for you to take every morning." c. "What do you understand about what happened to you?" d."When did you start experiencing this indigestion?" ANS: C Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse should ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the client's misconception about recent pain and the cause of that pain. A nurse prepares a client for coronary artery bypass graft surgery. The client states, "I am afraid I might die." How should the nurse respond? a. "This is a routine surgery and the risk of death is very low." b."Would you like to speak with a chaplain prior to surgery?" c. "Tell me more about your concerns about the surgery." d."What support systems do you have to assist you?" ANS: C The nurse should discuss the client's feelings and concerns related to the surgery. The nurse should not provide false hope or push the client's 55 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) concerns off on the chaplain. The nurse should address support systems after addressing the client's current issue. An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first? a.A 42-year-old female who describes her pain as a dull ache with numbness in her fingers b.A 49-year-old male who reports moderate pain that is worse on inspiration c. A 53-year-old female who reports substernal pain that radiates to her abdomen d.A 58-year-old male who describes his pain as intense stabbing that spreads across his chest ANS: D All clients who have chest pain should be assessed more thoroughly. To determine which client should be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing, vise-like substernal pain that spreads through the client's chest, arms, jaw, back, or neck is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent cardiac cell death. A dull ache with numbness in the fingers is consistent with anxiety. Pain that gets worse with inspiration is usually related to a pleuropulmonary problem. Pain that spreads to the abdomen is often associated with an esophageal- gastric problem, especially when this pain is experienced by a male client. Female clients may experience abdominal discomfort with a myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal- gastric problems should be seen, they are not a higher priority than myocardial infarction. A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard? (Click the media button to hear the audio clip.) 56 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) a.Administer a diuretic. b.Document the finding. c. Decrease the IV flow rate. d.Evaluate the client's medications. ANS: B The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a stiffened ventricle. The nurse should document the finding, but no other intervention is needed at this time. A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? a. Location A b.Location B c. Location C d.Location D ANS: A The aortic valve is auscultated in the second intercostal space just to the right of the sternum. A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.) a.Assess for allergies to iodine. b.Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d.Insert a Foley catheter. e.Administer a prophylactic antibiotic. 57 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) A nurse reviews a client's laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a.Total cholesterol: 280 mg/dL b.High-density lipoprotein cholesterol: 50 mg/dL c. Triglycerides: 200 mg/dL d.Serum albumin: 4 g/dL e.Low-density lipoprotein cholesterol: 160 mg/dL ANS: A, C, E A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis. A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.) a.Assist the provider to place a central venous access device. b.Prepare for continuous blood pressure and pulse monitoring. c. Administer the client's prescribed beta blocker. d.Give the client nothing by mouth 3 to 6 hours before the procedure. e.Explain to the client that dobutamine will simulate exercise for this examination. ANS: B, D, E Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, should be performed. Beta blockers are often held prior to the procedure. 60 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.) a.Thrombophlebitis b.Stroke c. Pulmonary embolism d.Myocardial infarction e.Cardiac tamponade A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure? a.A 36-year-old woman with aortic stenosis b.A 42-year-old man with pulmonary hypertension c. A 59-year-old woman who smokes cigarettes daily d.A 70-year-old man who had a cerebral vascular accident A 36 year old woman with aortic stenosis Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure. A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left sided heart failure? a. "I have been drinking more water than usual." 61 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) b."I am awakened by the need to urinate at night." c. "I must stop halfway up the stairs to catch my breath." d."I have experienced blurred vision on several occasions." " I must stop halfway up the stairs to catch my breath " Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty 62 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) After administering newly prescribed captopril ( Capoten ) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client? a. Provide food to decrease nausea and aid in absorption. b. Instruct the client to ask for assistance when rising from bed. c. Collaborate with unlicensed assistive personnel to bathe the client. d.Monitor potassium levels and check for symptoms of hypokalemia. Instruct the client to ask for assistance when rising from bed. Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension. ACE inhibitors do not need to be taken with food. Collaboration with unlicensed assistive personnel to provide hygiene is not a priority. The client should be encouraged to complete activities of daily living as independently as possible. The nurse should monitor for hyperkalemia, not hypokalemia, especially if the client has renal insufficiency secondary to heart failure. A nurse assesses a client after administering isosorbide mononitrate ( lmdur ). The client reports a headache. Which action should the nurse take? a. Initiate oxygen therapy. b.Hold the next dose of Imdur. c. Instruct the client to drink water. d.Administer PRN acetaminophen. Administer PRN acetaminophen The vasodilating effects of isosorbide mononitrate frequently cause clients to have headaches during the initial period of therapy. Clients 65 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. The client's headache is not related to hypoxia or dehydration; therefore, these interventions would not help. The client needs to take the medication as prescribed to prevent angina; the medication should not be held. A nurse teaches a client who is prescribed digoxin ( Lanoxin ) therapy. Which statement should the nurse include in this client's teaching? "Avoid taking aspirin or aspirin-containing products." "Increase your intake of foods that are high in potassium." "Hold this medication if your pulse rate is below 80 beats/min." "Do not take this medication within 1 hour of taking an antacid." 66 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) " Do no take this medication within 1 hour of taking an antacid " Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin absorption, nor do these statements decrease complications of digoxin therapy. A nurse teaches a client who has a history of heart failure. Which statement should the nurse included in this client's discharge teaching? "Avoid drinking more than 3 quarts of liquids each day." "Eat six small meals daily instead of three larger meals." "When you feel short of breath, take an additional diuretic." "Weigh yourself daily while wearing the same amount of clothing." " Weigh yourself daily while wearing the same amount of client " Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of heart failure. The client should be taught to eat a heart- healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention. A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? a.Assess the client's respiratory status. b.Draw blood to assess the client's serum electrolytes. 67 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) The client with infective endocarditis does not pose any specific threat of transmitting the causative organism. Standard Precautions should be used. Bleeding precautions or reverse or contact isolation is not necessary. A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find? a. Heart rate that speeds up and slows down b.Friction rub at the left lower sternal border c. Presence of a regular gallop rhythm d.Coarse crackles in bilateral lung bases 70 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) Friction rub at the left lower sternal border The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related. After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks " Why is this important? How should the nurse respond? a. "Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures." b."Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness." c. "Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes." d."While your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke when you stand up." " Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by positon changes " Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period. The other options are false statements and do not correctly address the client's question. A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine ( Sandimmune ). Which statement should the nurse include in the client's discharge teaching? a. "Use a soft-bristled toothbrush and avoid flossing." 71 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) b."Avoid large crowds and people who are sick." c. "Change positions slowly to avoid hypotension." d."Check your heart rate before taking the medication." " Avoid large crowds and people who are sick " These agents cause immune suppression, leaving the client more vulnerable to infection. The medication does not place the client at risk for bleeding, orthostatic hypotension, or a change in heart rate. A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, " I know a transplant is my last chance, but I don't want to become a vegetable." How should the nurse respond? a. "Would you like to speak with a priest or chaplain?" b."I will arrange for a psychiatrist to speak with you." c. "Do you want to come off the transplant list?" d."Would you like information about advance directives?" " Would you like information about advance directives? " The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though he or she is crazy. The client needs to feel that he or she has some control over the future. The nurse personally provides care to address the client's concerns instead of pushing the client's issues off on a chaplain or psychiatrist. The nurse should not jump to conclusions and suggest taking the client off the transplant list, which is the best treatment option. 72 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) A nurse is caring with acute pericarditis who reports substenal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement? a.Apply an ice pack to the client's chest. b.Provide a neck rub, especially on the left side. c. Allow the client to lie in bed with the lights down. d.Sit the client up with a pillow to lean forward on. Sit the client up with a pillow to lean forward on Pain from acute pericarditis may worsen when the client lays supine. The nurse should position the client in a comfortable position, which usually is upright and leaning slightly forward. Pain is decreased by using gravity to take pressure off the heart muscle. An ice pack and neck rub will not relieve this pain. A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess? a. Preventricular contractions b.Atrial fibrillation c. Symptomatic bradycardia d.Sinus tachycardia Atrial fibrillation Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis. Preventricular contractions and bradycardia are not associated with valvular problems. These are usually identified in clients with electrolyte imbalances, myocardial infarction, and sinus node problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease in cardiac output. 75 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) A nurse is assessing a client with left sided heart failure. For which clinical manifestations should the nurse assess?(Select all that apply.) a. Pulmonary crackles b.Confusion, restlessness c. Pulmonary hypertension d.Dependent edema e. Cough that worsens at night Pulmonary crackles Confusion, restlessness Cough that worsens at night Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided heart failure occurs with problems from the pulmonary vasculature onward including pulmonary hypertension. Signs will be noted before the right atrium or ventricle including dependent edema. A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect?(Select all that apply.) a. Hematocrit: 32.8% b.Serum sodium: 130 mEq/L c. Serum potassium: 4.0 mEq/L d.Serum creatinine: 1.0 mg/dL e. Proteinuria f. Microalbuminuria Hematocrit: 32.8% Serum sodium: 130 mEq/L Proteinuria Microalbuminuria A hematocrit of 32.8% is low (should be 42.6%), indicating a dilutional ratio of red blood cells to fluid. A serum sodium of 130 mEq/L is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. These are early warning signs of 76 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) decreased compliance of the heart. The potassium level is on the high side of normal and the serum creatinine level is normal. A nurse assesses client on a cardiac unit. Which client should the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.) a.A 36-year-old woman with systemic lupus erythematosus (SLE) b.A 42-year-old man recovering from coronary artery bypass graft surgery c. A 59-year-old woman recovering from a hysterectomy d.An 80-year-old man with a bacterial infection of the respiratory tract e.An 88-year-old woman with a stage III sacral ulcer A 36 year old woman with systemic lupus erythematosus ( SLE ) A 42 year old recovering from coronary artery bypass graft surgery An 80 year old man with a bacterial infection of the respiratory tract Acute pericarditis is most commonly associated acute exacerbations of systemic connective tissue disease, including SLE; with Dressler's syndrome, or inflammation of the cardiac sac after cardiac surgery or a myocardial infarction; and with infective organisms, including bacterial, viral, and fungal infections. Abdominal and reproductive surgeries and pressure ulcers do not increase clients' risk for acute pericarditis. After teaching a client with congestive heart failure ( CHF ), the nurse assesses the client's understanding. Which statement indicates a correct understanding of the teaching related to nutritional intake?(Select all that apply.) a. "I'll read the nutritional labels on food items for salt content." b."I will drink at least 3 liters of water each day." c. "Using salt in moderation will reduce the workload of my heart." 77 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) Select all that apply.) a.Teach the client about dietary restrictions. b.Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. c. Encourage the client to take a baby aspirin each day. d.Confirm that an echocardiogram has been completed. e.Consult a social worker for additional resources. Teach the client about dietary restrictions Ensure the client is prescribed an antiotensin-converting enzyme ( ACE ) inhibitor. The Heart Failure Core Measure Set includes discharge instructions on diet, activity, medications, weight monitoring and plan for worsening symptoms, evaluation of left ventricular systolic function (usually with an echocardiogram), and prescribing an ACE inhibitor or angiotensin receptor blocker. Aspirin is not part of the Heart Failure Core Measure Set and is usually prescribed for clients who experience a myocardial infarction. Although the nurse may consult the social worker or case manager for additional resources, this is not part of the Core Measures. A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this client's safety prior to discharging home? a. "Are your bedroom and bathroom on the first floor?" b."What social support do you have at home?" c. "Will you be able to afford your oxygen therapy?" d."What spiritual beliefs may impact your recovery?" e. "Are you able to accurately weigh yourself at home?" " Are your bedroom and bathroom on the first floor " 80 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) " What social support do you have at home? " " What spiritual beliefs may impact your recovery? " To ensure safety upon discharge, the nurse should assess for structural barriers to functional ability, such as stairs. The nurse should also assess the client's available social support, which may include family, friends, and home health services. The client's ability to adhere to medication and treatments, including daily weights, should also be reviewed. The other questions do not address the client's safety upon discharge. A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection?(Select all that apply.) a. Shortness of breath b.Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension Shortness of breath Abdominal bloating New-onset bradycardia Clinical manifestations of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction. A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect?(Select all that apply.) a. Weight gain b.Night sweats c. Cardiac murmur 81 ATI Leadership Management Proctored Exam (Latest Completed Version) (Questions and Answers) d.Abdominal bloating e. Osler's nodes Night sweats Cardiac murmur Osler's nodes Clinical manifestations of infective endocarditis include fever with chills, night sweats, malaise and fatigue, anorexia and weight loss, 82