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Ati lpn med surg level 3 II
Total Questions : 40
Showing 10 questions, Sign in for moreA nurse is caring for a client who has hypertension and recently developed drooping facial features. When contacting the provider, which of the following statements should the nurse include as part of the background component of the SBAR communication tool?
A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.)
A nurse in a provider's office is reinforcing teaching with a client who has risk factors for atherosclerosis. The nurse should help the client identify which of the following as treatment goals?
Client has a history of left-sided heart failure, hypertension, chronic atrial fibrillation with controlled rate, coronary artery disease (coronary bypass surgery 5 years ago).
Client was admitted to hospital directly from provider office visit. Reports increasing weakness and shortness of breath with minimal exertion.
Basic Metabolic Profile (BMP):
Glucose 148 mg/dL (200 mg/dL)
BUN 18 mg/dL (10 to 20 mg/dL)
Creatinine 0.94 mg/dL (0.05 to 1.3 mg/dL)
Sodium 142 mEq/L (136 to 145 mEq/L)
Potassium 4.4 mEq/L (3.5 to 5 mEq/L)
Chloride 100 mEq/L (98 to 106 mEq/L)
Calcium 9.6 mg/dL (9 to 10.5 mg/dL)
Phosphorus 4,2 mg/dL (3 to 4.5 mg/dL)
Cardiac Enzyme Laboratory Report:
TROPONIN T 0.06 ng/mL (less than 0.1 ng/mL)
TROPONIN 10.1 ng/mL (less than 0.3 ng/mL)
B-natriuretic peptide (BNP) 800 ng/mL (less than 100 ng/mL)
ECG Report: Atrial fibrillation, rate 135/min
Chest x-ray Report: Cardiomegaly with bilateral pleural chest effusions indicative of heart failure.
Physical Assessment:
Neurological: Client is alert, oriented x 3. Follows simple commands, responds to questions appropriately, moves all extremities well.
Cardiac: Heart rate is elevated at 138 beats/min, irregular rhythm. Pulses to lower extremities irregular and weak. Telemetry monitor showing atrial fib with rapid ventricular response (RVR). Client denies chest pain or discomfort.
Respiratory: Respirations at 28/min, O2 saturation 93% on 2 L via nasal cannula. Frequent cough noted with pink-tinged sputum. Client denies shortness of breath at this time.
Gastrointestinal: Bowel sounds active x 4 quadrants. States last bowel movement this morning with no irregularities.
Genitourinary: States no problems voiding. Urine clear, yellow.
Temperature 37.2° C (98.9° F)
Heart rate 138/min
Respiratory rate 28/min
Blood pressure 96/75 mm Hg
O2 saturation 93% on 2 L/min via nasal cannula
A nurse is assisting with the admission of a client who has a history of heart failure.
Which of the following findings require immediate follow-up by the nurse? Select all that apply.
A nurse is reinforcing teaching with a young adult female client who has been prescribed lisinopril. Which of the following instructions should the nurse plan to include? (Select all that apply.)
A nurse is administering nicardipine to a client who has a BP of 180/120 mm Hg. Which of the following actions should the nurse take first?
A 46-year-old African-American man is in an outpatient clinic for a physical examination. His BP is 126/84 mm Hg. his BMI is 24, and he reports no previous medical problems. Which of the following actions should the nurse take?
A nurse is collecting data on a client who is postoperative following abdominal surgery. Which of the following data should the nurse collect first?
A nurse is monitoring a client's peripheral circulation. Identify where the nurse should palpate to check the posterior tibial pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
Explanation
To palpate the posterior tibial pulse, the nurse should place their fingers just behind the medial malleolus, which is the bony prominence on the inner side of the ankle. This is where the posterior tibial artery passes and is a common site for checking peripheral circulation in the lower extremities.
A nurse is planning care for a group of clients on a medical-surgical unit. Which of the following actions should the nurse take first?
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