Quiz 3 Flashcards
(20 cards)
which assessment finding would be the earliest and most sensitive indicator that there is an alteration in intracranial regulation?
change in LOC
a nurse assesses a client who is prescribed a medication that inhibits angiotensin 1 from converting into angiotensin 2. For which expected therapeutic effect should the nurse assess?
blood pressure decrease from 180/72 to 144/60
after teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client’s understanding. Which food choice for lunch indicates the client correctly understood the teaching?
grilled chicken breast with glazed carrots
a nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?
a 34 yr old NPO status who is receiving IV D5W
a nurse assesses a client on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure?
a 36 yr old woman with aortic stenosis
when assessing a 56 yo male on a cardiac unit, a nurse identifies the presence of an S1 gallop. Which action should the nurse take next?
assess for other signs of left heart failure
a nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client’s teaching?
do not take this medication within 1 hr of taking an antacid
a nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?
assess respiratory status
a nurse cares for an older adult client with HF. The client states I dont know what to do. I dont want to be a burden to my daughter, but I cant do it alone. Maybe I should die. How should the nurse respond?
would you like to talk more about this
a nurse collaborates with an UAP to provide care for client with congestive HF. Which instructions should the nurse provide to the UAP when delegating care? SATA
- accurately record intake and output
- use the same scale to weigh the client each morning
- make sure the client changes positions every 2 hrs
a nurse receives report on a client who had a L sided stroke and has homonymous hemaniaopsia. What action by the nurse is most appropriate for this client?
rotate the client’s meal tray when the client stops eating
a client with a stroke is being evaluated for fibrinolytic therapy. What info from the client or family is most important for the nurse to obtain?
time of symptom onset
a student nurse is preparing morning meds for a client who had a stroke. The student plans to hold the docusate sodium because the client had a large stool earlier. What action by the supervising nurse is best?
inform the student the reasons the docusate should be given to this patient
a client in the ED is having a stroke and needs a carotid artery angioplasty with stent placement. The client’s mental status is deteriorating. What action by the nurse is most appropriate?
attempt to find the family to sign a consent
Discharge teaching related to digoxin for a 3 month old infant with a cardiac defect should include what info.. SATA
- give the med at regular intervals
- notify the HP if more than 2 consecutive doses are missed
the nurse is caring for a newborn with a large ventricular septal defect who has undergone pulmonary artery banding. Which assessment finding indicates that the pulmonary artery band is functioning effectivey?
breath sounds are clear and equal bilaterally
which signs and symptoms would be expected in a child who has tetralogy of Fallot. SATA
- history of squatting
- murmur
when doing post op teaching for a preschool age child with a heart defect on how to perform coughing and deep breathing exercises in a post op period, which teaching principle should the nurse address first?
build on the child’s current level of knowledge
as part of pre-op teaching the nurse tells parents of a child going for a Tetralogy of Fallot repair that postop, the child may….
be placed on a sodium restricted diet
which intervention is the greatest priority for the therapeutic management of a child with congestive HF caused by pulmonary stenosis?
administer furosemide to decrease systemic venous congestion
