MEDSERGE 2 FLASHCARDS
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
A. Increased heart rate
B. Increased blood pressure
C. Increased respiratory rate
D. Increase hematocrit
E. Increased temperature Incre...
medserge 2 flashcards a nurse is assessing a client who has fluid overload which of the following findings should the nurse expect select all that apply a increased heart r
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MEDSERGE 2 FLASHCARDS
A nurse is assessing a client who has fluid overload. Which of the following
findings should the nurse expect? (Select all that apply.)
A. Increased heart rate
B. Increased blood pressure
C. Increased respiratory rate
D. Increase hematocrit
E. Increased
temperature
Increased heart rate
B. Increased blood pressure
C. Increased respiratory rate
A nurse is caring for a client who is prescribed warfarin therapy for an
artificial heart valve. Which of the following laboratory values should the
nurse monitor for a therapeutic effect of warfarin?
prothrombin time
.A nurse is assessing a client who is receiving one unit of packed RBCs to
treat intraoperative blood loss. The client reports chills and back pain, and
the client's blood pressure is 80/64 mm Hg. Which of the following actions
should the nurse take first? stop the infusion of blood
.A nurse is caring for a client who is receiving a unit of packed red blood
cells. Fifteen minutes following the start of the transfusion, the nurse notes
that the client is febrile, with chills and red-tinged urine. Which of the
following transfusion reactions should the nurse suspect?
hemolytic
A nurse in an emergency department is caring for a client who had a
seizure and became unresponsive after stating she had a sudden, severe
headache and vomiting. The client's vital signs are as follows: blood
pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a
temperature of 38.2° C (100.8° F). Which of the following neurologic
disorders should the nurse suspect?
hemorrhagic stroke
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A nurse is caring for a client who returns to the nursing unit from the
recovery room after a sigmoid colon resection for adenocarcinoma. The
client had an episode of intraoperative bleeding. Which finding indicates to
the nurse that the client may be developing hypovolemic shock
increase heart rate ftom 88 to 110/min
A nurse is caring for a client who has hypernatremia and requires IV fluid
therapy due to his NPO status. Which of the following solutions should the
nurse prepare to infuse for this client?
0.45% sodium chloride
A nurse is caring for a client who has pericarditis and reports feeling a
new onset of palpitations and shortness of breath. Which of the following
assessments should indicate to the nurse that the client may have
developed atrial fibrillation?
different apical and radial pulses
,A nurse is assessing a client's radial pulse and determines that the pulse is
irregular. Which of the following actions should the nurse take
,assess the apical pulse for a full minute
A nurse is assessing an older adult client who is receiving digoxin. The nurse
should recognize that which of the following findings is a manifestation of
digoxin toxicity?
Anorexia
Rationale:Anorexia, vomiting, confusion, headache, and vision changes are
manifestations of digoxin toxicity
.A nurse is assessing a client who is receiving dopamine IV to treat left
ventricular failure. Which of the following findings should indicate to the
nurse that the medication is having a therapeutic effect?
systolic BP is increaed
A nurse in the emergency department is caring for a client who took 3
nitroglycerin tablets sublingually for chest pain. The client reports relief
from the chest pain but now he is experiencing a headache. Which of the
following statements should the nurse make?
a headache is an expected adverse effect of this medication
A nurse is providing discharge teaching for a client who has pulmonary
edema and is about to start taking furosemide. Which of the following
instructions should the nurse include?
eat foods that contain potassium
loop diuretics lose potassium!
A nurse on a telemetry unit is caring for a client who has unstable angina
and is reporting chest pain with a severity of 6 on a 0 to 10 scale. The
nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the client
states that his chest pain is now a severity of 2. Which of the following
actions should the nurse take?
administer another nitroglycerin tablet
A nurse is caring for a client who is at 6 weeks of gestation and has
pneumonia. While the nurse is obtaining the client's history, the client tells
the nurse that she takes the herb feverfew for migraine headaches. Which
of the following actions should the nurse take?
explain to the client that she should not take this herb while pregnant
A nurse is caring for an older adult client. The nurse informs the client
that straining while defecating can cause which of the following
dysrhythmias
A nurse is caring for a client who has a central venous catheter and
suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The
nurse suspects air embolism and clamps the catheter immediately. What
other action should the nurse take at this time place the client on his left
side in trendelenburg position
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A nurse is caring for a client who has hypovolemic shock. Which of the
following should the nurse recognize as an expected finding?
oliguria
A nurse is caring for a client who is in the compensatory stage of shock.
Which of the following findings should the nurse expect?
, Blood pressure 115/68 mmHg
Rationale:The sympathetic nervous system is stimulated, resulting in the
release of epinephrine and norepinephrine. These catecholamines help
maintain the client's blood pressure remains within normal limits during the
compensatory stage of shock.
A nurse in an urgent care center is assessing a client who reports a sudden
onset of irregular palpitations, fatigue, and dizziness. The nurse finds a
rapid and irregular heart rate with a significant pulse deficit. Which of the
following dysrhythmias should the nurse expect to find on the ECG?
A fib
A nurse is among the first responders to a mass-casualty incident and
does not know what type of personal protective equipment (PPE) is
needed. Which of the following actions should the nurse take
choose highest level of protection equipment available
A charge nurse is making a room assignment for a client who has scabies.
In which of the following rooms should the nurse place the client?
a private room
A nurse is reviewing the EKG strip of a client who has prolonged vomiting.
Which of the following abnormalities on the client's EKG should the nurse
interpret as a sign of hypokalemia?
Abnormally prominent U wave
Rationale:Although U waves are rare, their presence can be associated
with hypokalemia, hypertension and heart disease. For a client who has
hypokalemia, the nurse should monitor the EKG strip for a flattened T
wave, prolonged PR interval, prominent U wave, or ST depression.
A nurse is caring for a client who is in premature labor and is receiving
terbutaline. The nurse should monitor the client for which of the following
adverse effects that should be reported to the provider?
dyspnea
.A nurse is assessing a 3-year-old child who has aortic stenosis. Which of
the following findings should the nurse expect? (Select all that apply.)
hypotensi
on weak
pulses
murmur
A nurse is caring for an 8-year-old child who has acute rheumatic fever.
Which of the following assessments is the nurse's priority immediately
after admission? auscultating the rate and characteristics of the childs
heart sounds
A nurse is caring for a client who has a T-4 spinal cord injury. Which of
the following client findings should the nurse identify as an indication the
client is at risk for experiencing autonomic dysreflexia?
the clients bladder becomes
distended severe hyperkalemia..
widedned P
wave before
QRS
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