Orthostatic (postural) Hypotension

- Is a sustained decrease of at least 20 mm Hg in systolic BP or 10 mmHg in diastolic BP in

3 minutes of moving from a lying or sitting to a standing position.

Prothrombin

A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse
would monitor:

A. Platelet count

The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s
platelet count currently is 80,000. It will be most important to teach the client and family about:

A. Bleeding precautions

The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During
administration, the nurse should:

Check the blood glucose level.

B
.

The six-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate.
Which finding should be reported to the doctor?

C Heart rate of 60bpm

.

The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:

C Leave the medication in the brown bottle

.

The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in
saturated fats?
 C Turkey breast
.

The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse
should check the:

B Neck
.

The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at
the:

A. Phlebostatic axis

The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client
with hypertension. The nurse should:

Administer the medications.

B
.

The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings
include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing
diagnosis?

B Fluid volume deficit

.

A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention
would be most important to include in the nursing care plan?

A. Assess for signs of abnormal bleeding.

The client with a pacemaker should be taught to:

D. Monitor his pulse rate

client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed
to:

A. Have a Protime done monthly

A client has an order for streptokinase. Before administering the medication, the nurse should assess the client
for:

B A history of streptococcal infection

.

The infant is admitted to the unit with tetralogy of Fallot. The nurse would anticipate an order for which
medication?

A. Digoxin

The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal
defect will:

A. Tire easily

The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:

C Ventricular tachycardia
.

A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The
nurse should teach the client that Lovenox injections should:
 B Be injected into the abdomen
.

The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The
correct method of administering these medications is to:

. Administer the medication separate