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The nurse is caring for a 63 year old female with history of hypertension and complaints of shortness of breath.  Day 1: Bilateral breath sounds clear and present throughout, Weight 80kg(176 LB), Urine output 480ml/8 hours. Vital Signs: Temp-99.7, BP 108/50, Pulse 98, Resp rate-20, O2Sat 95% Room Air. Day 4: Breath sounds scattered, crackles heard bilaterally. Apical heart rate rapid and irregular. Audible s3 Gallop. Weight 82.1kg(181 LB). Urine output 320ml/8 hours. Vital Signs: Temp-98.2, BP 138/80,  Pulse 112, Resp rate-28, O2Sat 88% Room Air.  Provider Prescription: Lopressor 25mg PO Daily Lasix 20mg PO BID Potassium 10MEQ BID Out of each assessment finding, please select the findings that indicate the client’s status has improved. Please Select all that apply.

A client is diagnosed with mitral stenosis and new onset atrial-fibrillation.  Which interventions will the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply

A client is on a 1500 ml fluid restriction and 2 gm sodium diet due to a diagnosis of Heart Failure.  The nurse enters a client’s room and finds her in the bathroom drinking water from the sink.  What is the best nursing action?

The nurse determines that a client has a characteristic symptom of pericarditis.  What symptoms does the nurse recognize as significant for this diagnosis?

In the care of a client receiving drug therapy for hypertension, which assessment best determines the effectiveness of the medication?

A client in the emergency department who is being monitored with a portable monitor/defibrillator develops this rhythm. What action will the nurse take first?

Which nursing action will the nurse delegate to unlicensed assistive personnel (UAP) when administering a transfusion of packed red blood cells (PRBCs) to a client with blood loss?

Which measures will best help control of hypertension?  Select all that apply.

An older adult client is taking digitalis (Digoxin) 0.25 mg twice a day and furosemide (Lasix) 40 mg daily for heart failure (HF).  She has complained of increasing lethargy and nausea over the past 2 days; however she is still able to take her medication.  Her blood pressure is 150/98 mm Hg; pulse is 110 beats/min and irregular; respiratory rate is 18 breaths/min. What laboratory information is most important for the nurse to evaluate?

A client with Type A Hemophilla has been admitted to the hospital with severe pain and swelling in the right knee. What will the nurse do first?