A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse.

Which of the following initial questions posed by the nurse is MOST appropriate?.

A patient who has recently had an acute myocardial infarction (AMI) ambulates in the hospital hallway. Which data would indicate to the nurse that the patient should stop and rest?.

The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse helps identify a risk factor for IE?.

A nurse is caring for a client who has heart failure.

Nurses' Notes.

Day 1: Vital Signs.

Bilateral breath sounds clear and present throughout.

Weight 80 kg (176 lb). Urine output 480 mL/8 hr. Day 4: Breath sounds scattered, crackles heard bilaterally.

Apical heart rate rapid and irregular.

Audible S3 gallop.

Weight 82.1 kg (181 lb). Urine output 320 mL/8 hr. Vital Signs.

Day 1: Temperature 37.6° C (99.7° F). Blood pressure 108/50 mm Hg. Pulse 98/min.

Respiratory rate 20/min.

Pulse oximetry 95% on room air.

Day 4: Temperature 36.8° C (98.2° F). Blood pressure 138/80 mm Hg. Pulse 112/min.

Respiratory rate 28/min.

Pulse oximetry 88% on room air.

A nurse is reviewing the assessment findings for the client on day 4. Which of the following findings requires further action? (Select all that apply.).

The nurse is caring for a patient with mitral regurgitation. Where would the nurse listen to best hear a murmur typical of mitral regurgitation?.

A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test is most specific for the nurse to monitor in determining whether the patient has had an AMI?.

A nurse is caring for an adolescent in an emergency department.

Vital Signs.

2300: Medical History.

Blood pressure 120/78 mm Hg. Apical pulse rate 100/min.

Respiratory rate 20/min.

2400: Temperature 37.9° C (100.2° F). Oxygen saturation 98% on room air.

Nurses' Notes.

Blood pressure 112/64 mm Hg. Apical pulse rate 108/min.

Respiratory rate 28/min.

Temperature 38.9° C (102° F). Oxygen saturation 95% on room air.

Medical History.

History of rheumatic fever with resulting cardiac valve damage.

Nurses' Notes.

2300: Adolescent brought to emergency department by their parent.

Adolescent reports intermittent low-grade fever and anorexia.

Manifestations presented a few days after having dental work performed.

Now they are worse.

Adolescent noticed shortness of breath with exertion today.

Adolescent in semi-reclining position.

Respirations easy and unlabored while at rest.

Mild dyspnea observed when adolescent ambulated to the room.

Lung sounds clear bilaterally.

Oral mucous membranes pink with petechiae noted.

Adolescent reports diffuse joint pain as 2 on a scale of 0 to 10. 2400: Adolescent restless and sweating, sitting in high-Fowler's position.

Dyspnea noted at rest.

Adolescent reports pain in mid-chest as dull, aching, and as 2 on a scale of 0 to 10. Few coarse rales auscultated bilaterally.

The nurse reports the 2400 assessment findings to the provider.

Which of the following should the nurse anticipate the provider will prescribe? For each potential provider's prescription, specify if the potential prescription is anticipated or contraindicated for the client.

While auscultating a patient's heart sounds, a nurse detects a fourth heart sound (S4). The nurse understands that this finding possibly indicates:.

A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action would the nurse take first?.

A patient who has heart failure recently started taking digoxin in addition to furosemide and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider?.

After receiving a change-of-shift report about the following four patients on the cardiac care unit, which patient would the nurse assess first?.