Adult Health 1 Final Exam

A nurse is assisting a client with mild chronic obstructive pulmonary disease (COPD) to set a goal related to the condition. Which of the following is an appropriate goal for this client? A. Increase walking distance around a city block without shortness of breath. B. Maintain activity level of walking to the mailbox. C. Continue with current level of mobility at home. D. Relieve shortness of breath to a level as close as possible to tolerable.

A. Increase walking distance around a city block without shortness of breath.

When caring for a client who has risk factors for fluid and electrolyte imbalances, which assessment finding is the highest priority for the nurse to follow up? A. Irregular heart rate B. Blood pressure 96/53 mm Hg C. mild confusion D. Weight loss of 4 lb

A. Irregular heart rate

A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? A. antipyretic B. anti-inflammatory C. analagesic D. Antiplatelet aggregate

D. Antiplatelet aggregate

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. sinus bradycardia B. sinus tachycardia C. Ventricular fibrillation D. Atrial fibrillation

D. Atrial fibrillation

A deep partial and full thickness burn is usually very painful. True False

False

2. Arterial ulcers tend to be symmetrical and form a ___ whereas venous ulcers tend to be asymmetrical and form a ___

deep crater shallow wound

The nurse recognizes that CO2 is regulated by the ___ and HCO3 is regulated by the ___

lungs kidneys

The first line of defense when the pH is out of balance is: A. chemical buffers B. kidneys C. heart D. lungs

A. chemical buffers

A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? A. decreased breath sounds B. crackles C. rhonchi D. wheezes

A. decreased breath sounds

The nurse is caring for a client with coronary artery disease. What is the nurse's priority goal for the client? A. enhance myocardial oxygenation B. educate the client about his symptoms C. administer sublingual nitroglycerin D. decrease anxiety

A. enhance myocardial oxygenation

A superficial burn injury that is at the epidermal level is considered what degree of burn? A. first degree B. third degree C. second degree D. full thickness

A. first degree

What intervention is a priority when treating a client with HIV/AIDS? A. fluid and electrolyte balance B. neurological status C. psychological status D. skin integrity

A. fluid and electrolyte balance

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A. fried chicken B. Tapioca pudding C. mashed potatoes D. dinner roll

A. fried chicken

You are caring for a new client on your unit who is third-spacing fluid. You know to assess for what type of edema? A. generalized B. dependent C. pitting D. brassy

A. generalized

Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia? A. hypotension B. hypertension C. warm moist skin D. bradycardia

A. hypotension

A client with allergies has been advised to have an allergy test. The nurse needs to administer an injection to the client for allergy testing. Which injection route is most suitable for allergy testing? A. intradermal B. subcutaneous C. intravenous D. intramuscular

A. intradermal

The nurse teaches the client that osteoarthritis: A. is the most common and frequently disabling of joint disorders. B. affects young males C. requires early treatment because most of the damage appears to occur early in the course of the disease. D. affects the cartilaginous joints of the spine and surrounding tissues.

A. is the most common and frequently disabling of joint disorders

The nurse is caring for a client who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following? A. shortness of breath B. Epistaxis C. sputum production D. throat discomfort

A. shortness of breath

What does the following determine? A. sinus tachycardia B. sinus bradycardia C. Atrial fibrillation D. normal sinus rhythm

A. sinus tachycardia

A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does bloody fluid results indicate? A. trauma B. infection C. emphysema D. cancer

A. trauma

A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. What position should the nurse help the client into? A. tripod position B. left lateral position C. high fowler's position D. semi-fowler's position

A. tripod position

You have been asked to change your client's pressure wound and use a wet-to-dry dressing. What is the purpose of this type of dressing? A. The packed gauze is a temporary fix before surgery B. The packed gauze works to remove (debride) the dead or injured tissue C. The packed gauze is works in wounds that have eschar. D. The packed gauze liquefies the slough so it can be cleansed from the wound

B. The packed gauze works to remove (debride) the dead or injured tissue

A nurse enters an adult client's room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first? A. Leave the client's room to call for the code team B. Attach the AED to the client. C. Begin chest compressions after calling for the code team D. Administer rescue breathing.

C. Begin chest compressions after calling for the code team

A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.) A. Measure the client's vital signs every 4 hours. B. Place the client in high-Fowler's position. C. Check peripheral pulses in the affected extremity. D. Keep the client's hip and leg extended E. Have the client remain in bed up to 6 hr.

C. Check peripheral pulses in the affected extremity. D. Keep the client's hip and leg extended E. Have the client remain in bed up to 6 hr.

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate doing what action? A. Defibrillation B. Radiofrequency catheter ablation C. Elective cardioversion D. CPR

C. Elective cardioversion

What does the following determine? A. sinus tachycardia B. unreadable C. atrial fibrillation D. ventricular fibrillation

C. atrial fibrillation

A nurse is caring for a client who develops the following rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority? A. Airway management B. Amiodarone administration C. Epinephrine administration D. Defibrillation

D. Defibrillation

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect? A. cough and wheezing B. Blood-tinged sputum C. decreased Brain Natriuretic Peptide (BNP). D. Distended jugular veins

D. Distended jugular veins

The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water? A. intravascular fluid B. extracellular fluid C. Interstitial fluid D. Intracellular fluid

D. Intracellular fluid

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? A. Slow B. Bounding C. Not palpable D. Irregular

D. Irregular

AIDS is a ___ , and HIV is a ___

a disease a virus

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? A. blood pressure B. respirations C. pulse D. temperature

C. pulse

What does the following determine? A. sinus tachycardia B. unreadable C. sinus bradycardia D. normal sinus rhythm

C. sinus bradycardia

The nurse is caring for a client who has had diarrhea for two days which has led to metabolic acidosis. This acidotic state is considered the following: or relative acidosis A. actual acid excess B. relative acidosis

B. relative acidosis

A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg PO daily. Available is digoxin PO 0.25 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.5

A nurse is teaching a newly licensed nurse about evaluating a cardiac rhythm. Which of the following options should the nurse identify as the P wave in the ECG complex? D A B C

A

The most diagnostic clinical symptom of pleurisy is: A. Stabbing pain during respiratory movements. B. Dullness or flatness on percussion over areas of collected fluid. C. Dyspnea and coughing. D. Fever and chills.

A. Stabbing pain during respiratory movements.

A client wants to prevent the development of diabetes, osteoarthritis, and high blood pressure because many family members have the conditions. Which response will the nurse state to this client? A. "Although they are considered genetic disorders, environment factors can influence their development." B. "I understand your concern. These conditions are primarily associated with a specific ethnic group." C. "The development of these conditions will depend upon the age of your father." D. "These conditions are not inherited conditions, and therefore are not affected by genetics."

A. "Although they are considered genetic disorders, environment factors can influence their development."

A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.) A. "I should limit my exercise." B. "I must stop smoking." C. "I need to monitor my weight." D. "I am limiting my intake of fast foods."

A. "I must stop smoking." B. "I need to monitor my weight." C. "I am limiting my intake of fast foods."

A nurse is performing an ECG on a client who is experiencing chest pain. Which of the following statements should the nurse make? A. "I will need to apply electrodes to your chest and extremities." B. "The radioactivity from the dye lasts only a few hours." C. "The test will be complete in 20 minutes." D. "You might feel a slight pain while the test is being done."

A. "I will need to apply electrodes to your chest and extremities."

The nurse is giving an educational talk to a local parent-teacher association. A parent asks how he can help his family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections? A. "Make sure your family has all their childhood immunizations." B. "Encourage your family to adopt a healthy diet and exercise regimen." C. "Encourage your family to stop smoking." D. "Make sure your family has regular checkups."

A. "Make sure your family has all their childhood immunizations."

A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub? A. 20 mL or less B. no fluid C. 20-30 ml D. greater than 40 ml

A. 20 mL or less

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? A. Abnormally prominent U wave B. Inverted P wave C. Elevated ST segment D. Wide QRS

A. Abnormally prominent U wave

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? A. Acute pain related to biliary spasms B. Imbalanced nutrition: Less than body requirements related to biliary inflammation C. Deficient knowledge related to prevention of disease recurrence D. Anxiety related to unknown outcome of hospitalization

A. Acute pain related to biliary spasms

The nurse at the beginning of the evening shift in the emergency department receives a report at 1900 on the following clients. Which client would the nurse assess first? A. An 62-year-old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office B. An 85-year-old with COPD with wheezing and an O2 saturation of 89% on 2 L of oxygen C. A 73-year-old with emphysema who has 300 mL of intravenous fluid remaining D. A 74-year-old with chronic bronchitis who has BP 128/58, HR 104, and R 26

A. An 62-year-old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office

Which of the following treatments are necessary for a client that has pneumonia? Select all that apply. A. Antibiotics B. oxygen therapy to keep sats at 92 and above C. gradual increase of activity D. fluid restriction E. bed rest

A. Antibiotics B. oxygen therapy to keep sats at 92 and above C. gradual increase of activity

A client is admitted to the emergency department with a stab wound and is now presenting dyspnea, tachypnea, and sucking noise heard on inspiration and expiration. The nurse should care for the wound in which manner? A. Apply airtight dressing. B. Clean the wound and leave open to the air. C. Apply direct pressure to the wound. D. Apply vented dressing

A. Apply airtight dressing.

Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. A. Crackles in the lung fields B. Shortness of breath C. Distended neck veins D. bradycardia E. Decreased blood pressure

A. Crackles in the lung fields B. Shortness of breath C. Distended neck veins

A client has a potassium level of 2.8. The doctor has ordered Potassium IV push. What is the nurses next action? Select all that apply. A. DO NOT GIVE POTASSIUM IV PUSH. YOU WILL KILL YOUR PATIENT. B. DO NOT GIVE POTASSIUM IV PUSH. YOU WILL KILL YOUR PATIENT. C. DO NOT GIVE POTASSIUM IV PUSH. YOU WILL KILL YOUR PATIENT. D. DO NOT GIVE POTASSIUM IV PUSH. YOU WILL KILL YOUR PATIENT

A. DO NOT GIVE POTASSIUM IV PUSH. YOU WILL KILL YOUR PATIENT. B. DO NOT GIVE POTASSIUM IV PUSH. YOU WILL KILL YOUR PATIENT. C. DO NOT GIVE POTASSIUM IV PUSH. YOU WILL KILL YOUR PATIENT. D. DO NOT GIVE POTASSIUM IV PUSH. YOU WILL KILL YOUR PATIENT

A client is admitted to the medical surgical floor with a history of Coronary Artery Disease (CAD). Which cardiac risk factors can the client control? A. Diabetes, hyp[ercholesterolemia, and hypertension B. Diabetes, hypercholesterolemia, and heredity C. Diabetes, age, and gender D. Age, gender, and heredity

A. Diabetes, hyp[ercholesterolemia, and hypertension

Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? A. Elevated hematocrit level B. Low urine specific gravity C. Abnormal potassium level D. Low white blood count

A. Elevated hematocrit level

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? A. Extracellular fluid volume deficit B. Altered blood urea nitrogen (BUN) value C. metabolic alkalosis D. respiratory acidosis

A. Extracellular fluid volume deficit

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury? A. Fever and change in urine clarity B. Lower back pain C. Burning sensation on urination D. Frequency of urination

A. Fever and change in urine clarity

A client who has been diagnosed with cholecystitis is being discharged home from the ED to be scheduled for later surgery. The client received morphine during the present ED admission and is visibly drowsy. When providing health education to the client, what would be the most appropriate nursing action? A. Give verbal and written instructions to the client and a family member. B. Telephone the client the next day with verbal instructions. C. Give verbal instructions to one of the client's family members. D. Give written instructions to client.

A. Give verbal and written instructions to the client and a family member.

The nurse is creating a care plan for a client suffering from allergic rhinitis. What outcome should the nurse identify? A. Improved coping with lifestyle modifications B. Improved skin integrity C. Safe injection of corticosteroids D. Appropriate use of prophylactic antibiotics

A. Improved coping with lifestyle modifications

Your client has a diagnosis of heart failure. Which of the following orders would you question? A. Normal saline bolus of 1 liter over 3 hours. B. Daily weights C. Diuretic therapy D. Low sodium diet

A. Normal saline bolus of 1 liter over 3 hours.

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take? A. Obtain an EKG B. Maintain oxygen saturations greater than or equal to 92%. C. Administer enteric-coated acetaminophen D. Administer ibuprofen

A. Obtain an EKG

What intervention is a priority for a client diagnosed with osteoarthritis? A. Physical therapy and exercise B. hydrotherapy C. Colchicine D. Allopurinol

A. Physical therapy and exercise

A client has had several diagnostic tests to determine if he has systemic lupus erythematosus (SLE). What result is very specific indicator of this diagnosis? A. Positive Anti-dsDNA antibody test B. Positive Anti-Sm antibodies C. Positive ANA titer D. Elevated ESR

A. Positive Anti-dsDNA antibody test

The nurse's plan of care for a client with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to candidiasis. What nursing intervention best addresses this risk? A. Providing thorough oral care before and after meals B. Administering prophylactic antibiotics C. Promoting nutrition and adequate fluid intake D. Applying skin emollients as needed

A. Providing thorough oral care before and after meals

A client is suspected of sepsis from a postsurgical incision infection. What characteristic of sepsis would the nurse recognize? Select all that apply. A. Temperature of 102.5F B. Heart rate of 130 beats/minute C. Respiratory rate of 28 breaths/minute D. PaCO2 of 42 mm Hg E. Blood pressure of 120/80 mm Hg

A. Temperature of 102.5F B. Heart rate of 130 beats/minute C. Respiratory rate of 28 breaths/minute

A client with HIV has a T4-cell count of 200/mm3, and the client has been diagnosed with Pneumocystis pneumonia. What does this indicate to the nurse? A. The client has converted from HIV infection to AIDS. B. The client has advanced HIV infection. C. The client's T4-cell count has decreased due to the Pneumocystis pneumonia. D. The client has another infection present that is causing a decrease in the T4-cell count.

A. The client has converted from HIV infection to AIDS.

The nurse is administering a skin test for detection of exposure to tuberculosis. How would the nurse determine if the client was exposed to tuberculosis? A. The injection area swells if the client has developed antibodies against the antigen. B. The injection area will become painful with in duration if the client has antibodies against the antigen. C. The client will have a productive cough. D. The injection area will break out in a fine macular rash.

A. The injection area swells if the client has developed antibodies against the antigen.

The third line of defense when the pH is out of balance are the kidneys. Why are the kidneys the third line of defense? A. The kidneys take longer to have the full effect, however the effects last much longer. B. Because the kidneys work faster than buffers and the lungs C. Anatomically, the kidneys would naturally be the next in line below the lungs.

A. The kidneys take longer to have the full effect, however the effects last much longer.

A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? A. To remove air from the pleural space B. To drain copious sputum secretions C. To monitor bleeding around the lungs D. To drain copious sputum secretions

A. To remove air from the pleural space

The nurse is caring for a client who experienced a MI 3.5 hours ago. What lab value would the nurse expect to be elevated? A. Troponin I B. Unconjugated bilirubin C. Serum amylase D. Aspartate aminotransferase (AST)

A. Troponin I

The nurse is caring for a client who has ventilator associated pneumonia. The spouse asks the nurse how their spouse developed this type of pneumonia. The response that is most accurate is: A. Ventilator associated pneumonia develops due to artificial airways and being on a ventilator. B. Ventilator associated pneumonia develops from being cared for in the hospital and getting a common microorganism, MRSA. C. Ventilator associated pneumonia develops from upper respiratory infections, not getting the vaccine and being around others with Upper respiratory infections. D. Ventilator associated pneumonia develops when a person cannot swallow adequately.

A. Ventilator associated pneumonia develops due to artificial airways and being on a ventilator.

A nurse is managing the care of a client with osteoarthritis. What is the appropriate treatment strategy the nurse will teach the about for osteoarthritis? A. administration of nonsteroidal anti-inflammatory drugs (NSAIDs) B. administration of opioids for pain control. C. administration of monthly intra-articular injections of corticosteroids. D. vigorous physical therapy for the joints

A. administration of nonsteroidal anti-inflammatory drugs (NSAIDs)

what does the following determine? A. asystole B. ventricular tachycardia C. atrial fibrillation D. leads are off of patient; check on patient

A. asystole

A nurse is providing care for a client who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply. A. atelectasis B. pneumonia C. hemorrhage D. Malignant hyperthermia E. chronic gastritis

A. atelectasis B. pneumonia C. hemorrhage

In a diagnosis of a lower urinary tract infection, which structures could be affected? Select all that apply: A. bladder B. urethra C. ureter D. kidney

A. bladder B. urethra

A client with systemic lupus erythematosus (SLE) has the classic rash of lesions on the cheeks and bridge of the nose. What term should the nurse use to describe this characteristic pattern? A. butterfly rash B. Bull's eye rash C. papular rash D. pustular rash

A. butterfly rash

A 5-year-old has been diagnosed with a severe walnut allergy after experiencing an anaphylactic reaction. Which topic is the nurse's priority when providing health education to the family? A. carrying and epi pen B. Beginning immunotherapy C. Maintaining the child's immunization status D. Avoiding all foods that have a high potential for allergies

A. carrying and epi pen

A 52-year-old client is scheduled for diagnostic testing to address prolonged signs and symptoms of genitourinary dysfunction. What signs and symptoms are particularly suggestive of urinary tract disease? Select all that apply. A. pain B. gastrointestinal symptoms C. changes in voiding D. Petechiae E. jaundice

A. pain B. gastrointestinal symptoms C. changes in voiding

The nurse reviews the results of a client's ventilation-perfusion (V/Q) scan. For which condition will the nurse plan care when the ventilation-perfusion ratio is less than 0.80? A. pneumonia B. Cardiogenic shock C. Pulmonary emboli D. Pulmonary infarction

A. pneumonia

A critical care nurse is caring for a client with a hemodynamic monitoring system in place. For what complications should the nurse assess? Select all that apply. A. pneumothorax B. air embolism C. bronchospasm D. Atelectasis E. infection

A. pneumothorax B. air embolism C. bronchospasm

The nurse is caring for a client with symptoms of gallbladder disease. Which diagnostic test will the nurse anticipate preparing the client for to confirm the diagnosis? A. ultrasound B. Cholescintigraphy C. Oral cholecystography D. Abdominal x-ray

A. ultrasound

The nurse is providing care for a client who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? A. unequal peripheral pulses between extremities B. Reddened extremities with muscle atrophy C. Visible clubbing of the fingers and toes

A. unequal peripheral pulses between extremities

A nurse is caring for a client who is scheduled for a stress test. Which of the following comments made by the client should indicate to the nurse that the client may require a chemical stress test? A. "I ride my stationary bike every morning" B. "I require assistance when moving from my recliner to the restroom" C. I normally do water aerobics twice per week "I walk up and down stairs daily with little difficulty."

B. "I require assistance when moving from my recliner to the restroom"

The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level? A. 135 mEq/L B. 115 mEq/L C. 160 mEq/L D. 130 mEq/L

B. 115 mEq/L

The nurse is caring for a client who sustained third degree burns to the front side of the left arm and hand, and the front side of the chest and abdomen. Using the rule of nines, what percentage of the body surface area is burned? A. 27% B. 22.5% C. 36% D. 18%

B. 22.5%

A nurse is assessing her client's wound. What is the width of the wound in this picture? A. 4cm B. 5cm C. 7cm D. 6cm

B. 5cm

The nurse is caring for a client who sustained 2nd degree burns to the front and back of the head. What percentage of body surface area is burned? A. 18% B. 9% C. 10% D. we don't use percentage of BSA when it comes to the head

B. 9%

The nurse in the emergency department is caring for a client recently admitted with a likely myocardial infarction (MI). The nurse understands that the client's heart is pumping an inadequate supply of oxygen to the tissues. The nurse knows the client is at an increased risk for MI due to which factor? A. Elevated B-natriuretic peptide (BNP) B. Arrhythmias C. Dehydration D. Use of thrombolytics

B. Arrhythmias

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? A. Differences in upper and lower lung sounds. B. Different apical and radial pulses, C. Differences between oral and axillary temperatures. D. Different blood pressures in the upper limbs.

B. Different apical and radial pulses,

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Abdominal distension B. Hacking cough C. Jugular venous distention D. Dependent edema

B. Hacking cough

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply) A. Genetic predisposition B. Hypercholesterolemia C. Obesity D. Hypertension E. Smoking

B. Hypercholesterolemia C. Obesity D. Hypertension E. Smoking

The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of which imbalance? A. Hypercalcemia B. Hypovolemia C. Hypermagnesemia D. Metabolic alkalosis

B. Hypovolemia

A client has arrived on the telemetry floor following a cardiac catheterization that was accessed through the client's femoral artery. Which of the following actions should the nurse plan to take? A. Instruct the client to perform range-of-motion exercises to his lower extremities. B. Perform neurovascular checks with vital signs. C. Ambulate the client 1 hr following the procedure. D. Restrict the client's fluid intake.

B. Perform neurovascular checks with vital signs.

A client who has an artery blockage is undergoing a Percutaneous Transluminal Coronary Angioplasty (PTCA). Following the procedure, the client will have what medication for the life of the stent? A. Beta blocker B. Plavix C. Ace inhibitor D. Thrombolytic therapy (tPA)

B. Plavix

A 68 year-old man with a history of COPD and chronic carbon dioxide retention presents to the emergency room complaining of worsening dyspnea and an increase in the frequency and purulence of his sputum production over the past 2 days. His oxygen saturation is 78% on room air. Before he is place on supplemental oxygen, a room air arterial blood gas is drawn and reveals: pH 7.25, PCO2 68, HCO3 31. What is going on with this client: A. metabolic acidosis B. Respiratory acidosis with metabolic compensation C. metabolic alkalosis D. Respiratory alkalosis with metabolic compensation

B. Respiratory acidosis with metabolic compensation

A client reports chest pain that occurs when snow skiing but resolves when resting. The nurse knows these symptoms are common for which type of angina? A. variant B. Stable C. Unstable D. intractable

B. Stable

The critical care nurse and the other members of the care team are assessing the client to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A. Stable nutritional status and ABGs B. Stable vital signs and ABGs C. Normal orientation and level of consciousness D. Pulse oximetry above 80% and stable vital signs

B. Stable vital signs and ABGs

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? A. The QRS duration is 0.20 seconds. B. The P wave falls before the QRS complex. C. The P-R interval measures 0.22 seconds. D. The T wave is in the inverted position.

B. The P wave falls before the QRS complex.

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.) A. Plasma low-density lipoproteins (LDL) B. Troponin I C. Troponin T D. Myoglobin E. CPK

B. Troponin I C. Troponin T D. Myoglobin E. CPK

How would you stage this wound? A. Stage 4 B. Unstageable C. Stage 3 D. Stage 2

B. Unstageable

The nurse cares for a client in the emergency department who has a B-type natriuretic peptide (BNP) level of 624. The nurse recognizes that this finding is most indicative of which condition? A. hypertension B. heart failure C. Myocardial infarction D. Coronary artery disease

B. heart failure

A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what? A. respiratory arrest B. hemodynamic instability C. GI hypermotility D. hypokalemia

B. hemodynamic instability

A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A. hypokalemia B. hypocalcemia C. hyperkalemia D. hypercalcemia

B. hyperkalemia

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 hematocrit B. increased respiratory rate C. increased blood pressure D. increased heart rate E. increased temperature

B. increased respiratory rate C. increased blood pressure D. increased heart rate

A 70-year-old client is brought into the VA hospital with complaints of severe nausea and weakness. Over the past week, has been consuming large quantities of TUMS (calcium carbonate). His ABG's reveal pH 7.45, PCO2 49, PO2 68, HCO3- 34. What is going on with this client? A. metabolic acidosis with the respiratory system compensating B. metabolic alkalosis with the respiratory system compensating.

B. metabolic alkalosis with the respiratory system compensating.

A nurse is caring for a client who is currently in a Diabetic Ketoacidosis, state. Which ABG would correlate with DKA? A. pH 7.60, C02 34, HC03 28 B. pH 7.25, C02 34, HC03 28 C. pH 7.50, C02 34, HC03 28

B. pH 7.25, C02 34, HC03 28

A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings? A. metabolic acidosis B. respiratory alkalosis C. metabolic alkalosis D. respiratory acidosis

B. respiratory alkalosis

A nurse reviews the arterial blood gas (ABG) values of a client: pH, 7.52; PaCO2, 29 mm Hg; and HCO3--, 23 mEq/L. What do these values indicate? A. metabolic alkalosis B. respiratory alkalosis C. metabolic acidosis D. respiratory acidosis

B. respiratory alkalosis

A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status? A. edema B. weight C. vital signs D. intake and output

B. weight

A nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor. The nurse is aware that hyperkalemia may be associated with changes to the T-wave. On the graphic, which area of the electrocardiogram (ECG) represents the T-wave? A B C D

C

A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature and reported "dry mouth." The nurse suspects the client is experiencing which condition? A. hyperkalemia B. hypercalcemia C. dehydration D. hypervolemia

C. dehydration

A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching? A. "A weight loss program can decrease my LDL cholesterol level." B. "Exercising regularly will increase HDL cholesterol levels." C. "Increasing my intake of foods containing trans-fatty acids can lower my risk." D. "Adding foods containing omega-3 fatty acids to my diet can lower my risk."

C. "Increasing my intake of foods containing trans-fatty acids can lower my risk."

A nurse is providing instructions to a client who has a new prescription for nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include? A. "Stop taking the medication and notify your provider if you develop a headache." B. "The medication can take up to 15 minutes to take effect." C. "Place the tablet under your tongue" D. "Avoid taking the medication prior to exercising."

C. "Place the tablet under your tongue"

The nurse is teaching a client with suspected acute myocardial infarction about serial isoenzyme testing. When is it best to have isoenzyme creatinine kinase of myocardial muscle (CK-MB) tested? A. 30 minutes to 1 hour after pain B. 12 to 18 hours after admission C. 4 to 6 hours after pain D. 2 to 3 hours after admission

C. 4 to 6 hours after pain

A client experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client's pH value to be: A. 7.45 B. 7.30 C. 7.50

C. 7.50

A nurse is assigned four clients with diagnoses that rule out myocardial infarction (MI) due to chest pain. Which client's test results best demonstrate the specific diagnosis of unstable angina? A. A 54-year-old client with elevated creatine kinase myocardial band (CK-MB) and ST segment elevations in two contiguous leads on the electrocardiogram (ECG). B. A 48-year-old client with T wave inversions, ST elevation, and abnormal Q waves. C. A 63-year-old client with an increase in myoglobin, no elevation in the ST segment, and no elevation in troponins. D. A 72-year-old client with elevated troponins and no elevation in the ST segment.

C. A 63-year-old client with an increase in myoglobin, no elevation in the ST segment, and no elevation in troponins.

Regarding burn injuries, what is the number one intervention the nurse does after assuring the scene is safe and the client is no longer on fire? A. cover the wound with a dry dressing B. chest compressions C. Airway management D. call 911

C. Airway management

A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. The nurse should give the client which of the following information about anginal pain? A. The pain often radiates to the jaw or the back. B. The pain persists with rest and organic nitrates. C.The pain usually lasts longer than 20 min. D. Exertion and anxiety can trigger the pain.

C. Exertion and anxiety can trigger the pain.

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following orders should the nurse initiate first? A. Obtain a blood sample B. Attach the leads for a 12-lead ECG. C. Initiate oxygen therapy. D. Insert the IV catheter.

C. Initiate oxygen therapy.

A nurse in the ED receives a phone call from a client who reports nausea and unrelieved chest pain after taking 3 nitroglycerin tablets 5 min apart. Which of the following is an appropriate response by the nurse? A. Advise the client to come to ED B. Tell the client to take an antacid C. Instruct the client to call 911. D. Tell the client to take another nitroglycerin tablet in 15 min.

C. Instruct the client to call 911.

The nurse is performing a health history for a new client. Which should the nurse identify as a risk factor for cellulitis in an​ adult? A. Impetigo B. GERD C. Peripheral vascular disease D. hypotension

C. Peripheral vascular disease

What does the nurse recognize as one of the best indicators of the patient's renal function? A. specific gravity B. Urine osmolality C. Serum creatinine D. Blood urea nitrogen

C. Serum creatinine

The nurse collects a drainage sample to be cultured from the affected area of a client with cellulitis. Which organism should the nurse suspect is the most likely cause of the​ cellulitis? A. Escherichia coli B. Bacillus subtilis C. Staphylococcus aureus D. C-diff

C. Staphylococcus aureus

What is the following EKG determine? A. ventricular fibrillation B. tachycardia C. atrial fibrillation D. unreadable

C. atrial fibrillation

In what order does the nurse interpret the ABG? A. pH, HC03, C02 B. C02, HC03, pH C. pH, C02, HC03 D. HC03, C02, pH

C. pH, C02, HC03

The nurse is providing home care instruction to the client with cellulitis. Which​ statement, if made by the​ client, should concern the​ nurse? ​A. "I will be sure to get enough rest and stay off my affected​ leg." ​B. "I will keep all​ follow-up appointments with my healthcare​ provider." ​C. "I will take my antibiotics until the affected area looks less​ red."' ​D. "I will keep my affected leg elevated to keep swelling​ down."

C. ​"I will take my antibiotics until the affected area looks less​ red."'

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse.

D

An adult client is brought into the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy. The nurse reconciles the client's medication list and notes that salt tablets had been prescribed. What would the nurse do next? A. Continue to monitor client with another appointment. B. Be prepared to administer a sodium chloride IV C. Be prepared to administer a lactated Ringer's IV. D. Consider sodium restriction with discontinuation of salt tablets

D. Consider sodium restriction with discontinuation of salt tablets

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? A. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. B. Troponin is a lipid whose levels reflect the risk for coronary artery disease. C. Troponin is a protein that helps transport oxygen throughout the body. D. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.

D. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.

The nurse is caring for a client who is admitted to the medical unit for the treatment of a venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment. What is the nurse most likely to find during an assessment of this client's wound? A. hemorrhage B. deep wound bed C. pale colored wound bed D. heavy exudate

D. heavy exudate

The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (ADH)? A. Increased platelets B. Decreased hemoglobin C. increased serum potassium D. increased serum sodium

D. increased serum sodium

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by: A. constipation B. tremors C. diaphoresis D. muscle weakness

D. muscle weakness

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? A. PaCO 36 B. HCO 21 mEq/L C. O saturation 95% D. pH 7.48

D. pH 7.48

A client with emphysema is at a greater risk for developing which acid- base imbalance? A. metabolic alkalosis B. respiratory alkalosis C. metabolic acidosis D. respiratory acidosis

D. respiratory acidosis

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? A. Respiratory alkalosis B. metabolic acidosis C. metabolic alkalosis D. respiratory acidosis

D. respiratory acidosis

A patient who is admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.60; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 28 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: A. respiratory acidosis B. metabolic acidosis C. metabolic alkalosis D. respiratory alkalosis

D. respiratory alkalosis

Greater concentration of ions means ___ pH levels. Lower concentration of ions means ___ pH levels

Decreased Increased

How does blood flow through the heart, starting at the superior and inferior vena cava:

enters right atrium passes through the tricuspid valve enters right ventricle moves through the pulmonary valve goes to the lungs and comes back with oxygenated blood enters left atrium passes through mitral/bicuspid valve enters left ventricle passes through the aortic valve exits through the aorta