Adults final

A client with a history of hypertension treated with a diuretic and an ACE inhibitor arrives in ED with reports of a severe headache and nausea and has a blood pressure of 238/118. Which question should the nurse ask to follow up on these findings? a. "have you consistently taken your medications?" b. "Have you recently taken any antihistamines?" c. "Did you take any acetaminophen (Tylenol) today?" d. "Have there been recent stressful events in your life?"

"Have you consistently taken your medications?"

A client asks the nurse "What are the risk factors for developing multiple sclerosis?" Which statements by the nurse is correct? A. "Having a close relative with MS increases your risk" B. "A sedentary lifestyle can cause a person to develop MS" C. "Eating a high fat diet is the number one risk factor for MS" D. "Living in southern United States increases your risk"

A. "Having a close relative with MS increases your risk"

The family of a client diagnosed with severe head injury asks the nurse, "Why can't you give our son some strong medication for pain control?" Which is the most appropriate response by the nurse? A. "It is difficult to see changes in his brain function with these medications" B. "It is difficult to determine if he even has pain due to the severity of his injury" C. "His blood pressure may increase to a dangerous level with strong pain medications" D. "We are not sure how he will respond to a strong pain medication"

A. "It is difficult to see changes in his brain function with these medications"

A client hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on oxygen therapy. Which instruction should the nurse include in the discharge teaching? A. "Oxygen use can improve your quality of life if used more than 15 hours per day" B. "Apply vaseline or petroleum jelly on lips and nose to prevent dryness and irritation" C. "Avoid use of a microwave oven when using your supplemental oxygen" D. "As long as you do not smoke, it is safe to go into areas where others are smoking cigarettes or cigars."

A. "Oxygen use can improve your quality of life if used more than 15 hours per day"

the nurse teaches a client information about transient ischemic attacks (TIAs). which statements made by the nurse is accurate? A. "it is important that you seek treatment for any stroke symptoms" B." if you experience a TIA you are at 50% risk of developing stroke" C. "symptoms from a transient ischmic attack last 24 hours or more" D. "there is no risk that you experience a TIA that you will have a stroke"

A. "it is important that you seek treatment for any stroke symptoms"

An hour after a left pleural chest tube is inserted for a hemopneumothorax, a client reports incisional pain at a "7" (based on 0 to 10 scale). Breath sounds are decreased on the left side, and the pleural drainage system has 100 mL of bloody drainage with a positive air leak. Which action should the nurse take? A. Administer prescribed pain medication B. milk the client tube to remove any clots C. Check tube patency by clamping tubing D. Drain the blood from the collection chamber

A. Administer prescribed pain medication

An unconscious client is admitted to the emergency department (ED) with a head injury. The client's family asks many questions about the treatment being given. Which action is best for the nurse to take? A. Allow the family to stay with the client and explain all procedures to them B. Call the family's pastor or spiritual advisor to take them to the chapel C. Refer the family members to the hospital counseling service to deal with their anxiety D. Ask the family to stay in the waiting room until the assessment is completed

A. Allow the family to stay with the client and explain all procedures to them

Which is a priority action for the nurse to take with a client in the postictal phase of a seizure? A. Assess the client's breathing pattern B. Determine the client's love of sleepiness C. Reorient the client to time, person and place D. Position the client comfortably

A. Assess the client's breathing pattern

a client with left sided weakness that stared 60 minutes earlier is admitted into the ED and diagnostic tests are ordered. which test should be done first? A. computed tomography (CT) scan B. CBC C. 12 lead ECG D. chest x-ray

A. CT scan

A client diagnosed with a right-sided pneumothorax has continuous bubbling in the suction-control of a water suction collection device. Which action by the nurse is most important?? A. Continue to monitor the collection device B. Notify the surgeon of a possible hemopneumothorax C. Document the presence of an intermittent air leak D. Adjust the dial on the wall regulator

A. Continue to monitor the collection device

The nurse assess a client diagnosed with PAD. Which clinical manifestation swill the nurse expect to find? (select all that apply) A. decrease hair growth on toes B. brownish "brawny" colored skin C. pallor with extremity elevation D. edema around ankles and feet E. scaling eczema of lower legs

A. Decreased hair growth on toes C. Pallor with extremity elevation

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment finding would indicate the client has developed post concussion syndrome? A. Decreased short-term memory B. Decrease in headache frequency C. Increased energy level D. Improved cognitive function

A. Decreased short-term memory

A client diagnosed with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the clients ventilation? A. Encourage the client to sit up at the bedside in a chair and lean forward B. Have the client rest in bed with the head elevated 15 to 20 degrees C. Place the client in Trendelenburg position with pillows behind the head D. Ask the client to rest in bed in a high-Fowler's position with the knees flexed

A. Encourage the client to sit up at the bedside in a chair and lean forward

The nurse admits a client diagnosed with a basal skull fracture. The nurse notes ecchymosis around both eyes and clear drainage from the client's nose. Which admission order should the nurse question? A. Insert nasogastric (NG) tube to low suction B. Apply cold packs intermittently to face C. Keep the head of bed (HOB) elevated D. Turn client side to side every 2 hours

A. Insert nasogastric (NG) tube to low suction

A registered nurse (RN) is performing a nasopharyngeal swab for influenza. Which action would indicate POOR technique? A. Insert, gently rotate, and immediately remove swab B. support client's head to reduce tendency to pull away during procedure C. Place swab into transport container after collection D. Insert swab straight back along floor of nasal passage

A. Insert, gently rotate, and immediately remove swab

The clinic nurse makes a follow-up telephone call to a client diagnosed with asthma. The client reports having a baseline peak flow reading of 600 L/min, and the current peak flow is 420 L/min. Which action should the nurse take first? A. Instruct the client to use prescribed albuterol (Ventolin HFA) B. Ask about recent exposure to any new allergens or asthma triggers C. Tell the client to go to the hospital emergency department D. Question the client about use of the prescribed inhaled corticosteroids

A. Instruct the client to use prescribed albuterol (Ventolin HFA)

The nurse is caring for a client who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the healthcare provider? A. Oxygen saturation of 88% on room air B. Respiratory rate of 24 breaths/minute when lying flat C. Blood pressure of 135/90 mmHg D. Pain level of "5" (on 0 to 10 scale) with deep breaths in

A. Oxygen saturation of 88% on room air

Which factors will the nurse consider when calculating the CURB-65 score for a client with pneumonia? SELECT ALL THAT APPLY A. Respiratory Rate B. Blood pressure C. Blood urea nitrogen (BUN) D. Oxygen Saturation E. Presence of confusion

A. Respiratory Rate B. Blood pressure C. Blood urea nitrogen (BUN) E. Presence of confusion

A client develops a left tension pneumothorax after insertion of a central venous catheter. Which will the nurse expect to find? A. Right tracheal deviation B. Bradycardia C. Hypertension D. Client reports pain with exhalation

A. Right tracheal deviation

A client newly diagnosed with persistent asthma with recurring attacks is being discharged. Which topic should the nurse anticipate in the discharge teaching? A. Self-administration of inhaled corticosteroids B. Side effects of sustained-release theophylline C. Use of long-acting B-adrenergic medications D. Complications associated with oxygen therapy

A. Self-administration of inhaled corticosteroids

A client who has been treated for status epileptics (SE) in the emergency department (ED) will be transferred to the medical nursing unit. Which equipment should the nurse have available in the clients assigned room? Select all that apply A. Side-rail pads B. Nasogastric tube C. Tongue blade D. Oxygen Mask E. Suction tubing

A. Side-rail pads D. Oxygen Mask E. Suction tubing

A client having an acute asthma attack is in a state of panic. Which intervention should the nurse implement? A. Utilize the "talk-down" approach B. Use music or television as a distraction C. Lay the client down in a suing position D. Use intravenous (IV) sedation

A. Utilize the "talk-down" approach

A client diagnosed with asthma is scheduled for spirometry testing. Which action should the nurse take to prepare the client for this procedure? A. Withhold bronchodilators for 6 to 12 hours before the examination B. Give the rescue medication immediately before testing C. Ensure that the client has been NPO for several hours before the test D. Administer oral corticosteroids two hours before the procedure

A. Withhold bronchodilators for 6 to 12 hours before the examination

which clients are at risk for ischemic stroke (select all that apply) A. a client diagnosed with hypertension B. a client diagnosed with pneumothorax C. an 87 year old client D. a client diagnosed with type 2 diabetes E. an African American client

A. a client diagnosed with hypertension C. an 87 year old client D. a client diagnosed with type 2 diabetes E. an African American client

A client diagnosed with bacterial pneumonia has coarse and thick sputum. Which action should the nurse plan to promote airway clearance? A. assist client to splint their chest when coughing B. Teach pursed-lip breathing technique C. Encourage client to wear nasal O2 cannula D. Restrict oral fluids throughout the day

A. assist client to splint their chest when coughing

The nurse cares for a client after peripheral artery bypass surgery. Which is a priority action 24 hours postnop? A. assist client with ambulation four to six times throughout the day B. assist the client to sit in a chair with legs in a dependent position C. place client in side-lying position with both knees in a flexed position D. maintain bedrest with both legs elevated on pillows

A. assist client with ambulation four to six times throughout the day

a left handed client with left sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care? A. assist the client to eat with the right hand B. provide a wide variety of food choices C. provide oral care before and after meals D. teach the client "chin-tuck" technique

A. assist the client to eat with the right hand

the 70 year old female client with left sided hemiparesis arrives by ambulance to the ED. which action should the nurse take first? A. check the respiratory rate and effort B. send the client for a CT scan C. take the clients BP D. assess the Glasgow coma scale

A. check RR and effort

a client is receiving IV heparin following a diagnosis of PE. the nurse notes that the client has purplish color to their fingertips, and the platelet count is 15,000mm3. which action should the nurse take? A. discontinue the heparin and notify provider B. request an order for idarucizumb (pracbind) C. administer oxygen and notify the provider D. request an order for vitamin K

A. discontinue the heparin and notify provider

a client is prescribed with an IV infustion of 5% dectrose in water. The nurse observes that the skin around the IV infusion side is red, warm to touch, and painful. Which priority action should the nurse take? A. discontinue the peripheral IV catheter B. Place a warm compress on the area C. change the D5W to 0.9% normal saline D. administer oral acetaminophen

A. discontinue the peripheral IV catheter

a client with a left brain stroke suddenly bursts into tears when family members visit. which response by the nurse is appropriate for this situation? A. explain to the family that depression is normal following a stroke B. teaches the family that emotional outbursts are common after strokes C. has family members leave the clients alone for a few minutes D. using a calm voice the nurse asks the client to stop crying

A. explain to the family that depression is normal following a stroke

the nurse cares for a client diagnosed with acute arterial ischemia. which clinical manifestation will the nurse expect to observe? (select all that apply) A. pain B. pallor C. petechiae D. paresthesia E. Pruitus

A. pain B. pallor D. paresthesia

A client diagnosed with PAD has an ulcer on their right second toe. Which finding would the nurse expect to see with an arterial ulcer? A. pale, pink granulation B. serosangeous drainage C. dilated superficial veins D. dry scaly, skin around ankles

A. pale, pink granulation

The nurse teaches a client diagnosed with chronic heart failure about the identification of acute decompensated heart failure symptoms using the acronym FACES. Which information will the nurse include in the teaching? select all that apply F=fluid overload S= side effects of medication A=activity limitation C=chest congestion/cough E=edema

A=activity limitation C=chest congestion/cough E=edema

The nurse reviews information collected by a client diagnosed with asthma. Which findings would indicate the client's asthma is being well controlled? Select all that apply A. Nighttime awakenings occurring two or less times per week B. Symptoms occurring two or less days per week C. Peak flow meter greater than 80% of personal best D. Use of short acting B2 agonist (SABA) two or less days per week E. No interference with normal activities of daily living (ADLs)

All are correct A. Nighttime awakenings occurring two or less times per week B. Symptoms occurring two or less days per week C. Peak flow meter greater than 80% of personal best D. Use of short acting B2 agonist (SABA) two or less days per week E. No interference with normal activities of daily living (ADLs)

A client diagnosed with tonic-clonic seizures notifies the nurse that they are about to have a seizure. Which actions should the nurse take in order of priority from first to last? A. Turn the client to their side B. Ease the client to the floor C. Time and observe seizure activity D. Obtain a set of vital signs

B, A, C, D

Which instruction should the nurse include in an exercise teaching plan for a client diagnosed with chronic obstructive pulmonary disease (COPD)? A. "Avoid upper body strength training exercise, as this will make your breathing more difficult and increase shortness of breath" B. "Walking combined with strength training are the best ways to strengthen muscles and improve activity endurance" C. "It is not recommended that clients diagnosed with chronic obstructive pulmonary disease (COPD) perform physical exercise of any kind" D. "If it takes longer than two minutes to return to baseline, you need to proceed at a slower pace during the next exercise period."

B. "Walking combined with strength training are the best ways to strengthen muscles and improve activity endurance"

Which is a priority question for the nurse to ask during a PAD assessment? A. "do you get dizzy when getting out of bed?" B. " do you have leg pain when walking?" C. "do you have SOB at night?" D."do your feet swell at the end of the day?"

B. "do you have leg pain when walking?"

a client with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. which response by the nurse is accurate? A. "a catheter with a deflated balloon is positioned at the narrow area and the balloon is inflated to flattened the plaque" B. "the obstruction plaque is surgically removed from inside an artery in the neck" C. " the diseased portion of the artery in the brain is replaced with a synthetic graft" D. "a wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed"

B. "the obstruction plaque is surgically removed from inside an artery in the neck"

The nurse monitors a client in the emergency department with a chest tube for a hpmopnemothorax. Which assessment finding would most concern the nurse? A. A large air leak in the water-seal chamber B. 400 mL of blood noted one hour after insertion C. Subcutaneous emphysema at the insertion site D. Reports of pain with each deep

B. 400 mL of blood noted one hour after insertion

Which client(s) are at increased risk to develop influenza? Select all that apply A. 24-yr-old client with allergies to penicillin and cephalosporin B. 42-yr-old client who has been diagnosed with an autoimmune disorder C. 36-yr-old client who is seven months pregnant D. 76-yr-old client who resides at a nursing home E. 30-yr-old client who cross country skis

B. 42-yr-old client who has been diagnosed with an autoimmune disorder C. 36-yr-old client who is seven months pregnant D. 76-yr-old client who resides at a nursing home

The nurse prepares to administer pneumoccal conjugate vaccine (Preener 13) to a 72 year old client. Which criteria would prevent the client from receiving the vaccine? A. A client on warfarin (Coumadin) with an International Normalized Ratio (INR) or 2.1 seconds B. A temperature of 101.2°F (38.4°C) in the last 12 hours C. Currently hospitalized on the surgical unit recovering from an appendectomy D. Currently hospitalized with heart failure (HF), but prognosis is improving

B. A temperature of 101.2°F (38.4°C) in the last 12 hours

A client has just been admitted with bacterial pneumonia and sepsis. The client is unable to provide a sputum sample. Which action should the nurse implement first? A. Administer acetaminophen (Tylenol) 650 mg oral tablets B. Administer ciprofloxacin (cipro) 400mg IV C. Request respiratory therapy administer a nebulizer treatment D. Send the client to radiology for chest X-ray

B. Administer ciprofloxacin (cipro) 400mg IV

The nurse reviews the medication administration record (MAR) for a client having an acute asthma attack. Which medication should the nurse administer first? A. Salmeterol (Serevent) 50 mpg per dry-powder (DPI) B. Albuterol (Ventolin HFA) 2.5 mg per nebulizer C. methylprednisolone (Solu-Medrol) 60 mg IV D. ipratropium (Atrovent) 2 puffs per metered-dose inhaler (MDI)

B. Albuterol (Ventolin HFA) 2.5 mg per nebulizer

The nurse is caring for a client diagnosed with cor pulmonale. The nurse should monitor the client for which expects finding? A. Finger clubbing B. Peripheral edema C. chest pain D. elevated temperature

B. Peripheral edema

The client diagnosed with a large acute epidural hematoma is admitted to the emergency department (ED). Continued monitoring indicates the client's condition is worsening. Which order will the nurse expect the provider to prescribe? A. Start an infusion of unfractioned heparin B. Prepare the client for a craniotomy C. Initiate high-dose barbiturate therapy D. Administer IV furosemide (Lasix)

B. Prepare the client for a craniotomy

The nurse teaches a client diagnosed with asthma about pursed-lip-breathing. Which action by the client would indicate to the nurse that further teaching is needed? A. Ratio of inhalation to exhalation is 1:3 B. Puffs up their cheeks- while exhaling C. Inhales slowly through the nose D. Practices by blowing through a straw

B. Puffs up their cheeks- while exhaling

A client diagnosed with chronic obstructive disease (COPD) has coarse crackles throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective? A. Change the oxygen flow rate to the highest prescribed rate B. Teach the client to use the Flutter airway clearance device C. Reinforce the ongoing use of pursed lip breathing techniques D. Teach the client about consistent use of inhaled corticosteroids

B. Teach the client to use the Flutter airway clearance device

The nurse cares for a client admitted the previous day with a basilar skull fracture who developed rhinorrhea. Which assessment finding indicates a possible complication that should be reported to the health care provider (HCP) A. Postaricular ecchymosis (Battle's sign) B. Temperature of 103.4F C. Bilateral periorbital ecchymosis (Raccoon eyes) D. Post-nasal sinus drainage

B. Temperature of 103.4F

The client with right lower-lobe pneumonia has been treated with IV antibiotics for three days. Which assessment data obtained by the nurse indicates that the treatment is effective? A. The client coughs up small amounts of green mucus B. The client's white blood cell (WBC) count is 9000/uL C. Bronchial breath sounds are heard at the right base D. Increased tactile remits is palpable over the right chest

B. The client's white blood cell (WBC) count is 9000/uL

While the nurse is transporting a client on a stretcher to the radiology department, the client begins having a tonic-clonic seizure. Which action should the nurse take? A. Insert an oral airway during the seizure to maintain a patent airway B. Time and observe and record the details of the seizure and postictal state C. Restrain the client's arms and legs to prevent injury during the seizure D. Avoid touching the client to prevent further nervous system stimulation

B. Time and observe and record the details of the seizure and postictal state

Which information will the nurse include in the asthma teaching plan for a client being discharged? A. "Use mometasone (Asmanex Twisthaler) when you first start experiencing asthma symptoms." B. Tremors are an expected side effect with albuterol (Ventolin HFA)." C. "Hold your breath for two to three seconds after using ciclesonide (Alvesco) meter-dosed inhaler (MDI)." D. "Inhale slowly and deeply when using fluticasone (Flovent Diskus) dry powder inhaler (DPI)

B. Tremors are an expected side effect with albuterol (Ventolin HFA)."

A client is admitted with a head injury from a collision while playing football. After noting that the client has developed clear nasal drainage which action should the nurse take? A. Obtain a specimen of the fluid to send for culture and sensitivity B. Use a testing strip to determine whether glucose is present C. Compress the nares with pair of nasal thongs D. Offer Kleenex and have the client gently blow their nose

B. Use a testing strip to determine whether glucose is present

The nurse prepares a client for an electroencephalography (EEG). Which action would be appropriate for the nurse to take before the procedure? A. Administer anti-seizure medications B. Wash and dry the client's hair C. Have the client drink coffee D. Change diet to "nothing by mouth" (NPO)

B. Wash and dry the client's hair

after receiving charge of shift report on the following four clients, which client should the nurse see first? A. a 40 year old client who experienced a transient ischemic attack yesterday who has a dose of aspirin due. B. a 60 year old client with right sided weakness who has an infusion of tPA C. a 30 year old client with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled D. a 50 year old client who has a. fib and new order for warfarin

B. a 60 year old client with right sided weakness who has an infusion of tPA

which client is most at risk to develop a PE? A. client diagnosed with infective endocarditis of the aortic valve? B. client diagnosed with an active deep vein thrombosis in the right leg C. client diagnosed with left ventricular myocardial infarction (MI) D. client diagnosed with pleural effusion requiring chest insertion

B. client diagnosed with an active deep vein thrombosis in the right leg

a male client who has right sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activites. the nurse observes that when the client's wife is visiting , she feeds and dresses him. which nursing diagnosis is most appropriate for the client? A. impaired nutrition less than body requirements related to hemiplegia and aphsia B. disabled family coping related to inadequate understanding by clients spouse C. interrupted family processes related to effects of illness of a family member D. situational low self esteem related to increasing dependence of spouse for care.

B. disabled family coping related to inadequate understanding by clients spouse

a client with a DVT suddenly develops dysonea, tachypnea, and chest discomfort. Which action should the nurse take first? A. Encourage the client to cough and deep breathe B. elevate HOB C. contact the healthcare provider D. administer IV morphine sulfate

B. elevate HOB

when caring for a client with a new right sided homonymous hemianopsia resulting from a stroke, which interventions should the nurse include in the plan of care? A. apply an eye patch to the right eye B. place needed objects on the client's left side C. approach the client from the right side D. teach the client that the left visual deficit will resolve

B. place needed objects on the clients left side

a client is diagnosed with a right hemisphere stroke. Which clinical manifestation would the nurse expect to find based on this diagnosis? A. ineffective coping related to depression and distress about disability B. risk for injury related to denial of deficits and impulsiveness C. impaired verbal communication related to speech language deficits D. impaired physical mobility related to right sided hemiplegia

B. risk for injury related to denial of deficits and impulsiveness

which is an appropriate food for a client with a stroke who has mild dysphagia? A. fruit juice B. scrambled eggs C. fortified milkshakes D. pureed meat

B. scrambled eggs

a client is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? A. the client reports that symptoms began with a severe headache B. the client has A. fib C. the client has dysphasia D. the client has a history of brief episodes of right sided hemiplegia

B. the client a fib

which information about the client who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? A. the client reports a severe and unrelenting headache B. the clients BP is 90/50 C. the CSF report shows RBC's D. the client reports having a stiff neck

B. the clients BP is 90/50

the home health nurse is caring for an 81 year old who had a stroke 2 months ago. Based on the information shown in the accompanying figure from the history, physical assessment and physical and occupational therapy, which problem is the highest priority? history: well controlled type 2 diabetes for 10 years. married 45 years, spouse has heart failure and chronic obstructive pulmonary disease. Physical assessment: oriented to time, place and person. speech clear. minimal left leg weakness. PT/OT: uses cane with walking. spouse does household cleaning and cooking and assists patient with bathing and dressing. A: impaired transfer ability B: risk for caregiver role strain C: ineffective health maintenance D:risk for hypoglycemia

B: risk for caregiver role strain

Which statement by the client who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? A. "I can take acetaminophen (Tylenol) for my headache" B. "I do not even remember being in an accident" C. "I am going to drive home and go to bed" D. "I will return if i feel dizzy or nauseated"

C. "I am going to drive home and go to bed"

The nurse teaches a client about care for the first two or three days after a head injury. Which statement by the client indicates understanding? A. "I will call my doctor the next day if I experience any problems with my vision" B. "Since I did not lose consciousness it is alright for me to be home alone" C. "I will avoid driving and ask my family to take me to my follow up appointment" D. "I will need to limit my consumption of alcohol to one beer per day"

C. "I will avoid driving and ask my family to take me to my follow up appointment"

The nurse teaches a client diagnosed with pneumonia. Which statement by the client indicates a good understanding of the discharge instructions? A. "I will schedule separate appointments for the pneumonia and influenza vaccines" B. "I will cancel my follow up chest x-ray appointment if i feel better next week" C. "I will continue to do deep breathing and coughing exercises at home" D. I will call my healthcare-provider if I feel tired after one week

C. "I will continue to do deep breathing and coughing exercises at home"

A client is suspected of having influenza. Which assessment data obtained by the nurse would support this diagnosis? A. Temperature of 99.1°F B. Purulent nasal discharge C. Abrupt onset of symptoms D. Mild, localized, muscle aches

C. Abrupt onset of symptoms

A client is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by their spouse. Which action will the nurse take first? A. Access pupil reaction to light B. Palpate the head for injuries C. Check patency of airway D. Verify Glasgow Coma Scale (GOS) score

C. Check patency of airway

The nurse completes an admission assessment on a client diagnosed with asthma. Which information from their home medication list indicates a need for a change in therapy? A. Client is prescribed albuterol (Ventolin HFA) and bubesonide (Pulmicort Flexhaler) B. Client is prescribed albuterol (Ventolin HFA) and theophylline (Theo-24) C. Client is prescribed albuterol (Ventolin HFA) and salmeterol (Serevent) D. Client is prescribed albuterol (Ventolin HFA) and montelukast (Singulair)

C. Client is prescribed albuterol (Ventolin HFA) and salmeterol (Serevent)

Which assessment finding in a client prescribed omalizumab (Xolair) subcutaneously (SQ) for asthma would need to be reported immediately to the healthcare provider? A. Pain at injection site B. Peak flow reading 75% of normal C. Flushing and hives D. Respiratory rate 24 breaths/minute

C. Flushing and hives

Postural drainage with percussion and vibration is ordered twice daily for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which intervention should the nurse include in the plan of care? A. Schedule the procedure one hour after the client eats B. Maintain the client in the lateral position for 20 minutes C. Give the prescribed albuterol (Ventolin HFA) before the therapy. D. Perform percussion after assisting the client to the drainage position

C. Give the prescribed albuterol (Ventolin HFA) before the therapy.

A client diagnosed with pneumonia has a fever of 101.4°F (38.6°C), a non productive cough, and an oxygen saturation of 88% on room air. The client reports weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the priority? A. Ineffective airway clearance related to thick secretions B. Impaired transfer ability related to weakness C. Impaired gas exchange related to respiratory congestion D. Hyperthermia related to infectious illness

C. Impaired gas exchange related to respiratory congestion

The nurse assesses the chest of a client diagnosed with consolidated pneumococcal pneumonia. Which finding would the nurse expect? A. pleural friction rub B. Hyperresonance to percussion C. Increased tactile remits D. Dry, nonproductive cough

C. Increased tactile remits

The client has been taking phenytoin (Dilantin) for two years. Which assessment will the nurse preform when evaluating for adverse effects from the medication? A. Auscultates bowel sounds B. Listen to lung sounds C. Inspects oral mucosa D. checks pupil reaction to light

C. Inspects oral mucosa

A client diagnosed with chronic obstructive pulmonary disease (COPD) is receiving 35% oxygen via a Venturi mask. Which action by the nurse is appropriate for the care of this equipment? A. Drain moisture condensation from the corrugated tubing every hour. B. Give a high enough flow rate to keep the bag from collapsing C. Keep air entrainment ports clean and unobstructed D. Wash and dry under the mask every eight hours

C. Keep air entrainment ports clean and unobstructed

Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? A. Facial grimaces, patting motions, and lip smacking B. Jerking in one extremity that spreads gradually to adjacent areas C. Loss of consciousness, body stiffening, and violent muscle contractions. D. Vacant staring and abruptly ceasing all activity

C. Loss of consciousness, body stiffening, and violent muscle contractions.

A nurse gives a presentation on prevention of head injuries. Which topic is associated with the MOST common cause of head injuries? A. Assaults B. Recreational sports C. Motor vehicle accidents (MVAs) D. War related injuries

C. Motor vehicle accidents (MVAs)

A client is admitted to the emergency department for an acute asthma exacerbation. Emergency Medical Technicians (EMTs) report the client is tachycardic, tachypnic, and has both inspiratory and expiratory wheezing. On assessment the nurse notes that there is no wheezing but the client is still struggling to breathe. Which action should the nurse implement first? A. Administer IV methylprednisolone (Solu-Medrol) B. Document changes in respiratory status C. Notify the healthcare provider D. Encourage the client to cough and deep breath

C. Notify the healthcare provider

A client diagnosed with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the client for the procedure? A. Remind the client not to eat or drink anything for six hours B. Obtain a collection device to hold three liters of pleural fluid C. Position the client sitting up on the side of the bed D. Start a peripheral IV line to administer sedatives

C. Position the client sitting up on the side of the bed

The emergency department (ED) nurse receives a status report on the following clients who have been admitted with head injuries. Which client should the nurse assess first? A. Lost consciousness for a few seconds after a fall B. Current Glasgow Coma Scale score is 13 C. Right pupil is 10mm and unresponsive to light D. Cranial x-ray shows a linear skull fracture

C. Right pupil is 10mm and unresponsive to light

A client is admitted to the emergency department (ED) with an open stab wound to the left chest. Which action should the nurse take? A. Keep the head of the client's bed positioned flat B. Position the client so that the left chest is dependent. C. Tape a nonporous dressing on three sides over the wound D. Cover the wound tightly with an occlusive dressing

C. Tape a nonporous dressing on three sides over the wound

The home health nurse is visiting a client diagnosed with chronic obstructive pulmonary disease (COPD). Which nursing action is appropriate to implementation for a nursing diagnosis of impaired breathing pattern related to anxiety? A. suggest the use of over-the-counter sedative medications B. Titrate oxygen to keep saturation at least 90% C. Teach the client how to use pursed-lip breathing D. Discuss a high-protein, high-calorie diet with the client

C. Teach the client how to use pursed-lip breathing

A client diagnosed with influenza A is prescribed oseltamivir (Tamiflu) five days after developing symptoms. Which statement is the MOST appropriate for the nurse to make when teaching the client about this medication? A. The medication will alleviate symptoms within 24 hours of taking the first dose B. It's safe to take this medication and receive the influenza vaccine at the same time C. This medication may not be effective because of the delay in starting treatment D. Do not take this medication if you have a lactose food allergy

C. This medication may not be effective because of the delay in starting treatment

The nurse teaches a client diagnosed with asthma about peak flow meter use. Which action by the client indicates that teaching was successful? A. Takes montelukast (Singular) for peak flows in the red zone B. Calls the healthcare provider when the peak flow is in the green zone C. Uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone. D. Inhales rapidly through the peak flow meter mouthpiece

C. Uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone.

a63 year old clients who began experiencing right arm and leg weakness is admitted into the ED in which order will the nurse implement these actions included in the stroke protocol? A. obtain CT scan without contrast B. infuse tPA C. administer O2 D. perform baseline neuro assessment

C. administer O2 D. perform baseline neuro assessement A. obtain CT B. infuse tPA

a female client who had a stroke 24 hours ago has expressive aphasia. Which is an appropriate nursing intervention to help the client communicate? A. develop a list of words that the client can read and practice reciting B. have the client practice her facial and tongue exercises with a mirror C. ask questions that the client can answer with "yes" or "no" D. prevent embarrassing the client by answering for her if she does not respond

C. ask questions that the client can answer with "yes" or "no"

the nurse assess the lower extremities of a client diagnosed with chronic venous insufficiency (CVI) which clinical manifestations will the nurse expect to observe? A. brittle toenails B. cap refill > 3 seconds C. brawny skin color D. absent pedial pulses

C. brawny skin color

The nurse receives change-of-shift report on the following clients diagnosed with chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? A. Client with a productive cough of thick green mucous B. Client with bilateral lower peripheral edema C. client with a respiratory rate of 38 breaths/min D. Client with loud expiratory wheezes

C. client with a respiratory rate of 38 breaths/min

The nurse cares for a client abdominal surgery. The reports a feeling of "fullness" in their right leg. Which is the priority action for the nurse to take? A. review the medication administration record (MAR) B. measure the circumference of the right and left leg C. compare skin temperature of right and left foot D. assess for pain with deep palpation of right leg

C. compare skin temperature of right and left foot

The nurse cares for a client diagnosed with varicose veins. Which will the nurse expect the client to report? A. decreased hair growth of the leg B. shooting pains down the leg C. dull pain relieved by walking D. thickened toe nails

C. dull pain relieved by walking

The nurse cares for a client diagnosed with an embolic stroke. Which is the nurse most likely to observe? A. RR 28/min B. BP 96/48 C. irregular heart rhythm 152 BPM D. blood glucose 60 mg/dL

C. irregular heart rhythm 152 bpm

The nurse reviews ankle brachial index readings on a client at risk for right lower extremity PAD, right ankle systolic pressure equals 140 mmHG. Brachial systolic pressure equlas 120 mmHG. Which is the best interpretation of the results? A. severer RLE arterial disease B. non-compressible arteries in RLE C. normal RLE arterial blood flow D. mild RLE arterial disease

C. normal RLE arterial blood flow

the nurse cares for a client with superficial vein thrombosis of the left leg. which clinical manifestation will the nurse expect to find on assessment? A. generalized edema B. cool skin temperature C. palpable, cordlike vein D. brawny, leathery skin

C. palpable cordlike vein

Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

C. the patients usual BP is 170/94

What information should the nurse include in a teaching plan for a client newly diagnosed with chronic obstructive pulmonary disease (COPD)? A. "Pulmonary rehabilitation programs offer very little benefit" B. "If you quit smoking, your lungs will heal and you will no longer have COPD" C. "Pneumococcal vaccination is contraindicated for clients with lung disease" D. "A bronchodilator with metered-dose inhaler should be readily available"

D. "A bronchodilator with metered-dose inhaler should be readily available"

a client diagnosed with cerebral atherosclerosis is prescribe clopidogrel (Plavix). which statements will the nurse include when teaching the client about this medication? A. "this medication will dissolve clots in the cerebral arteries" B. "this medication will reduce cerebral artery plaque formation" C. "monitor and record you BP daily" D. "Call you health care provider if stools look tarry"

D. "Call you health care provider if stools look tarry"

The nurse provides dietary teaching for a client diagnosed with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which client statement indicates that the teaching has been effective? A. "I will decrease my intake of meat and poultry" B. " I will drink lots of fluids with my meals" C. "I will exercise for 15 minutes before meals" D. "I can have ice cream as a snack every day"

D. "I can have ice cream as a snack every day"

Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures? A. Give phenytoin (Dilantin) 100 mg IV. B. Monitor level of consciousness (LOC). C. Obtain computed tomography (CT) scan. D. Administer lorazepam (Ativan) 4 mg IV.

D. Administer lorazepam (Ativan) 4 mg IV.

a client will attempt oral feedings for the first time after having a stroke. which action should should the nurse take after assessing the gag reflex? A. order a varied pureed diet B. assess the client's appetite C. offer the client a sip of juice D. assist the client into a chair

D. Assist the client into a chair

A client with severe chronic obstructive pulmonary disease (COPD) tell the nurse. "I wish I were dead! I'm just a burden on everybody." Based on this information, which nursing diagnosis is most appropriate? A. Complicated grieving related to expectation of death B. Deficient knowledge related to lack of education about COPD C. Ineffective coping related to unknown outcome of illness D. Chronic low self-esteem related to physical dependence

D. Chronic low self-esteem related to physical dependence

The nurse obtains the following assessment data on an older client diagnosed with influenza. Which information will be MOST important for the nurse to communicate to the healthcare provider? A. Fever of 100.4°F (38°C) B. Myalgia and persistent headache C. sore throat and frequent cough D. Diffuse crackles in the lungs

D. Diffuse crackles in the lungs

The charge nurse observes a new nurse care for a client with a wet chest tube system. Suction is set at -20 cm of H2O. An air leak is present. Which action by the new nurse requires immediate intervention by the charge nurse? A. Instructs client to use incentive spirometry ever hour while awake B. Increases wall suction until gentle bubbling is present in suction control chamber C. Ambulates client to bathroom while maintaining continuous wall suction D. Elevates drainage system above insertion site to check drainage

D. Elevates drainage system above insertion site to check drainage

The nurse cares for a client diagnosed with a pleural effusion. Documentation states, "Chest tube to -20cm of pressure. Tidaling present. No air leak noted." Which is the best interpretation of this statement? A. The water seal chamber needs sterile water added B. The affected lung has fully expanded C. A leak is present around the chest tube insertion site D. Fluid is still present in the pleural space

D. Fluid is still present in the pleural space

Which type of generalized seizure is characterized by sudden, excessive jerking of extremities in a conscious client? A. Absence seizure B. Atonic seizure C. Tonic seizure D. Myoclonic seizure

D. Myoclonic seizure

When assessing a client who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. Which intervention is most appropriate for the nurse to take? A. Prepare for emergency thoracentesis B. Administer a short-acting bronchodilator (SABA) C. Instruct the client on the use of incentive spirometry D. Prepare for chest tube insertion

D. Prepare for chest tube insertion

A client diagnosed with tonic-clonic seizures tells the nurse they feel depressed a few days before they have a seizure. The nurse knows this is which seizure phase? A. Postictal phase B. Aural phase C. Ictal phase D. Prodromal phase

D. Prodromal phase

Which action will the emergency department (ED) nurse anticipate for a client diagnosed with a concussion who did not lose consciousness? A. Arrange to admit the client to the neurologic unit for 24 hours of observation B. Coordinate the transfer of the client to the operating room (OR) C. Transport the client to radiology for magnetic resonance imaging (MRI) D. Provide discharge instructions about monitoring neurologic status

D. Provide discharge instructions about monitoring neurologic status

The nurse admits a client with a possible contusion after a car accident to the emergency department (ED). Which finding is MOST important to report to the healthcare provider (HCP)? A. The blood pressure (BP) is 162/94 mmHg B. The client is unable to remember the accident C. The client reports having a severe, dull headache D. The client takes warfarin (Coumadin) daily

D. The client takes warfarin (Coumadin) daily

a client has a ruptured cerebral aneurysm and subarachnoid hemorrhage. which intervention will the nurse include in the plan of care? A. assist to dangle on the edge of the bed and assess for dizziness B. insert orophayngeal airway to prevent airway obstruction C. encourage patient to couch and deep breathe every 4 hours D. apply intermittent pneumatic compression stockings

D. apply intermittent pneumatic compression stockings

A client diagnosed with a stroke experiences facial drooping on the right side and right sided arm and leg paralysis. When admitting the client, which clinical manifestation will the nurse expect first? A. right sided neglect B. impulsive behavior C. hyperactive left sided tendon reflexes D. difficulty comprehending instructions

D. difficulty comprehending instructions

The nurse in the emergency department receives arterial blood gas results for four recently admitted clients diagnosed with obstructive pulmonary disease (COPD). Which result requires rapid action by the nurse? A. pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg B. pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg C. pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg D. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg

D. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg

The nurse cares for a client diagnosed with PAD. Which intervention is most appropriate to implement for pain control? A. wrap a moist heat source around the right leg B. elevate legs so they are above heart level C. Apply TEDS D. place bed in the reverse trandleneburg position

D. place bed in reverse trandelenburg position

a client arrives in the ED with hemiparesis and dysarthia that started 2 hours previously and health records show a history of several transient ischemic attacks (TIAs). the nurse anticipates preparing the client for which procedure? A. transluminal angioplasty B. surgical endartercotomy C. IV heparin drip administration D. tPA infusion

D. tPA infusion

the nurse is caring for a client who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? A. BP is 144/86 B. there are fine crackles at the lung bases C. the pulse is 102 D. the client has difficultly speaking

D. the client has difficulty speaking

A 55 year old male weighing 115 kg has a hisotyr of tobacco use, high BP and sedentary lifestyle. Which factor indicated risk for PAD? A. sedentary lifestyle B. high BP C. excess weight D. tobacco use

D. tobacco use

a client is being treated for DVT. the provider has prescribed 60mg of enoxaparin (lovanox) SQ. before administering the medication, the nurse checks the clients lab results. Which is most appropriate action for the nurse to take? PTT 12.5 seconds INR 2 seconds platelet count 15,000 A. contact the pharmacist for a lower dose of the medication B. administer medication as prescribed by the provider C. assess the client for signs of bruising on the extremities D. withhold the dose of medication and contact the provider

D. withhold the dose of medication and contact the provider

What is the best method for assessing circulation in a client after peripheral bypass surgery? (in picture form)

Doppler pedal pulse

a client in the ED with sudden-onset right sided weakness is diagnosed with an intracerebral hemorrhage. which information is most important to communicate to the health care provider? A. the clients BP is 144/90 B. the client takes a diuretics because of a history of hypertension C. the client has a. fib and takes warfarin D. the clients speech is difficult to understand

`C. the client has a.fib and takes warfarin

The nurse teaches the client diagnosed with chronic stable angina about sublingual nitroglycerine (nitrostat). Which statement by the client indicates a need for further teaching? a. "I can take the nitroglycerine tablets ten minutes apart until the pain goes away." b. "This medication may cause me to experience headaches, dizziness, and flushing." c. "Once I open the bottle, I will need to replace the medication in six months." d. "It is normal to have a tingling sensation after placing a tablet under my tongue."

a. "I can take the nitroglycerine tablets ten minutes apart until the pain goes away."

The nurse teaches a client diagnosed with chronic heart failure about dietary restrictions. Which statement by the client indicates an understanding of the teaching? a. "I will avoid foods that contain over 400 mg sodium per serving." b. "I don't need to worry about sodium intake if I restrict my fluids." c. "Prepared frozen meals are healthy and low in sodium." d. "I can eat grilled cheese sandwiches several times a week."

a. "I will avoid foods that contain over 400 mg sodium per serving."

The nurse teaches a client diagnosed with heart failure about home care. Which statement will the nurse include in the teaching? a. "notify your provider for a weight gain of three pounds over 2 days." b. "Exercise needs to be limited to 30 minutes two times a week." c. "fluid intake needs to be restricted to less than one liter per day." d. "total sodium needs to be limited to 3-4 grams per day."

a. "notify your provider for a weight gain of three pounds over 2 days."

Which client is a the recommended blood pressure goal according to the JNC 8 guidelines? a. 57-year-old client diagnosed with chronic kidney disease and bp of 134/80 mm Hg b. 72-year-old client with 20-years tobacco use and bp of 160/90 mmHg c. 42-year-old client with BMI of 39 and bp of 156/94 mm Hg d. 66-year-old client diagnosed with type 2 diabetes and a bp of 148/82 mm Hg

a. 57-year-old client diagnosed with chronic kidney disease and bp of 134/80 mm Hg

After receiving a client's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important to report to the health care provider? a. bilateral crackles in the lungs b. blood glucose 132 mg/dL c. blood pressure 114/58 mm Hg d. temperature 100.2

a. bilateral crackles in the lungs

The nurse cares for a client after a pericardial thoracentesis procedure, and notes muffled heart sounds. Which is most likely the cause of this finding? a. cardiac temponade b. acute coronary syndrome c. aortic stenosis d. heart failure

a. cardiac temponade

A nurse cares for a client diagnosed with acute decompensated left ventricular heart failure and severe fluid overload. The glomerular filtration rate is 30 mL/min. Which medication would the nurse expect the provider to prescribe? a. furosemide (Lasix) b. hydrochlorothiazide (Ezide) c. enalapril (Vasotec) d. spironlactone (Aldactone)

a. furosemide (Lasix)

During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is a. hypertension b. fluid overload c. cardiac dysrhythmias d. S3 and S4 heart sounds

a. hypertension

The nurse teaches and elderly client about enalaril (Norvasc). The nurse instructs the client to avoid taking this medication with meals. Which is the best explanation for this instruction? a. may worsen postprandial hypotension b. may cause nausea and vomiting with meals c. may reach toxic levels when combined with food d. may cause orthostatic hypotension in elderly clients

a. may worsen postprandial hypotension

A client diagnosed with infective endocarditis reports painful, tender, pea-sized lesions on the fingers and toes. Which is the best description of these findings? a. osler's nodes b. splinter hemorrhages c. roth's spots d. janeway's lesions

a. osler's nodes

A client is diagnosed with acute pericarditis. Which actions will the nurse include in the plan of care? select all that apply. a. provide simple, complete explanations of all procedures b. administer anit-inflammatory medications as ordered c. keep head of the bed 30 degrees or less d. encourage client ot walk 4-6 times/day e. provider an over bed table so the client can sit leaning forward

a. provide simple, complete explanations of all procedures b. administer anit-inflammatory medications as ordered e. provider an over bed table so the client can sit leaning forward

When caring for a client with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? a. report of severe chest pain b. blood pressure 104/74 mm Hg c. heart rate 102 beats/minute d. pedal pulses 1+ bilaterally

a. report of severe chest pain

Which set of postural vital signs indicates orthostatic hypotension? a. supine 120/70, 70; sitting 102/64, 86; standing 100/60, 92 b. supine 138/86, 74; sitting 136/84, 80; standing 134/82, 82 c. supine 124/76, 88; sitting 124/74, 92; standing 122/74, 92 d. supine 100/70, 72; sitting 100/68, 74; standing 98/68, 80

a. supine 120/70, 70; sitting 102/64, 86; standing 100/60, 92

The nurse teaches a client diagnosed with hypercholesteremia about lifestyle modifications. Which statement by the client indicates an understanding of the teaching? a. "I will make a habit of exercising 30 minutes two to three times a week." b. "I need to lose weight and achieve a BMI of 24.9 kg/m2 or less." c. "I will reduce my nicotine intake by switching to e-cigarettes." d. "I will avoid eating foods like tofu, soybean, flaxseed and walnuts."

b. "I need to lose weight and achieve a BMI of 24.9 kg/m2 or less."

A client experiencing chest pain is admitted to the emergency department and all of the following are ordered. Which one should the nurse arrange to be completed first? a. PA/lateral chest x-ray b. 12-lead ECG c. nitroglycerine 0.4 mg SL d. insertion of a peripheral IV

b. 12-lead ECG

Which client has the highest risk for increased mortality related to coronary artery disease? a. 49-year-old Caucasian male with blood pressure of 139/82 b. 72-year-old african american female with low density lipoprotein of 300 mg/dL c. 43-year-old african american male with a waist circumference of 35 inches. d. 26-year-old hispanic male who smokes one pack of cigarettes per day.

b. 72-year-old african american female with low density lipoprotein of 300 mg/dL

Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.

b. Assist the patient onto the bedside commode every 2 hours.

The nurse cares for a client experiencing a myocardial infarction. Which clinical manifestation would the nurse expect to see? a. oral temperature of 98.2 b. ashen, clammy cool skin c. urine output of 60 mL/hour d. serum glucose of 56 mg/dL

b. ashen, clammy cool skin

Propranolol (Inderal) is prescribed for a client diagnosed with hypertension. The nurse should consult with the health care provider before giving this medication for which medical diagnosis? a. myocardial infarction (MI) b. asthma c. daily alcohol use d. peptic ulcer disease

b. asthma

The nurse care a 70-year-old client who uses hydrochlorothiazide and enalapril (Norvasc) but whose self-monitored blood pressure continues to be elevated. Which client information may indicate a need for change? a. client takes a daily multivitamin tablet b. client uses ibuprofen (motrin) to treat osteoarthritis c. client checks bp daily just after getting up d. client drinks wine three to four times a week

b. client uses ibuprofen (motrin) to treat osteoarthritis

Which client is at risk to develop infective endocarditis? select all that apply a. client diagnosed with myocardial infarction b. client with PICC line c. Client with a prosthetic heart valve d. client with history of IV drug use e. Client prescribed hemodialysis 3 times/week

b. client with PICC line c. Client with a prosthetic heart valve d. client with history of IV drug use e. Client prescribed hemodialysis 3 times/week

Catopril (Capoten), furosemide (Lasix), and metoprolol (Toprol XL) are prescribed for a client diagnosed with chronic systolic heart failure. Blood pressure is 136/82. Heart rate is 68 bpm. Prior to medication administration the nurse reviews the client's labs. Which is a priority action for the nurse to take? sodium-140 potassium-6.8 GFR-53 Creatinine-3.2 Hemoglobin-12 hematocrit-37 a. hold the furosemide (Lasix) and notify provider b. hold the catopril and notify the provider c. hold the metoprolol and notify provider d. administer all the medications as ordered

b. hold the catopril and notify provider

Which assessment finding by the nurse caring for a client who has had coronary artery bypass grafting (CABG) using a right radial artery graft is the most important to communicate to the health care provider? a. fine crackles heard at both lung bases b. pallor and weakness of the right hand c. reports of incisional chest pain d. pink color on both sides of the sternal incision

b. pallor and weakness of the right hand

The nurse cares for a client diagnosed with chronic stable angina. Which will the nurse expect the client to report? a. "I have chest discomfort with activity that is not relieved with nitroglycerine (NTG)" b. "I have chest discomfort that is unpredictable but relieved with nitroglycerine (NTG)." c. "I have chest discomfort during physical activity but it goes away with rest." d. "I have chest discomfort that wakes me up at night and lasts more than 20 minutes."

c. "I have chest discomfort during physical activity but it goes away with rest."

The nurse provides discharge teaching to a client diagnosed with infective endocarditis. Which statement will the nurse include in the teaching? a. "It is normal to have a fever after being on antibiotics for more than a week." b. "Other than using the bathroom, you must stay on complete bedrest." c. "You need to avoid people experiencing a cold or cold-like symptoms" d. "It's recommended that you see a dentist once every 5 years"

c. "You need to avoid people experiencing a cold or cold-like symptoms"

An older client has been diagnosed with possible white coat hypertension. Which planned action by the nurse best addresses the suspected cause of the hypertension? a. schedule the client for regular blood pressure checks in the clinic b. inform the client and caregiver that major dietary changes will be needed c. Teach the client how to self-monitor and record BP's at home d. Instruct the client about the need to decrease stress levels

c. Teach the client how to self-monitor and record BP's at home

The nurse cares for a client diagnosed with Prinzmetal's angina. Which medication would the nurse expect the provider to prescribe? a. metorolol (Lopressor) b. captopril (capoten) c. amlodipine (norvasc) d. ranolazine (ranexa)

c. amlodipine (norvasc)

A client diagnosed with acute pericarditis reports severe, sharp chest pain. Which is the best action for the nurse to take? a. instruct the client to lie down and bend knees towards their chest. b. place the client on their left side in sim's position c. assist the client to sit up and lean forward d. place the client in a supine position

c. assist the client to sit up and lean forward

The nurse cares for a client admitted with acute shortness of breath. Which diagnostic test will be most useful in determining whether the client has heart failure? a. 12-lead-ECG b. arterial blood gases (ABG's) c. b-type natriuretic peptide (BNP) d. serum troponin

c. b-type natriuretic peptide (BNP)

A nuse administers propranolol (Inderal) to a client diagnosed with unstable angina. Which assessment finding is the most important to report to the health care provider? a. Heart rate decreased from 80 to 72 beats per minute b. client reports they are experiencing a headache. c. development of audible expiratory wheezes. d. blood pressure decreases from 138/78 to 126/72

c. development of audible expiratory wheezes.

The nurse reviews a clients medical record. Based on the following information, which topic about reducing the risk for hypercholesteremia should be a priority discussion? a. Importance of maintaining a healthy BMI (22 kg/m2) b. Importance of daily physical exercise (works full time outside as a landscaper-gardener) c. dietary changes to improve lipid levels (HDL 35 mg/dL, LDL 165 mg/dL) d. risk associated with previous tobacco use (quit smoking 2 years ago)

c. dietary changes to improve lipid levels (HDL 35 mg/dL, LDL 165 mg/dL)

A 45-year-old female with a history of diabetes is prescribed a cholesterol lowering medication. Which lab value indicates a therapeutic response to the medication? a. triglycerides 500 mg/dL b. high-density lipoprotein 30 mg/dL c. low-density liprotein 64 mg/dL d. total cholesterol 300 mg/dL

c. low-density lipoprotein 64 mg/dL

The nurse administers digoxin (Lanoxin) to a client diagnosed with acute decompensated heart failure. Which manifestation indicates an early sign of digitalis toxicity? a. tachycardia b. low urine ouput c. nausea and vomiting d. muscle pain

c. nausea and vomiting

A client diagnosed with acute decompensated left and right sided heart failure has jugular venous distention, increased heart rate, and is using accessory muscles during respiration. Which intervention would be the most appropriate for the nurse to take? a. administer 500 mL 0.9% normal saline bolus b. administer spironolactone (Aldactone) c. place client in high-fowlers position d. obtain 12-lead-ECG

c. place client in high-fowlers position

A client diagnosed with hypercholesteremia is prescribed nicotinic acid (Niacin). After starting the medication, the client calls the clinic with reports of itching and facial flushing. After informing the provider, which is the best response by the provider that the nurse should expect? a. "this is an allergic reaction. Tell the client I will perscribe them a different medication." b. "these symptoms will go away on their own. Tell the client to continue taking the medication." c. Tell the client to take their Niacin dose along with Benadryl before going to bed." d. "Tell the client to take 325 mg of aspirin half hour before each dose"

d. "Tell the client to take 325 mg of aspirin half hour before each dose"

The nurse teaches a client about a new prescription for colesvelam (welchol). Which statement will the nurse include in the teaching? a. "this medication helps you lose weight so you can reduce exercising to three times per week" b. "this medication can be taken at the same time as all other medications on an empty stomach." c. "if you miss taking a dose, make sure that you double up your dose the next day." d. "taking a stool softener with this medication can reduce the chances of you developing constipation."

d. "taking a stool softener with this medication can reduce the chances of you developing constipation."

A client diagnosed with acute decompensated heart failure goes into flash pulmonary edema. The nurse notes that the client is severely dyspnic, anxious, tachypnic, and tachycardic. Which prescribed order should the nurse administer to improve gas exchange? a. IV diazepam (Valium) 2.5 mg b. Increase dopamine infusion by 2 mcg/kg/min c. Increase nitroglycerin infusion by 5 mcg/min d. IV morphine sulfate 4 mg

d. IV morphine sulfate 4 mg

The nurse cares for a client admitted tot the hospital for suspected acute pericarditis. Which is the best method for auscultating a pericardial friction rub? a. listen with the diaphragm of the stethoscope with client laying supine and breathing normally. b. Listen to all heart sounds while client breathes normally and is in semi-fowlers position c. Listen at the base of the heart while client breathes normally and is in high-fowlers position. d. Listen at mid-lower left sternal border with client leaning forward and holding their breath.

d. Listen at mid-lower left sternal border with client leaning forward and holding their breath.

A client diagnosed with chronic heart failure returns to the clinic after two weeks of metoprolol (Toprol XL) administration. Which assessment finding is most important for the nurse to report to the health care provider? a. reports feeling fatigued b. 2+ bilateral pedal edema c. Heart rate 60 bmp d. blood pressure 78/42 mm Hg

d. blood pressure 78/42 mm Hg

The nurse reviews laboratory reports for a client diagnosed with non-ST-elevated myocardial infarction five days earlier. Which cardiac enzyme marker will still be elevated at this time? a. creatinine kinase (CK-MB) b. myoglobin c. homocysteine d. cardiac-specific troponin

d. cardiac-specific troponin

The nurse cares for a client diagnosed with acute systolic left ventricular heart failure. Which clinical manifestation is the nurse most likely to observe? a. abdominal ascites b. generalized anasarca c. jugular vein distention d. crackles in the lungs

d. crackles in the lungs

A client who has recently started taking pravastatin (pravachol) reports several symptoms to the nurse. Which information is most important to communicate to the health care provider? a. nausea when taking the drugs before meals b. flushing and pruitis after taking the drugs c. dizziness with rapid position changes d. generalized muscle aches/pains

d. generalized muscle aches/pains

Which action will the nurse in the hypertension clinic take to obtain an accurate blood pressure for a new client? a. assist the client tot he supine position for BP measurements b. obtain 2 bp readings in the dominant at and average the results. c. deflate the bp cuff at a rate of 5 to 10 mm Hg per second d. have the client sit in a chair with their feet flat on the floor.

d. have the client sit in a chair with their feet flat on the floor.

The client diagnosed with primary hypertension is prescribed ambulatory blood pressure monitoring. ABPM readings indicate an increase in systolic blood pressure during sleep. Which is the best interpretation of this finding? a. aldosterone levels are increased during sleep b. early manifestations of hypertensive crisis c. resistance to antihypertensive medications d. increased risk for cardiovascular disease

d. increased risk for cardiovascular disease

The nurse cares for a client admitted to the cardiac unit diagnosed with unstable angina. The client reports they are experiencing sudden onset of chest discomfort. Which order of action should the nurse take? a. auscultate heart sounds and breath sounds b. obtain a 12-lead ecg c. assess pain and obtain a set of vitals d. place client in high fowlers and apply supplemental oxygen e. give 0.4 mg sublingual nitroglycerine

d. place client in high fowlers and apply supplemental c. assess pain and obtain a set of vitals b. obtain a 12-lead ecg e. give 0.4 mg sublingual nitroglycerine a. auscultate heart sounds and breath sounds

The nurse cares for a client diagnosed with infective endocarditis. The echocardiography report indicates "a vegetative mass present on the tricuspid valve". The client is at risk to develop which complication? a. liver embolization b. renal embolization c. cerebral embolization d. pulmonary embolization (PE)

d. pulmonary embolization (PE)

A client is diagnosed with hypercholesteremia is perscribed atorvastatin (Lipitor). Which laboratory test would indicate an adverse effect from this medication? a. fasting low-density lipoprotein 68 mg/dL b. serum blood glucose 84 mg/dL c. serum creatinine 0.75 mg/dL d. serum ALT/SGPT 467 units/L

d. serum ALT/SGPT 467 units/L

The nurse prepares to administer IV furosemide (Lasix) to a client diagnosed with stage 2 hypertension. Which assessment finding is the most important to report to the health care provider? a.blood glucose level of 175 mg/dL b. most recent bp reading of 138/94 mm Hg c. orthostatic systolic bp decrease of 12 mm Hg d. serum potassium level of 2.9 mEq/L

d. serum potassium level of 2.9 mEq/L