AH2 final exam study guide

For the first several hours after a cardiac catheterization, it is most essential for the nurse to: (A) monitor the client's apical pulse and blood pressure (B) keep the head of the client's bed elevated 45 degrees (C) encourage the client to cough and deep breathe every 2 hours (D) check the client's temperature every hour until it returns to normal

Answer: A Rationale: An apical pulse is taken to detect dysrhythmias related to cardiac irritability; blood pressure is monitored to detect hypotension, which may indicate bleeding or shock.

When teaching a community health class the nurse informs the group that the person at highest risk of developing prostate cancer is: a) 55 yo Black male b) 45 yo white male c) 55 yo Asian male d) 45 yo Hispanic male

Answer: A Rationale: Cancer of the prostate is rare before age 50 but increases with each decade; black men develop cancer of the prostate twice as often and at an earlier age than white men.

The nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, the nurse should consider which finding significant? a) Rheumatic fever b) Croup c) Severe staphylococcal infection d) Medullary sponge kidney

Answer: A Rationale: Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup — a severe upper airway inflammation and obstruction that typically strikes children ages 3 months to 3 years — may cause latent complications, such as ear infection and pneumonia. However, it doesn't affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, eventually may lead to hypertension but doesn't damage heart structures.

A physical assessment finding that the nurse would expect to be present in the patient with acute left-sided heart failure is a) bubbling crackles and dyspnea b) hepatosplenomegaly and tachypnea c) peripheral edema and cool, diaphoretic skin d) frothy, blood-tinged sputum and distended jugular veins

Answer: A Rationale: Clinical manifestations of cute left-sided heart failure are those of pulmonary edema, with bubbling crackles and tachycardia; frothy, blood-tinged sputum; severe dyspnea; tachypnea; and orthopnea. Severe tachycardia and cool, clammy, skin are present as a result of stimulation of the sympathetic nervous system from hypoxemia. Systemic edema reflected by jugular vein distention, peripheral edema, and hepatosplenomegaly are characteristic of right-sided heart failure.

A 62-year-old has hypertension and smokes a pack of cigarettes per day. She has no symptoms of CAD, but a recent LDL level is 154 mg/dL. Based on these findings, the nurse would expect that treatment for the patient would include (A) diet therapy only (B) drug therapy only (C) diet and drug therapy (D) exercise instruction only

Answer: A Rationale: Diet therapy is indicated for a patient without CAD who has two or more risk factors and an LDL level greater than 130 mg/dL. When the patient's LDL levels are greater than 160 mg/dL, drug therapy would be added to diet therapy. Exercise is indicated to reduce risk factors throughout treatment.

The nurse determines that further dietary teaching is indicated when a patient with dumping syndrome says, a) "I should eat bread with every meal." b) "I should avoid drinking fluids with my meals." c) "I should eat smaller meals about six times a day." d) "I need to lie down for 30 to 60 minutes after my meals."

Answer: A Rationale: Dietary control of dumping syndrome includes small, frequent meals with low carbohydrate content and elimination of fluids with meals. The patient should also lie down for 30 to 60 minutes after meals. These measures help delay stomach emptying, preventing the rapid movement of a high-carbohydrate food bolus into the small intestine.

During the immediate postoperative care of the recipient of a kidney transplant, the nurse expects to a) regulate fluid intake hourly based on urine output b) find urine-tinged drainage on abdominal dressing c) medicate the patient frequently for abdominal flank pain d) remove the urinary catheter to evaluate the ureteral implant

Answer: A Rationale: Fluid and electrolyte balance is critical in the transplant-recipient patient, especially because diuresis often begins soon after surgery. Fluid replacement is adjusted hourly, based on kidney function and output. Urine-tinged drainage on the abdominal dressing may indicate leakage from the ureter implanted into the bladder, and the health care provider should be notified. The donor patient has a flank incision where the kidney was removed,; the recipient patient has an abdominal incision where the kidney was placed in the iliac fossa. The urinary catheter is usually used for 2-3 days to monitor urine output and kidney function.

A home health nurse visits a 40 yo housewife who is receiving hemodialysis. When reviewing the diet with the client, the nurse encourages her to include: a) rice b) potatoes c) canned salmon d) barbecued beef

Answer: A Rationale: Foods high in carbohydrates and low in protein, sodium, and potassium are encouraged for these clients.

When a patient is admitted to the emergency dept. following a head injury, the nurse's first priority in management of the patient one a patent airway is confirmed is A) maintaining cervical spine precautions B) determine the presence of increased ICP C) monitoring for changes neurologic status D) establishing IV access with a large-bore catheter

Answer: A Rationale: In addition to monitoring for a patent airway during emergency care of the patient with a head injury, the nurse must always assume that a patient with a head injury may also have a cervical spit injury. Maintaining cervical spine precautions in all assessment and treatment activities with the patient is essential to prevent additional neurologic damage.

The nurse recognizes that fibrinolytic therapy for the treatment of an MI has not been successful when the patient (A) continues to have chest pain (B) develops major GI or genitourinary (GU) bleeding during treatment (C) has a marked increase in CK enzyme levels within 3 hours of therapy (D) develops premature ventricular contractions and ventricular tachycardia during treatment

Answer: A Rationale: Indications that the occluded coronary artery is patent, and blood flow to the myocardium is reestablished following thrombolytic therapy, including relief of chest pain; return of ST segment to baseline on the ECG; the presence of reperfusion dysrhythmias; and marked, rapid rise of the CK enzyme within 3 hours of therapy. If chest pain is unchanged, it is an indication that reperfusion was not successful.

A patient with ulcerative colitis has a total colectomy with formation of a terminal ileum stoma. An important nursing intervention for this patient postoperatively is to a) measure the ileostomy output to determine the status of the patient's fluid balance. b) change the ileostomy appliance every 3 - 4 hours to prevent leakage of drainage onto the skin. c) emphasize that the ostomy is temporary and the ileum will be reconnected when the large bowel heals. d) teach the patient about the high-fiber, low-carbohydrate diet required to maintain normal ileostomy drainage.

Answer: A Rationale: Initial output from a newly formed ileostomy may be as high as 1500 to 2000 mL daily, and intake and output must be accurately monitored for fluid and electrolyte imbalance. Ileostomy bags may need to be emptied every 3-4 hours, but the appliance should not be changed for several days unless there is leakage onto the skin A terminal ileum stoma is permanent, and the entire colon has been removed. A return to a normal, pre surgical diet is the goal for the patient with an ileostomy, with restrictions based only on the patient's individual tolerances.

When discussing nutrition with a client who has inflammatory bowel disease of the ascending colon, the most appropriate suggestion by the nurse concerning food to include in the diet is: a) scrambled eggs and applesauce b) barbecues chicken and French fries c) fresh fruit salad with cheddar cheese d) chunky peanut butter on whole wheat bear

Answer: A Rationale: Low residue foods produce less fecal waste, decreasing bowel contents and irritation; protein promotes healing and calories provide energy.

A client, admitted to the cardiac care unit with a myocardial infarction, complains of chest pain. The nursing intervention most effective in relieving the client's pain is to administer the ordered: (A) morphine sulfate 2 mg IV (B) nitroglycerin sublingually (C) oxygen per nasal cannula (D) lidocaine hydrochloride 50 mg IV bolus

Answer: A Rationale: Morphine is an opioid analgesic that acts on the central nervous system by a sympathetic mechanism. Morphine decreases systemic vascular resistance, which decreases left ventricular after load, thus decreasing myocardial oxygen consumption.

A patient newly diagnosed with acute hepatitis B asks about drug therapy to treat the disease. The most appropriate response by the nurse is informing the patient that a) there are no specific drug therapies that are effective for treating acute viral hepatitis b) only chronic hepatitis C is treatable, primarily with antiviral agents and alpha-interferon c) no drugs can be used for treatment of viral hepatitis because of the risk of additional liver damage d) alpha-interferon

Answer: A Rationale: No specific drugs are effective treating acute viral hepatitis, although supportive drugs, such as antiemetics, sedatives, or antipruritics, may be used for symptom control. Antiviral agents, such as lamivudine or ribacvarin, and alpha-interferon may be used for treating chronic hepatitis B or C.

The nurse suspects stable angina rather than MI pain in the patient who reports chest pain that (A) is relieved by nitroglycerin (B) is a sensation of tightness or squeezing (C) does not radiate to the neck, back, or arms (D) is precipitated by physical or emotional exertion

Answer: A Rationale: One of the primary differences between the pain of angina and the pain of an MI is that angina pain is usually relieved by rest or nitroglycerin, which reduces the oxygen demand of the heart, whereas MI pain is not. Both angina and MI pain can cause a pressure or squeezing sensation; may radiate to the neck, back, arms, fingers, and jaw; and may be precipitated by exertion.

A client with an aldosterone-secreting adenoma is scheduled for surgery to remove the tumor. The client wonders what will happen if surgery is canceled. The nurse bases a response on the fact that: A) Heart and kidney damage may occur if the tumor is not removed. B) Surgery will prevent the tumor from metastasizing to other organs. C) Chemotherapy is as reliable as surgery to treat adenomas of this type. D) Radiation therapy or surgery can be just as effective if the tumor is small.

Answer: A Rationale: Renal and cardiac complications will occur if hypertension is not arrested.

The health care provider prescribes spironolactone (Aldactone) for the patient with chronic heart failure. Diet modification related to the use of this drug that the nurse includes in patent teaching include a) decreasing both sodium and potassium intake b) increasing calcium intake and decreasing sodium intake c) decreasing sodium intake and increasing potassium intake d) decreasing sodium intake and using salt substitutes for seasoning

Answer: A Rationale: Spironolactone is a potassium-sparing diuretic, and when it is the only diuretic used in the treatment of heart failure, moderate to low levels of potassium should be maintained to prevent development of hyperkalemia. Sodium intake is usually reduced to at least 2300 mg/day in patients with heart failure, but salt substitutes cannot be freely used because most contain high concentrations of potassium.

After a transurethral vaporization of the prostate, the patient returns to the unit with a urinary retention catheter and a continuous bladder irrigation. What should the nurse do first when the client indicates the need to urinate? a) Assess that the tubing attached to the collection bag is patent. b) Obtain the patient's vital signs before notifying the practitioner. c) Explain that the balloon inflated in the bladder causes this feeling. d) Review the patient's intake and output that was documented in the previous shift.

Answer: A Rationale: The drainage tubing may be obstructed. Retained fluid raises intravesicular pressure, causing discomfort similar to the urge to void.

During an acute attack of diverticulitis, the patient is a) monitored for signs of peritonitis b) treated with daily medicated enemas c) prepared for surgery to resect the involved colon d) provided with a heating pad to apply to the left lower quadrant

Answer: A Rationale: The inflammation and infection of diverticula cause small perforations with spread of the inflammation to the surrounding area in the intestines. Abscesses may form, or complete perforation with peritonitis may occur. Systemic antibiotic therapy is often used, but medicated enemas would increase intestinal motility and increase the possibility of perforation, as would the application of heat. Surgery is indicated when it is necessary to drain abscesses or to resect an obstructing inflammatory mass.

A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During the admission of the patient, the nurse places highest priority on A) maintaining a patent airway B) assessing the patient for head and other injuries C) maintaining immobilization of the cervical spine D) assessing the patient's motor and sensory function

Answer: A Rationale: The need for a patent airway is the first priority for any injured patient, and a high cervical injury may decrease the gag reflex and ability to maintain an airway, as well as the ability to breathe. Maintaining cervical stability is then a consideration, along with assessing for other injuries and the patient's neurological status.

A patient is admitted to the emergency department with acute abdominal pain. The nursing intervention that should be implemented first is a) measurement of vital signs b) administration of prescribed analgesics c) assessment of the onset, location, intensity, duration, and character of the pain d) physical assessment of the abdomen for distention, assess, abnormal pulsations, bowel sounds, and pigmentation changes

Answer: A Rationale: The patient with an acute abdomen may have significant fluid or blood loss into the abdomen, and evaluation of blood pressure (BP) and heart rate (HR) should be the first intervention, followed by assessment of the abdomen and the nature of the pain. Analgesics should be used cautiously until a diagnosis can be determined so that symptoms are not masked.

The nurse evaluates that management of the patient with upper GI bleeding is effective when assessment and laboratory findings reveal a a) decreasing blood urea nitrogen (BUN) b) hematocrit (Hct) of 35% c) urinary output of 20 mL/hr d) urine-specific gravity of 1.030

Answer: A Rationale: The patient's BUN is usually elevated with a significant hemorrhage because blood proteins are subjected to bacterial breakdown in the GI tract. With control of bleeding, the BUN will return to normal. During the early stage of bleeding, the hematocrit is not always a reliable indicator of the amount of blood lost or the amount of blood replaced and may be falsely high or low. A urinary output of <20 mL/hr indicates impaired renal perfusion and hypovolemia, and a urine-specific gravity of 1.030 indicates concentrated urine typical of hypovolemia.

A newly admitted patient who has suffered a right-sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, the nurse should a) place objects on the right side within the patient's field of vision. b) approach the patient from the left side to encourage the patient to turn the head. c) place objects on the patient's left side to assess the patient's ability to compensate. d) patch the affected eye to encourage the patient to turn the head to scan the environment.

Answer: A Rationale: The presence of homonymous hemianopsia in a patient with right-hemisphere brain damage causes a loss of vision in the left field. Early in the care of the patient, objects should be placed on the right side of the patient in the field of vision, and the nurse should approach the patient from the right side. Later in treatment, patients should be taught to turn the head and scan the environment and should be approached from the affected side to encourage head turning. Eye patches are used if patients have diplopia (double vision).

Which of the following signs and symptoms would most likely be found in a client with mitral regurgitation? a) exertion dyspnea b) confusion c) elevated creatine phosphokinase concentration d) chest pain

Answer: A Rationale: Weight gain, due to fluid retention and worsening heart failure, causes exertional dyspnea in clients with mitral regurgitation. The rise in left atrial pressure that accompanies mitral valve disease is transmitted backward into pulmonary veins, capillaries, and arterioles and eventually to the right ventricle. Signs and symptoms of pulmonary and systemic venous congestion follow.

A client is admitted to the coronary care unit with a tentative diagnosis of myocardial infarction. What type of pain should the nurse expect the client to describe? (A) severe, intense chest pain (B) burning sensation of short duration (C) mild chest pain, radiating to the fingers (D) squeezing chest pain, received by nitroglycerin

Answer: A Rationale: These are classic symptoms of a myocardial infarction; further medical evaluation and intervention are needed immediately.

The nurse evaluates the potency of an AV graft by a) palpating for pulses distal to the graft site b) auscultating for the presence of a bruit at the site c) evaluating the color and temperature of the extremity d) assessing for the presence of numbness and tingling distal to the site

Answer: B Rationale: A patent AV graft creates turbulent blood flow that can be assessed by listening for a bruit or palpated for a thrill as the blood passes through the graft. Assessment of neurovascular status in the extremity distal to the graft site is important to determine that the graft does not impair circulation to the extremity, but the neuromuscular status does not indicate whether the graft is open.

In teaching patients at risk for upper GI bleeding to prevent bleeding episodes. the nurse stresses that a) all stools and vomitus must be tested for the presence of blood b) the use of OTC medications of any kind should be avoided c) antacids should be taken with all prescribed medications to prevent gastric irritation d) misoprostol (Cytotec) should be used to protect the gastric mucosa in individuals with peptic ulcers

Answer: B Rationale: All OTC drugs should be avoided because their contents may include drugs that are contraindicated because of the irritating effects on the gastric mucosa. Patients are taught to test suspicious vomitus or stools for occult blood, but all stools do not need to be tested. Antacids cannot be taken with all medications because they prevent absorption of many drugs. Misoprostol is used to protect the gastric mucosa in patients who must take NSAIDs for other conditions because it inhibits acid secretion stimulated by NSAIDs.

A patient is admitted with a spinal cord injury at the C7 level. During assessment the nurse identifies the presence of spinal shock on finding A) paraplegia with a flaccid paralysis B) tetraplegia with total sensory loss C) total hemiplegia with sensory and motor loss D) spastic tetraplegia with loss of pressure sensation

Answer: B Rationale: At the C7 level, spinal shock is manifested by tetraplegia and sensory loss. The neurologic loss may be temporary or permanent. Paraplegia with sensory loss would occur a the level of T1. A hemiplegia occurs with central (brain) lesions affecting motor neurons and spastic paraplegia occurs when spinal shock resolves.

The nurse expects a patient with an ulcer of the posterior portion of the duodenum to experience a) pain that occurs after not eating all day b) back pain that occurs 2 to 4 hours following meals c) midepigastric pain that is unrelieved with antacids d) high epigastric burning that is relieved with food intake

Answer: B Rationale: Back pain is a common manifestation of ulcers located on the posterior aspect of the duodenum and is important for nurses to keep in mind during assessment of the patient, because the more typical epigastric burning and pain may not be present. Duodenal ulcers are more often relieved by food than are gastric ulcers, and when epigastric discomfort occurs, it is lower than that of gastric ulcers. Eating stimulates gastric acid production, increasing discomfort for patients with gastric ulcers, whereas the pain of duodenal ulcers usually occurs several hours after eating.

A patient with myocardial infarction is developing cariogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the patient for? a) bradycardia b) ventricular dysrhythmias c) rising diastolic blood pressure d) falling central venous pressure

Answer: B Rationale: Classic signs of cariogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure become apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium

The nurse recognizes the presence of Cushing's triad in the patient with: a) increased pulse, irregular respiration, increased BP b) decreased pulse, irregular respiration, increased pulse pressure c) increased pulse, decreased respiration, increased pulse pressure d) decreased pulse, increased respiration, decreased systolic BP

Answer: B Rationale: Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.

A client has been admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The complication the nurse will constantly observe for is: a) presence of heart murmur b) systemic emboli c) fever d) congestive heart failure

Answer: B Rationale: Emboli are the major problem; those arising in the right heart chambers will terminate in the lungs and left chamber emboli may travel anywhere in the arteries. Heart murmurs, fever, and night sweats may be present, but do not indicate a problem with emboli. CHF may be a result, but this is not as dangerous an outcome as emboli

Following a patient's esophagogastrostomy for cancer of the esophagus, it is important for the nurse to a) report any bloody drainage from the NG tube b) maintain the patient in semi-Fowler's or Fowler's position c) monitor for abdominal distention that may disrupt the surgical site d) expect to find decreased breath sounds bilaterally because of the surgical approach

Answer: B Rationale: Following esophageal surgery, the patient should be positioned in semi-Fowler's or Fowler's position to prevent reflux and aspiration of gastric secretions. NG drainage is expected to be bloody for 8 to 12 hours postoperatively. Abdominal distention is not a major concern following esophageal surgery, and even though the thorax may be opened during the surgery, clear breath sounds should be expected in all areas of the lungs.

When providing care for a patient with amyotrophic lateral sclerosis (ALS), the nurse recognizes that one of the most distressing problems experienced by the patient is A) painful spasticity of the face and extremities B) retention of cognitive function with total degeneration of motor function C) uncontrollable writhing and twisting movements of the face, limbs, and body D) the knowledge that there is a 50% change the disease has been passed to any offspring

Answer: B Rationale: In acute amyotrophic lateral sclerosis (ALS), there is gradual degeneration of motor neurons with extreme muscle wasting from lack of stimulation and use. However, cognitive function is not impaired, and patients feel trapped in a dying body. Chorea manifested by writhing, involuntary movements is characteristic of Huntington's disease. As an autosomal-dominant genetic disease, Huntington's disease also has a 50% chance of being passed to each offspring.

The pathophysiologic mechanism that results in the pulmonary edema of left-sided heart failure is a) increased right ventricular preload b) increased pulmonary hydrostatic pressure c) impaired alveolar oxygen and carbon dioxide exchange d) increased lymphatic flow of pulmonary extravascular fluid

Answer: B Rationale: In left-sided heart failure, blood backs up into the pulmonary veins and capillaries. This increased hydrostatic pressure in the vessels causes fluid to move out of the vessels and into the pulmonary interstitial space. When increased lymphatic flow cannot remove enough fluid from the interstitial space, fluid moves into the alveoli, resulting in pulmonary edema and impaired alveolar oxygen and carbon dioxide exchange. Initially the right side of the heart is not involved.

Following a generalized tonic-clonic seizure, the patient is tired and sleepy. The nurse should A) suction the patient before allowing him to rest B) allow the patient to sleep as long as he feels sleepy C) stimulate the patient to increase his level of consciousness D) check the patient's level of consciousness every 15 minutes for an hour

Answer: B Rationale: In the postictal phase of generalized tonic-clonic seizures, patients are usually very tired and may sleep for several hours, and the nurse should allow the patient to sleep as long as necessary. Suctioning is only performed if needed, and decreased LOC is not a problem postictally unless a head injury has occurred during the seizure.

A patient is admitted to the emergency dept. with a spinal cord injury at the level of T2. Which of the following findings is of most concern to the nurse? A) SpO2 of 92% B) HR of 42 beats / min C) Blood pressure of 88/60 D) Loss of motor and sensory function in arms and legs

Answer: B Rationale: Neurogenic shock associated with cord injuries above the level of T6 greatly decrease the effect of the sympathetic nervous system, and bradycardia and hypotension occur. A heart rate of 42 is not adequate to meet the oxygen requirements of the body, and while low, the BP is not at a critical point. The oxygen saturation is satisfactory, and the motor and sensory loss are expected.

A patient with an intracranial problem does not open his eyes to ay stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patient's GCS score as a) 6 b) 7 c) 9 d) 11

Answer: B Rationale: No opening of eyes = 1; incomprehensible words = 2; flexion withdrawal = 4 Total = 7

The nurse performs an admission assessment on a client who visits a health care clinic for the first time. The client tells the nurse that propylthiouracil (PTU) is taken daily. The nurse continues to collect data from the client, suspecting that the client has a history of what condition? A) Myxedema B) Graves' Disease C) Addision's Disease D) Cushing's Syndrome

Answer: B Rationale: PTU inhibits thyroid hormone synthesis and is used to treat hyperthyroidism, or Graves' Disease. Myxedema indicates hypothyroidism. Cushing's syndrome and Addison's disease are disorders related to adrenal function.

Answer: B Rationale: The patient is experiencing a cardiac tamponade that consists of excess fluid in the pericardial sac, which compresses the heart and the adjoining structures, preventing normal filling and cardiac output. Fibrin accumulation, a scarred and thickened pericardium, and adherent pericardial membranes occur in chronic constrictive pericarditis.

Answer: B Rationale: Patients with mechanical valves have an increased risk for thrombus formation as a result of RBC lysis. Therefore prophylactic anticoagulation therapy is used to prevent thrombus formation and systemic or pulmonary embolization. Nitrates are contraindicated for the patient with aortic stenosis because an adequate preload is necessary to open the stiffened aortic valve. Antidysrhythmics are used only if dysrhythmias occur, and alpha or beta adrenergic blocking agents may be used to control the HR as needed.

When assessing a patient with a diagnosis of left ventricular failure, the nurse expects to identify: a) crushing chest pain b) dyspnea on exertion c) jugular vein distention d) extensive peripheral edema

Answer: B Rationale: Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing.

Laboratory test results that the nurse would expect to find in a patient with cirrhosis include a) serum albumin: 7.0 g/dL b) bilirubin: total 3.2 mg/dL c) serum cholesterol: 260 mg/dL d) aspartate aminotransferase (AST): 6.0 U/L

Answer: B Rationale: Serum bilirubin, both direct and indirect, would be expected to be increased in cirrhosis. Serum albumin and cholesterol are decreased, and liver enzymes, such as AST and ALT, are elevated.

In replying to a patient's questions about the seriousness of her chronic kidney disease (CKD), the nurse knows that the stage of CKD is based on the a) total daily urine output b) glomerular filtration rate c) serum creatinine and urea levels d) degree of altered mental status

Answer: B Rationale: Stages of CKD are based on the glomerular filtration rate (GFR) or the presence of kidney damage over a period of 3 months. No specific markers of urinary output, azotemia, or urine output classify the degree of CKD.

A patient is admitted to the medical unit with a diagnosis of right ventricular heart failure. The nursing assessment that supports this medical diagnosis is: a) nocturnal orthopnea b) distended jugular veins c) shortness of breath on exertion d) decreased arterial blood pressure

Answer: B Rationale: Symptoms of right ventricular heart failure relate to retention of fluid; neck veins become distended because of increased back pressure from the right atrium.

A patient with a head injury has bloody drainage from the ear. To determine whether CSF is present in the drainage, the nurse A) examines the tympanic membrane for a tear B) tests the fluid for a halo sign on a white dressing C) tests the fluid with a glucose identifying strip or stick D) collects 5 mL of fluid in a test tube and sends it to the laboratory for analysis

Answer: B Rationale: Testing clear drainage for CSF in nasal or ear drainage may be done with a Desxtrostik or Tes-Tape strip, but if blood is present, the glucose in the blood will produce an unreliable result. To test bloody drainage, the nurse should test the fluid for a "halo" or "ring" that occurs when a yellowish ring encircles blood dripped onto a white pad or towel

A patient with acute pericarditis has markedly distended jugular veins, decreased BP, tachycardia, tachypnea, and muffled heart sounds. The nurse recognizes that these symptoms occur when: a) the pericardial space is obliterated with scar tissue and thickened pericardium b) excess pericardial fluid compresses the heart and prevents adequate diastolic filling c) the parietal and visceral pericardial membranes adhere to each other, preventing normal myocardial contraction d) fibrin accumulation on the visceral pericardium infiltrates into the myocardium, creating generalized myocardial dysfunction.

Answer: B Rationale: The patient is experiencing a cardiac tamponade that consists of excess fluid in the pericardial sac, which compresses the heart and the adjoining structures, preventing normal filling and cardiac output. Fibrin accumulation, a scarred and thickened pericardium, and adherent pericardial membranes occur in chronic constrictive pericarditis.

A thallium scan is scheduled for a client who had a myocardial infarction to: (A) Monitor the mitral and aortic valves (B) Establish the viability of myocardial muscle (C) Visualize the ventricular systole and diastole (D) Determine the adequacy of electrical conductivity

Answer: B Rationale: This is a radio nuclear study that determines viability of myocardial tissue; necrotic or scar tissue does not extract the thallium isotope.

An unconscious patient with increased ICP is on ventilatory support. The nurse notifies the health care provider when arterial blood gas (ABG) measurement results reveal a a) pH of 7.43 b) SaO2 of 94% c) PaO2 of 50 mmHg d) PaCO2 of 30 mmHg

Answer: C Rationale: A PaO2 of 50 mmHg reflects a hypoxemia that may lead to further decreased cerebral perfusion and hypoxia and must be corrected. The pH and SaO2 are within normal range, and a PaCO2 of 30 mmHg reflects an acceptable value for the patient with increased ICP.

A carotid endarterectomy is being considered for a patient who has had several TIAs. The nurse explains to the patient that this surgery a) is used to restore blood circulation to the brain following an obstruction of a cerebral artery b) involves intracranial surgery to join a superficial extra cranial artery to an intracranial artery c) involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke d) is used to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation.

Answer: C Rationale: An endarterectomy is a removal of an atherosclerotic plaque, and a plaque in the carotid artery may impair circulation enough to cause a stroke. A carotid endarterectomy is performed to prevent a cerebrovascular accident (CVA), as are most other surgical procedures. An extra cranial-intracranial bypass involves cranial surgery to bypass a sclerotic intracranial artery. Percutaneous transluminal angioplasty uses a balloon to compress stenotic areas in the carotid and vertebrobasilar arteries and often includes inserting a stent to hold the artery open.

A 60-year-old client with a long history of cardiovascular problems, including angina and hypertension, is to have a cardiac catheterization. During pericardiac catheterization teaching, the nurse explains to this client that the major purpose for this procedure is to: (A) obtain the pressures in the heart chambers (B) determine the existence of congenital heart disease (C) visualize the disease process in the coronary arteries (D) measure the oxygen content of various heart chambers

Answer: C Rationale: Angina is usually cause by narrowing of the coronary arteries; the lumen of the arteries can be assessed by cardiac catheterization. Although pressures can be obtained, they are not the priority for this client.

Acute pyelonephritis resulting from an ascending infection from the lower urinary tract occurs most often when a) the kidney is scarred and fibrotic b) the organism is resistant to antibiotics c) there is a preexisting abnormality of the urinary tract d) the patient does not take all of the antibiotics for treatment of a UTI

Answer: C Rationale: Ascending infections from the bladder to the kidney are prevented by normal anatomy and physiology of the urinary tract unless a preexisting condition, such as bladder tumors, prostatic hyperplasia, strictures, or stones, is present. Resistance to antibiotics and failure to take a full prescription of antibiotics for a UTI usually result in relapse or reinfection of the lower urinary tract.

The possibility of death from complications always accompanies an acute myocardial infarction. The most serious complication the nurse monitors the client for during the first 48 hours is: (A) pulmonary edema (B) pulmonary embolism (C) ventricular tachycardia (D) failure of the right ventricle

Answer: C Rationale: At least one half of all deaths occur from the life threatening dysrhythmia of ventricular tachycardia.

Patients at risk for renal lithiasis can prevent stones in many cases by a) leading an active lifestyle b) limiting protein and acid foods in the diet c) drinking enough fluids to produce a urine output of 2 L/day d) taking prophylactic antibiotics to control UTIs

Answer: C Rationale: Because crystallization of stone constituents can precipitate and unite to form a stone when in supersaturated concentrations, one of the best ways to prevent stones of any type is to keep the urine dilute and flowing, which is an output of about 2 L/day. Sedentary lifestyle is a risk factor for renal stones, but exercise also causes fluid loss and a need for additional fluids. Protein foods high in purine should be restricted only for the small percentage of patients with uric acid stones, and although UTIs contribute to stone formation, prophylactic antibiotics are not indicated.

During discharge instructions for a patient following a laparoscopic cholecystectomy, the nurse advises the patient to a) keep the incision areas clean and dry for at least a week b) report the need to take pain medication for shoulder pain c) report any bile-colored or purulent drainage from the incision d) expect some postoperative nausea and vomiting for a few days

Answer: C Rationale: Bile-colored drainage or pus from any incision may indicate an infection and should be reported to the health care provider immediately. The bandages on the puncture sites should be removed the day after surgery, followed by bathing or showering. Referred shoulder pain is a common and expected problem following laparoscopic procedures, when carbon dioxide used to inflate the abdominal cavity is not readily absorbed by the body. Cause and vomiting are not expected postoperatively and may indicate damage to other abdominal organs and should be reported to the HCP.

During the treatment of the patient with bleeding esophageal varices, it is most important that the nurse a) prepare the patient for immediate portal shunting surgery. b) perform guaiac testing on all stools to detect occult blood. c) maintain the patient's airway and prevent aspiration of blood. d) monitor for the cardiac effects of IV vasopressin and nitroglycerin

Answer: C Rationale: Bleeding esophageal varices are a medical emergency. During an episode of bleeding, management of the airway and prevention of aspiration of blood are critical factors. Occult blood as well as fresh blood from the GI tract would be expected and is not tested. Vasopressin causes vasoconstriction, decreased heart rate, and decreased coronary blood flow; nitroglycerin is given with the vasopressin to counter these side effects. Portal shunting surgery is performed for esophageal varices but not during an acute hemorrhage.

In the patient with chest pain, unstable angina can be differentiated from an MI by (A) ECG changes present at onset of pain (B) a chest x-ray indicating left ventricular hypertrophy (C) CK-MB enzyme elevations that peak 18 hours after the infarct. (D) the appearance of troponin in the blood 48 hours after the infarct.

Answer: C Rationale: CK-MB is a tissue enzyme that is specific to cardiac muscle and is released into the blood when myocardial cells die. CK-MB levels begin to rise about 6 hours after an acute MI, peak in about 18 hours and return to normal within 14-36 hours. This increase can demonstrate the presence of cardiac damage and the approximate extent of the damage. Troponin, a myocardial muscle protein released with myocardial damage, rises as quickly as CK does and remains elevated for 2 weeks. ECG changes are often not apparent immediately after infarct and may be normal when the patient seeks medical attention. An enlarged heart, determined by x-ray, indicates cardiac stress but is not diagnostic of an acute MI.

The patient with chronic pancreatitis is more likely than the patient with acute pancreatitis to a) need to abstain from alcohol b) experience acute abdominal pain c) have malabsorption and diabetes mellitus d) require a high-carbohydrate, high-protein, low-fat diet

Answer: C Rationale: Chronic damage to the pancreas causes pancreatic exocrine and endocrine insufficiency, resulting in a deficiency of digestive enzymes and insulin. Malabsorption and diabetes often result. Abstinence from alcohol is necessary in both types of pancreatitis, as is a high-carbohydrate, high-protein, and low-fat diet. Although abdominal pain is a major manifestation of chronic pancreatitis, more commonly a heavy, gnawing feeling occurs.

The health care provider has ordered IV dopamine (Intropin) for a patient in the emergency dept. with a spinal cord injury. The nurse determines that the drug is having the desired effect when assessment findings include A) a pulse rate of 68 B) respiratory rate of 24 C) BP of 106/82 D) temperature of 96.8 F (36.0 C)

Answer: C Rationale: Dopamine is a vasopressor that is used to maintain BP during states of hypotension that occur during neurogenic shock associated with SCI. Atropine would be used to treat a bradycardia. The temperature reflects some degree of poikilothermism, but this is not treated with medications.

The nurse teaches the patient with diverticulosis to a) use anticholinergic drugs routinely to prevent bowel spasm b) have an annual colonoscopy to detect malignant changes in the lesions c) maintain a high-fiber diet and use bulk laxatives to increase fecal volume d) exclude whole grain breads and cereals from the diet to prevent irritating the bowel

Answer: C Rationale: Formation of diverticula is common when decreased bulk of stool, combined with a more narrowed lumen in the sigmoid colon, causes high intraluminal pressures that result in saccular dilation or outpouching of the mucosa through the muscle of the intestinal wall. To prevent the high intraluminal pressure, fecal volume should be increased with use of high-fiber diets and bulk laxatives, such as psyllium hydrophilic mucilloid (Metamucil). Anticholinergic drugs are used only during an acute episode of diverticulitis, and the lesions are not premalignant.

A nurse teaches the signs of organ rejection to a patient who had a kidney transplant. Which sign would the client have to identify for the nurse to determine that the patient understands the teaching? a) weight loss b) subnormal temperature c) elevated blood pressure d) increased urinary output

Answer: C Rationale: Hypertension is caused by hypervolemia because of the failure of the new kidney.

While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. The nurse should a) use restraints to protect the patient from injury b) administer CNS depressants to lightly sedate the patient c) perform the exercises less frequently because posturing can increase ICP d) continue the exercises because they are necessary to maintain musculoskeletal function

Answer: C Rationale: If reflex posturing occurs during ROM or positioning of the patient, these activities should be done less frequently until the patient's condition stabilizes, because posturing can cause increases in ICP. Neither restraints nor CNS depressants would be indicated.

A female client has a tentative diagnosis of Cushing's syndrome. The nurse's physical assessment of this client will probably reveal the presence of: A) fever and tachycardia B) lethargy and constipation C) hypertension and moon face D) hyperactivity and exophthalmos

Answer: C Rationale: Increased glucocorticoids cause sodium and water retention, hypertension, and fat deposition, resulting in moon facies.

During the incubation period of viral hepatitis, the nurse would expect the patient to report a) pruritus and malaise b) dark urine and easy fatiguability c) anorexia and right upper quadrant discomfort d) constipation or diarrhea with light-colored stools

Answer: C Rationale: Incubation symptoms occur before the onset of jaundice and include a variety of GI symptoms as well as discomfort and heaviness un the upper right quadrant of the abdomen. Pruritus, dark urine, and light-colored stools occur with the onset of jaundice in the acute phase.

The nurse advises the male patient who has had an MI that during sexual activity (A) the patient should use the superior position (B) foreplay may cause too great an increase in heart rate (C) prophylactic nitroglycerin may be used if angina occurs (D) performance can be improved with the use of sildenafil (Viagra)

Answer: C Rationale: It is not uncommon for a patient who experiences chest pain on exertion to have some angina during sexual stimulation or intercourse, and the patient should be instructed to use nitroglycerin prophylactically. Positions during intercourse are a matter of individual choice, and foreplay is desirable because it allows a gradual increase in HR. Sildenafil (Viagra) should be used cautiously in men with CAD and should not be used with nitrates.

During assessment of a patient admitted to the hospital with an acute exacerbation of MS, the nurse would expect to find A) tremors, dysphasia, and ptosis B) bowel and bladder incontinence and loss of memory C) motor impairment, visual disturbances, and paresthesias D) excessive involuntary movements, hearing loss, and ataxia

Answer: C Rationale: Motor and sensory dysfunctions, including paresthesias as well as patchy blindness, blurred vision, and hearing loss, are the most common manifestations of MS. Bowel and bladder dysfunctions and ataxia also occur, but excessive involuntary movements, tremors, and memory loss are not seen in MS.

The earliest signs of increased ICP the nurse should assess for include a) Cushing's triad b) unexpected vomiting c) decreased level of consciousness (LOC) d) dilated pupil with sluggish response to light

Answer: C Rationale: One of the most sensitive signs of increased ICP is a decreasing LOC. A decrease in LOC will occur before changes in vital signs, ocular signs, or projectile vomiting occur.

Management of the patient with acute pancreatitis includes a) surgery to remove the inflamed pancreas b) pancreatic enemies administered with meals c) NG suction to prevent gastric contents from entering the duodenum d) endoscopic pancreatic sphincterotomy using endoscopic retrograde cholangiopancreatography (ERCP)Answer: C Rationale: Pancreatic rest and suppression of secretions are promoted by preventing any gastric contents from entering the duodenum, which would stimulate pancreatic activity. Surgery is not indicated for acute pancreatitis but may be used to drain abscesses or cysts. An ERCP pancreatic sphincterotomy may be performed when pancreatitis is related to gallstones. Pancreatic enzymes are necessary in chronic pancreatitis if a deficiency in secretion occurs.

Answer: C Rationale: Pancreatic rest and suppression of secretions are promoted by preventing any gastric contents from entering the duodenum, which would stimulate pancreatic activity. Surgery is not indicated for acute pancreatitis but may be used to drain abscesses or cysts. An ERCP pancreatic sphincterotomy may be performed when pancreatitis is related to gallstones. Pancreatic enzymes are necessary in chronic pancreatitis if a deficiency in secretion occurs.

A patient with a stroke has a right-sided hemiplegia. The nurse prepares family members to help control behavior changes seen with this type of stroke by teaching them to a) ignore undesirable behaviors manifested by the patient. b) provide directions to the patient verbally in small steps. c) distract the patient from inappropriate emotional responses d) supervise all activities before allowing the patient to pursue them independently.

Answer: C Rationale: Patients with left brain damage from stroke often experience emotional lability, inappropriate emotional responses, mood swings, and uncontrolled tears or laughter disproportionate or out of context with the situation. The behavior is upsetting and embarrassing to both the patient and the family, and the patient should be distracted to minimize its presence.Patients with right-brain damage often have impulsive, rapid behavior that requires supervision and direction.

A patient with a history of peptic ulcer disease is hospitalized with symptoms of a perforation. During the initial assessment, the nurse would expect the patient to report a) vomiting of bright-red blood b) projectile vomiting of undigested food c) sudden, severe upper abdominal pain and shoulder pain d) hyperactive stomach sounds and upper abdominal swelling

Answer: C Rationale: Perforation of an ulcer causes sudden, severe abdominal pain that is often referred to the shoulder, accompanied by a rigid, birdlike abdomen and other signs of peritonitis. Vomiting of blood indicates hemorrhage of an ulcer, and gastric outlet obstruction is characterized by projectile vomiting of undigested food, hyperactive stomach sounds, and upper abdominal swelling.

A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on the knowledge that A) rehabilitation measures cannot be initiated until spinal shock has resolved. B) the patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia. C) resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder. D) the patient will have complete loss of motor and sensory functions below the level of the injury, but autonomic functions are not affected.

Answer: C Rationale: Spinal shock occurs in about half of all people with acute spinal cord injury. In spinal shock, the entire cord below the level of the lesion fails to function, resulting in a flaccid paralysis and hypotonicity of most processes without any reflect activity. Return of reflex activity signals the end of spinal shock. Sympathetic function is impaired below the level of the injury because sympathetic nerves leave the spinal cord at the thoracic and lumbar areas and cranial parasympathetic nerves predominate in control over respirations, heart, and all vessels and organs below the injury. Neurogenic shock results from loss of vascular tone caused by the injury and is manifested by hypotension, peripheral vasodilation, and decreased CO. Rehabilitation activities are not contraindicated during spinal shock and should be instituted if the patient's cardiopulmonary status is stable.

The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with the administration of a) furosemide (Lasix) b) lovastatin (Mevacor) c) daily low-dose aspirin d) nimodipine (Nimotop)

Answer: C Rationale: The administration of anti platelet agents, such as aspiring dipyridamole (Persantine), and ticlopidine (Ticlid), reduces the incidence of stroke in those at risk. Anticoagulants are also used for prevention of embolic strokes but increase the risk for hemorrhage. Diuretics are not indicated for stroke prevention other than for their role in controlling BP, and antilipemic agents have not been found to have a significant effect on stroke prevention. The calcium-channel blocker nimodipine is used in patients with subarachnoid hemorrhage to decrease the effects of vasospasm and minimize tissue damage.

Following a laparoscopic cholecystectomy, the nurse would expect the patient to a) return to work in 2 to 3 weeks b) be hospitalized for 3 to 5 days postoperatively c) have four small abdominal incisions covered with small dressings d) have a T-tube placed in the common bile duct to provide bile drainage

Answer: C Rationale: The laparoscopic cholecystectomy requires four small abdominal incisions to visualize and remove the gallbladder, and the patient has small dressings placed over these incisions. The patient with an incisional cholecystectomy is usually hospitalized 3 to 5 days, whereas the laparoscopic procedure allows same or next-day discharge with return to work in 2 to 3 days.A T-tube is placed in the common bile duct after exploration of the duct during incisional cholecystectomy.

A man is brought to the emergency department by coworkers and is admitted with a possible myocardial infarction. Several hours later the client is experiencing severe chest pain. He is diaphoretic, and his pulse rate is 110 beats per minute. The nurse should immediately: (A) increase the oxygen flow (B) obtain the blood pressure and an electrocardiogram (C) notify the practitioner and administer the ordered morphine (D) administer the ordered nitroglycerin tablet until the pain subsides

Answer: C Rationale: The original myocardial infarction may be extending; the client's adaptations require immediate medical intervention and relief of pain.

An initial incomplete spinal cord injury often results in complete cord damage because of A) edematous compression of the cord resulting from damage to stabilizing ligaments B) continued trauma to the cord resulting from damage to stabilizing ligaments C) infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites. D) mechanical transection of the cord by sharp vertebral bone fragments after the initial injury.

Answer: C Rationale: The primary injury of the spinal cord rarely affects the entire cord, but the pathophysiology of the secondary injury may result in damage that is the same as mechanical severance of the cord. Complete cord dissolution occurs through auto destruction of the cord by hemorrhage, edema, and the presence of metabolites and norepinephrine, resulting in anoxia and infarction of the cord. Edema resulting from the inflammatory response may increase the damage as it extends above and below the injury site.

While caring for a 77-year old woman who has a urinary catheter, the nurse monitors the patient for the development of a UTI. The clinical manifestations the patient is likely to experience include: a) cloudy urine and fever b) urethral burning and bloody urine c) vague abdominal pain and disorientation d) suprapubic pain and slight decline in body temperature

Answer: C Rationale: The usual classic symptoms of UTI are often absent in older adults, who tend to experience non localized abdominal pain, rather than dysuria and suprapubic pain. They may also experience cognitive impairment characterized by confusion or decreased LOC.

While obtaining patient histories, the nurse identifies that the patient with the highest risk for CAD is: (A) a white man, age 54, who is a smoker and has a stressful lifestyle (B) an African American man, age 65, with obesity and a blood pressure (BP) of 130/86 (C) a white woman, age 72, with a BP172/100 and who is physically inactive (D) an Asian woman, age 45, with a cholesterol level of 240 mg/dL and a BP of 130/75

Answer: C Rationale: The white woman has one unmodifiable risk factor (age) and two major modifiable risk factors (HTN and physical inactivity). The other answer choices demonstrate less unmodifiable / modifiable risk factors, some of which may be minor. Additionally, Asians in the US have lower incidence of MI than do whites.

A patient has end-stage kidney disease and is receiving hemodialysis. During dialysis, the client complains of nausea and a headache and appears confused. Operating on standard protocols, the nurse should: a) give an analgesic b) administer an antiemetic c) decrease the rate of exchange d) discontinue the procedure immediately

Answer: C Rationale: These are symptoms of disequilibrium syndrome. which results from rapid changes in composition of the ECF and cerebral edema; the rate of exchange should be decreased.

After a cardiac catheterization, the client complains of tinging sensations in the affected leg. The nurse should first: (A) assess for bleeding at the catheter insertion site (B) evaluate the affected leg for signs of inflammation (C) compare femoral, popliteal, and pedal pulses in both legs (D) obtain the temperature, pulse, respirations, and blood pressure

Answer: C Rationale: Tingling indicates decreased arterial circulation to the extremity; it may be caused by an embolus distal to the arterial insertion site; checking all pulses will help locate an embolus.

Isoenzyme laboratory studies are ordered for a client who is suspected of having a myocardial infarction. The most reliable early indicator of myocardial insult is: (A) AST (B) Myoglobin (C) Troponin I and T (D) CK-MB and CPK totals

Answer: C Rationale: Troponin I and troponin T are proteins in the striated cells of cardiac tissue and are therefore unique markers for cardiac damage; elevations occur within 1 hours of a myocardial infarction and persist for 7 to 15 days. *CK isoenzyme levels, especially the MB subunit, begin to rise within 3 to 6 hours, peak in 12 to 18 hours, and are elevated for 48 hours after the occurrence of an MI.

A patient with a right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory-perceptual deficits. During the patient's rehabilitation, it is important for the nurse to a) avoid positioning the patient on the affected side b) place all objects for care on the patient's unaffected side. c) teach the patient to care consciously for the affected side. d) protect the affected side from injury with pillows and supports.

Answer: C Rationale: Unilateral neglect, or neglect syndrome, occurs when the patient with a stroke is unaware of the affected side of the body, which puts the patient at risk for injury. During the acute phase, the affected side is cared for by the nurse with positioning and support, but during rehabilitation the patient is taught to care consciously for and attend to the affected side of the body to protect it from injury. Patients may be positioned on the affected side for up to 30 minutes.

When a patient reports chest pain, unstable angina must be identified and treated because (A) the pain may be severe and disabling (B) ECG changes and dysrhythmias may occur during an attack (C) atherosclerotic plaque deterioration may cause complete thrombus of the vessel lumen (D) the spasm of a major coronary artery may cause total occlusion of the vessel with progression to MI

Answer: C Rationale: Unstable angina is associated with deterioration of a once-stable atherosclerotic plaque that ruptures, exposing the intima to blood and stimulating platelet aggregation and local vasoconstriction with thrombus formation. Patients with unstable angina require immediate hospitalization and monitoring because the lesion is at increased risk of complete thrombosis of the lumen with progression to MI. Any type of angina may be associated with severe pain, ECG changes, and dysrhythmias; and Prinzmetal's (variable) angina is characterized by coronary artery spasm.

The diagnostic test that is most useful in differentiating dyspnea related to pulmonary effects of heart failure from dyspnea related to pulmonary disease is a) exercise stress testing b) a cardiac catheterization c) b-type natriuretic peptide (BNP) levels d) determination of blood urea nitrogen (BUN)

Answer: C Rationale: bNP is released from the ventricles in response to ventricular stretch and is a good marker for heart failure. If bNP is elevated, shortness of breath is due to heart failure; if the bNP is normal, dyspnea is due to pulmonary disease. bNP opposes the actions of the renin-angiotensin-aldosterone system (RAAS), resulting in vasodilation and reduction of blood volume. Exercise stress testing and cardiac catheterization are more important tests to diagnose coronary artery disease, and although BUN may be elevated in heart failure, it is a reflection of decreased renal perfusion.

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient requests discharge. The nurse stresses that it is important for the patient to be evaluated primarily because a) the patient has probably experienced an asymptomatic lacunar stroke b) the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours c) neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off d) the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease

Answer: D Rationale: A TIA is a temporary focal loss of neurologic function caused by ischemia of an area of the brain, usually lasting only about 3 hours. TIAs may be due to micro emboli from heart disease or carotid or cerebral thrombi and are a warning of progressive disease. Evaluation is necessary to determine the cause of the neurologic deficit and provide prophylactic treatment if possible.

When caring for a patient with an acute exacerbation of a peptic ulcer, the nurse finds the patient doubled up in bed with shallow, grunting respirations. The initial appropriate action by the nurse is to a) notify the health care provider b) irrigate the patient's NG tube c) place the patient in high Fowler's position d) assess the patient's abdomen and vital signs

Answer: D Rationale: Abdominal pain that causes the knees to be drawn up and shallow, grunting respirations in a patient with peptic ulcer disease are characteristic of perforation, and the nurse should assess the patient's vital signs and abdomen before notifying the health care provider. Irrigation of the NG tube should not be performed because the additional fluid may be spilled into the peritoneal cavity, and the patient should be placed in a position of comfort, usually on the side with the head slightly elevated.

A nursing intervention that is indicated for the patient with hemiplegia is a) the use of a footboard to prevent plantar flexion b) immobilization of the affected arm against the chest with a sling c) positioning the patient in bed with each joint lower than the joint proximal to it. d) having the patient perform passive ROM of the affected limb with the unaffected limb

Answer: D Rationale: Active ROM should be initiated on the unaffected side as soon as possible, and passive ROM of the affected side should be started on the first day. Having the patient actively exercise the unaffected side provides the patient with active and passive ROM as needed. Use of footboards is controversial because they stimulate plantar flexion. The unaffected arm should be supported, but immobilization may precipitate a painful shoulder-hand syndrome. The patient should be positioned with each joint higher that the joint proximal to it to prevent dependent edema.

What should the nurse do when a patient is scheduled for a barium swallow? a) Give clear fluids on the day of the test b) Ask the patient about allergies to iodine c) Administer cleansing enemas before the test d) Ensure a laxative is ordered after the procedure

Answer: D Rationale: Barium will harden and may create an impaction; a laxative and increased fluids promote elimination of barium

What mechanical device increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock? a) Cardiac pacemaker b) Hypothermia-hyperthermia machine c) Defibrillator d) Intra-aortic balloon pump

Answer: D Rationale: Counterpulsation with an intra-aortic balloon pump may be indicated for temporary circulatory assistance in clients with cardiogenic shock. Cardiac pacemakers are used to maintain the heartbeat at a predetermined rate. Hypothermia-hyperthermia machines are used to cool or warm clients with abnormalities in temperature regulation. The defibrillator is commonly used for termination of life-threatening ventricular rhythms.

When admitting a patient with benign prostatic hyperplasia, the most relevant assessment made by the nurse is: a) perineal edema b) urethral discharge c) flank pain radiating to the groin d) distention of the lower abdomen

Answer: D Rationale: Distention of the suprapubic area indicates that the bladder is distended with urine and therefore palpable.

The nurse recognizes early signs of hepatic encephalopathy in the patient who a) manifests asterixis b) becomes unconscious c) has increasing oliguria d) is irritable and lethargic

Answer: D Rationale: Early signs of this neurologic condition include euphoria, depression, apathy, irritability, confusion, agitation, drowsiness, and lethargy. Loss of consciousness is usually preceded by asterisks, disorientation, hyperventilation, hypothermia, and alterations in reflexes. Increasing oliguria is a sign of hepatorenal syndrome.

A patient rapidly progressing toward end-stage renal disease asks about the possibility of a kidney transplant. In responding to the patient, the nurse knows that contraindications to kidney transplantation include a) hepatitis C infection b) coronary artery disease c) refractory hypertension d) extensive vascular disease

Answer: D Rationale: Extensive vascular disease is a contraindication of renal transplantation, primarily because adequate blood supply is essential to both the health of the new kidney and the circulation of immunosuppressive drugs. Other contraindications include disseminated malignancies, refractory or untreated cardiac disease, chronic respiratory failure, chronic infection, or unresolved psychosocial disorders. CAD may be treated with bypass surgery before transplantation, and transplantation can relieve hypertension. Hepatitis B or C infection is not a contraindication.

The nurse is evaluating the condition of a client after pericardicentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was unsuccessful? a) rising blood pressure b) clearly audible heart sounds c) client expressions of relief d) rising central venous pressure

Answer: D Rationale: Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are expected. The patient usually expresses immediate relief. Heart sounds are no longer muffled or distant.

The nurse determines that additional discharge teaching is needed when the patient with chronic heart failure says, a) "I will take my pulse every day and call the clinic if it is irregular or less than 50." b) "I should hold my digitalis and call a doctor if I experience nausea and vomiting." c) "I plan to organize my household tasks so I don't have to constantly go up and down the stairs." d) "I should weigh myself every morning and go on a diet if I gain more than 2 or 3 pounds in 2 days."

Answer: D Rationale: Further teaching is needed if the patient believes that a weight gain of 2 to 3 pounds in 2 days is an indication for dieting. In a patient with heart failure, this type of weight gain reflects fluid retention and is a sign of heart failure that should be reported to the health care provider.

The patient is admitted to the hospital with a diagnosis of Guillan-Barre syndrome. Which past medical history finding makes the client most at risk for this disease? A) Meningitis or encephalitis during the last 5 years B) Seizures of trauma to the brain within the last year C) Back injury or trauma to the spinal cord during the last 2 years D) Respiratory or gastrointestinal infection during the previous month

Answer: D Rationale: Guillan-Barre syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 -4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccinations or surgery.

While caring for the patient in the oliguric phase of AKI, the nurse monitors the patient for associated collaborative problems, notifying the health care provider when a) urine output is 300 mL/day b) edema occurs in the feet, legs, and sacral area c) the cardiac monitor reveals a depressed T wave and a sagging ST segment d) the patient experiences increasing muscle weakness and abdominal cramping

Answer: D Rationale: Hyperkalemia is a potentially life threatening complication o fAKI in the oliguric phase. Muscle weakness and abdominal cramping are signs of the neuromuscular impairment that occurs with hyperkalemia, in addition to the cardiac conduction abnormalities of a peaked T wave, prolonged PR interval, prolonged QRS interval, and depressed ST segment. Urine output of 300 ml/day is expected during the oliguric phase, as is the development of peripheral edema.

The family members of a patient with hepatitis A ask if there is anything that will prevent them from developing the disease. The best response by the nurse is a) "No immunization is available for hepatitis A, nor are you likely to get the disease." b) "Only individuals who have had sexual contact with the patient should receive immunization." c) "All family members should receive the hepatitis A vaccine to prevent or modify the infection." d) "Those who have had household or close contact with the patient should receive immune globulin."

Answer: D Rationale: Individuals who have been exposed to hepatitis A through household contact or food borne outbreaks should be given immune globulin within 1 to 2 weeks of exposure to prevent or modify the illness. Hepatitis A vaccine is used to provide preexposure immunity to the virus and is indicated for individuals at high risk for hepatitis A exposure. Although hepatitis A can be spread by sexual contact, the risk is higher for transmission with the oral-fecal route.

A nurse is obtaining the health history of a patient with a left ureteral calculus who is scheduled for a trans-urethral ureterolithotomy. Which description of pain should the nurse expect the client to report? a) Boring pain in the left flank b) Pain that intensifies on urination c) Dull paint that is constant in the costovertebral angle d) Spasmodic pain on the left side that radiates to the suprapubic area.

Answer: D Rationale: Pain with ureteral stones is caused by spasm ad is excruciating and intermittent; it follows the path of the ureter to the bladder.

If a patient on peritoneal dialysis develops symptoms of severe respiratory difficulty during the infusion of the dialysate solution, the nurse should: a) increase the rate of infusion b) auscultate the lungs for breath sounds c) place the patient in a low Fowler's position d) drain the fluid from the peritoneal cavity

Answer: D Rationale: Pressure from the fluid may cause upward displacement of the diaphragm; draining the solution reduces intra-abdominal pressure, which allows the thoracic cavity to expand on inspiration.

The nurse is admitting a client with Guillan-Barre syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? A) Nebulizer and pulse oximeter B) Blood pressure cuff and flashlight C) Flashlight and incentive spirometer D) Electrocardiographic monitoring electrodes and intubation tray

Answer: D Rationale: The client with Guillan-Barre syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.

A nurse is assessing a patient who reports frequency and burning when urinating. The nurse performs percussion to determine if there is tenderness that the presence of of an ascending urinary tract infection. Which area should be percussed? a) Tail of Spence b) Suprapubic area c) McBurney's Point d) Costovertebral angle

Answer: D Rationale: The costovertebral angle (angle formed by the lateral and downward curve of the lowest rib and the vertebral column of the spine itself) is percussed to determine if there is tenderness in the area over the kidney; this can be a sign of glomerulonephritis or severe upper urinary tract infection.

A patient with aortic valve endocarditis develops dyspnea, crackles in the lungs, and restlessness. The nurse suspects that the patient is experiencing: a) vegetative embolization to the coronary arteries b) pulmonary embolization from valve vegetations c) nonspecific manifestations that accompany infectious diseases d) valvular incompetence with possible infectious invasion of the myocardium

Answer: D Rationale: The dyspnea, crackles, and restlessness the patient is manifesting are symptoms of heart failure and decreased cardiac output (CO) that occurs in up to 80% of patients with aortic valve endocarditis as a result of aortic valve incompetence. Vegetative embolization from the aortic valve occurs throughout the arterial system and may affect any body organ. Pulmonary emboli occur in right-sided endocarditis.

When developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site, the nurse should include: (A) ambulating the client 2 hours after the procedure (B) checking the vital signs every 15 minutes for 8 hours (C) keeping the client NPO for 4 hours after the procedure (D) maintaining the supine position for a minimum of 4 hours.

Answer: D Rationale: The supine position prevents hip flexion, limiting injury and promoting healing of the catheter insertion site; if the head of the bed is elevated, it should not exceed 20 degrees. Any further flexion of the groin may compromise the clot at the femoral insertion site.

On the third postoperative day after a subtotal thyroidectomy for a tumor, a client complains of a "funny, jittery feeling." On the basis of this statement, the nurse's best action is to: A) Explain that this reaction is expected and not a concern B) Take the vital signs and place the client in a high-Fowler's position C) Request stat serum calcium and phosphorus levels and chart the results D) Test for Chvostek's and Trousseau's signs and notify the practitioner of the complaints

Answer: D Rationale: These symptoms may indicate impending hypocalcemic tetany, a complication after removal of parathyroid tissue during a thyroidectomy.

A nurse is discussing discharge instructions with a client who had a coronary artery bypass graft (CABG). The client states, "My wife is afraid to have sex with me. When will it be safe to have sex again?" Which is the most appropriate response by the nurse? (A) "You should wait at least 6 weeks, but check with your physician." (B)"You will need to talk that over with your physician before you leave." (C) When you feel you have recovered enough to resume sexual activity." (D) "As soon as you can climb one flight of stairs without fatigue or discomfort."

Answer: D Rationale: This addresses the client's request for information. The energy required for sexual intercourse is equivalent to that of climbing one flight of stairs.

The nurse expects that a client with mitral stenosis would demonstrate symptoms associated with congestion in the: a) aorta b) right atrium c) superior vena cava d) pulmonary circulation

Answer: D Rationale: When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle. Hence, because there is no valve to prevent backward flow into the pulmonary vein, the pulmonary circulation is under pressure.

A patient's wife asks the nurse why get husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. How should the nurse respond? a) "He didn't arrive within the time frame for that therapy." b) "Not everyone is eligible for this drug. Has he had surgery lately?" c) "You should discuss the treatment of your husband with his doctor." d) "The medication you are talking about dissolves clots and could cause more bleeding in your husband's head."

Answer: D Rationale: tPA dissolves clots and increases the risk for bleeding. It is not used with hemorrhagic strokes. If the patient had a thrombotic / embolic stroke the time frame would be important as well as a history of surgery. The nurse should answer the question as accurately as possible and then encourage the person to talk with the primary care physician if they have further questions.

A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion r/t cerebral edema. An appropriate nursing intervention for the patient is a) avoiding positioning the patient with hip and neck flexion b) maintaining hyperventilation to a PaCO2 of 15 to 20 mmHg c) clustering nursing activities to provide periods of uninterrupted rest d) routine suctioning to prevent respiratory secretions

Answer: a Rationale: Nursing care activities that increase ICP include hip and neck flexion, suctioning, clustering care activities, and noxious stimuli; they should be avoided or performed as little as possible in the patient with increased ICP. Lowering the PaCO2 below 20 mmHg can cause ischemia and worsening of ICP; the PaCO2 should be maintained at 30 to 35 mmHg.

A patient with an SCI suddenly experiences a throbbing headache, flushed skin, and diaphoresis above the level of injury. After checking the patient's vital signs and systolic BP of 210 and a HR of 58, number the list of nursing actions in order of priority from highest to lowest. Begin with #1 as first priority. ___Administer ordered PRN nifedipine (Procardia) ___Check for bladder distention ___Document the occurrence, treatment, and response ___Place call to physician ___Raise the HOB to >45 degrees ___Loosen tight clothing on the patient

Answers: 5 2 6 3 1 4 Rationale: Initial response by the nurse should be to elevate the HOB to decrease BP and to remove noxious stimulation. Frequently the trigger is bladder distention, which can be dealt with quickly. The physician needs to be notified as soon as possible and, depending on the communication system available to the nurse, he/she should get the call placed. Meanwhile, stay with the patient and loosen any restrictive clothing. The physician may order an antihypertensive and documentation should be an accurate and thorough description of the entire episode.

Identify whether the following statements are true (T) or false (F). A) Status epileptics is most serious in tonic-clonic seizures because it can cause ventilatory insufficiency and hypoxemia. B) Permanent brain damage may occur from status epileptics or any type of seizure. C) The most useful tool for diagnosing epilepsy is the EEG. D) Immediate medical care should be sought for all seizures. E) A tonic-clonic seizure with loss of consciousness that is preceded by an aura is a partial seizure that generalizes.

Answers: A) T B) T C) F, patient history and description of seizure D) F, first time or status E) T

The nurse finds a patient in bed having a generalized tonic-clonic seizure. During the seizure activity, the nurse should take the following actions (select all that apply): A) loosen restrictive clothing B) turn the patient to their side C) protect the patient's head from injury D) place a padded tongue blade between the patient's teeth E) restrain the patient's extremities to prevent soft tissue an bone injury **You will never have SATA questions on your quizzes, but they are good practice for the NCLEX**

Answers: A,B,C Rationale: The focus is on maintaining a patent airway and preventing injury. **NEVER, EVER stick anything in the mouth of a patient having a seizure...not a tongue blade, not a bite block, not your finger....NOTHING!**