Assignment #4

A client who has peripheral arterial disease of the lower extremities tells the nurse, "I walk so slowly that no one wants to walk with me." What is the best response by the nurse? 1 "A vascular rehabilitation program may help you." 2 "You should be sitting with your feet elevated, not walking." 3 "Try again tomorrow because maybe you will have a better day." 4 "They are not good friends if they are not willing to walk with you."

1

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. How is hemophilia inherited? 1 X-linked recessive trait 2 Y-linked recessive trait 3 X-linked dominant trait 4 Y-linked dominant trait

1

A client is admitted with a diagnosis of a ruptured spleen. The client's blood pressure is 100/60 mm Hg. What should the nurse assess in the client as an early sign of decreased arterial pressure? 1 Weak radial pulses 2 Warm, flushed skin 3 Lethargy with confusion 4 Increased pulse pressure

1

A client develops internal bleeding after abdominal surgery. Which signs and symptoms of hemorrhage should the nurse expect the client to exhibit? Select all that apply. 1 Pallor 2 Polyuria 3 Bradypnea 4 Tachycardia 5 Hypertension

1, 4

A client with newly diagnosed multiple myeloma asks, "How long do you think I have to live?" What is the most appropriate response by the nurse? 1 "Let me ask your primary healthcare provider for you." 2 "I can understand why you are worried." 3 "Tell me about your concerns as of the moment." 4 "It depends on whether the tumor has spread."

3

A client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures. The nurse should provide what initial emergency care? 1 Start an intravenous (IV) line, get blood for typing and crossmatching, and obtain a history 2 Assess vital signs, obtain a history, and arrange for emergency x-ray films 3 Conduct a thorough physical assessment, assess vital signs, and cover open wounds 4 Assess vital signs, control accessible bleeding, and determine the presence of critical injuries

4

A client returns from a radical neck dissection with two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention? 1 Cloudy wound drainage 2 Absence of the gag reflex 3 Decreased urinary output 4 Restlessness with dyspnea

4

What is the normal value of inspiratory reserve volume? 1 0.5 L 2 1.0 L 3 1.5 L 4 3.0 L

4

A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates that the nurse needs to follow up? 1 Whole milk with oatmeal 2 Garden salad with olive oil 3 Tuna fish with a small apple 4 Soluble fiber cereal with yogurt

1

During chest physiotherapy (CPT) a client reports fatigue, and the client's heart rate increases from 90 to 140 beats per minute. What should the nurse do next? 1 Interrupt the therapy. 2 Encourage deep breathing. 3 Place the client in the low-Fowler position. 4 Have the client complete the therapy before resting.

1

What is the most important nursing action when measuring a client's pulmonary capillary wedge pressure (PCWP)? 1 Deflate the balloon as soon as the PCWP is measured. 2 Have the client bear down when measuring the PCWP. 3 Place the client in a supine position before measuring the PCWP. 4 Flush the catheter with a heparin solution after the PCWP is determined.

1

A nurse reviews the plan of care for a client who is recovering from the acute phase of left ventricular failure. Which dietary restriction will the nurse expect to be included in the plan? 1 Sodium 2 Calcium 3 Potassium 4 Magnesium

1

A nurse is assessing a client with the diagnosis of primary hypertension. Which clinical finding does the nurse identify as an indicator of primary hypertension? 1 Mild but persistent depression 2 Transient temporary memory loss 3 Occipital headache in the morning 4 Cardiac palpitation during periods of stress

3

A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain? 1 Retrospective 24-hour calorie count 2 Elimination pattern during the last 30 days 3 Complete gynecological and sexual history 4 Presence of a cough and pulmonary secretions

4

A client with varicose veins is scheduled for surgery. Which clinical finding does the nurse expect to identify when assessing the lower extremities of this client? 1 Pallor 2 Ankle edema 3 Yellowed toenails 4 Diminished pedal pulses

2

A nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor. What intervention is the priority? 1 Elective cardioversion 2 Immediate defibrillation 3 An intramuscular (IM) injection of digoxin 4 An intravenous (IV) line for emergency medications

2

A nurse is caring for a client who was admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease and is receiving oxygen at 2 L/min via nasal cannula. What is the primary focus of therapy when caring for this client? 1 Limiting hydration 2 Improving ventilation 3 Decreasing exogenous oxygen 4 Correcting the bicarbonate deficit

2

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first? 1 Interview the client for a health history. 2 Assess the client's heart and lung sounds. 3 Monitor the client's pulse and temperature. 4 Obtain the client's blood specimen for electrolytes.

2

A client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis? 1 The fat-forming ketoacids were broken down. 2 The irregular heartbeat produced oxygen deficit. 3 The decreased tissue perfusion caused lactic acid production. 4 The client received too much sodium bicarbonate during resuscitation efforts.

3

A client returns from a cardiac catheterization procedure and is to remain in the supine position for 4 hours with the affected leg straight. What are these measures intended to prevent? 1 Orthostatic hypotension 2 Headache with disorientation 3 Bleeding at the arterial puncture site 4 Infiltration of radiopaque dye into tissue

3

A client who is in hypovolemic shock has a hematocrit value of 25%. What does the nurse anticipate that the primary healthcare provider will prescribe? 1 Lactated Ringer solution 2 Serum albumin 3 Blood replacement 4 High molecular dextran

3

A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions? 1 Client no longer is infected. 2 Tuberculin skin test is negative. 3 Sputum is free of acid-fast bacteria. 4 Client's temperature has returned to normal.

3

A nurse teaches a client how to perform diaphragmatic breathing. Which instruction should the nurse provide? 1 Take rapid, deep breaths 2 Breathe with hands on the hips 3 Expand the abdomen on inhalation 4 Perform exercises leaning forward while in a sitting position

3

The family of a client with right ventricular heart failure expresses concern about the client's increasing abdominal girth. What physiologic change should the nurse consider when explaining the client's condition? 1 Loss of cellular constituents in blood 2 Rapid osmosis from tissue spaces to cells 3 Increased pressure within the circulatory system 4 Rapid diffusion of solutes and solvents into plasma

3

The nurse administers oxygen to a client during the early postoperative period after open heart surgery. Why is this necessary? 1 The client will have closed-chest drainage in place. 2 Hypoxia can precipitate respiratory alkalosis. 3 Reduced oxygen levels can stimulate dysrhythmias. 4 Increased respiratory rates add to postoperative pain.

3

The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status? 1 Except with rare blood disorders, hemoglobin seldom affects oxygenation status. 2 There are many other factors that affect oxygenation status more than hemoglobin does. 3 A low hemoglobin level causes reduced oxygen-carrying capacity. 4 Hemoglobin reflects the body's clotting ability and may or may not affect oxygenation status.

3

The nurse is watching the technician obtain a 12-lead ECG. In which area should the nurse make sure the technician places the V1 lead? 1 Halfway between V2 and V4 2 Fourth intercostal space, left sternal border 3 Fourth intercostal space, right sternal border 4 Fifth intercostal space, left midclavicular line

3

What is the nurse primarily attempting to prevent when caring for a client in the initial stages of chronic lymphocytic leukemia (CLL)? 1 Injury 2 Fatigue 3 Infection 4 Cachexia

3

When assessing a client with heart failure, the nurse asks what aggravates the problem. Which activity should the nurse expect will cause the client the greatest distress? 1 Getting up from bed in the morning 2 Walking to visit the next-door neighbor 3 Climbing a flight of stairs to the bedroom 4 Leaving the table immediately after a meal

3

A client had a total knee replacement several days ago and has been receiving warfarin sodium therapy. An international normalized ratio (INR) is performed each afternoon, and the evening warfarin sodium dose is prescribed by the healthcare provider on a daily basis. The nurse identifies that the afternoon INR is 4.6. Which is the next action the nurse should take? 1 Assist with meal planning to decrease the intake of foods high in vitamin K 2 Obtain a blood specimen to have a partial thromboplastin time performed 3 Contact the healthcare provider to request the day's dosage of warfarin sodium 4 Maintain the client on bed rest until the healthcare provider reviews the laboratory results

4

A client is admitted to the hospital for a total hip replacement. Included in the primary healthcare provider's prescriptions is a prescription for digoxin 2.5 mg by mouth daily. The nurse knows that digoxin is supplied in 0.125 mg tablets. What should the nurse do? 1 Give half a tablet. 2 Administer two tablets. 3 Ask the client what dose was taken at home. 4 Verify the prescription with the primary healthcare provider.

4

A client is seen in the clinic with sickle cell anemia. The parents of the client ask how their child got sickle cell anemia. What is an accurate explanation? 1 Sickle cell anemia is a random condition with no known cause. 2 If one parent is a carrier and one is negative for the gene, the child will get the disease. 3 If both parents are carriers, all of their offspring will probably get this disease, and they should consider sterilization. 4 If both parents are carriers, the odds are one in four that an offspring will get the disease, and one in four that an offspring will be disease free.

4

A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care? 1 Elevate the foot of the bed. 2 Perform urinary catheter care every 12 hours. 3 Place in the high-Fowler position. 4 Perform a neurovascular assessment every 2 hours.

4

A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider? 1 Client pushes the airway out. 2 Client has snoring respirations. 3 Client's respirations are 16 breaths per min and shallow. 4 Client's systolic blood pressure drops from 130 to 90 mm Hg.

4

After an acute coronary syndrome a client begins a supervised, progressive jogging regimen and asks the nurse how to tell whether it is helping. What is the best response by the nurse? 1 "Intermittent claudication will be reduced." 2 "Your breathing will become regular and shallow." 3 "Perspiration will be less when you run, and you'll use less energy." 4 "You will be able to run progressively longer distances before tiring."

4

The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 mm Hg and 164/98 mm Hg. What is the appropriate nursing action in response to these readings? 1 Refer the client to a nutritionist after providing health teaching about a low-sodium diet. 2 Place the client in a recumbent position and call the paramedics for transport to the hospital. 3 Talk with the client to assess whether there is stress in the client's life and refer to a counseling service. 4 Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible.

4

What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension? 1 Wear support hose continuously. 2 Lie down for 30 minutes after taking medication. 3 Avoid tasks that require high-energy expenditure. 4 Sit on the edge of the bed for 5 minutes before standing.

4

After sustaining multiple internal injuries when hit by a motor vehicle, a client has a sudden drop in blood pressure to 80/60 mm Hg. What does the nurse determine probably caused this response? 1 Reduction in circulating blood volume 2 Diminished vasomotor stimulation to arterial walls 3 Vasodilation resulting from diminished vasoconstrictor tone 4 Cardiac decompensation resulting from electrolyte imbalance

1

The client is in atrial fibrillation. Which information should the nurse consider about atrial fibrillation when planning care for this client? 1 A loss of atrial kick 2 No physiologic changes 3 Increased cardiac output 4 Decreased risk of pulmonary embolism

1

What is the term for shock associated with a ruptured abdominal aneurysm? 1 Vasogenic shock 2 Neurogenic shock 3 Cardiogenic shock 4 Hypovolemic shock

4

The nurse notes asystole on the cardiac monitor. Which action should the nurse take immediately? 1 Defibrillate 2 Assess the client's pulse 3 Initiate advanced cardiac life support 4 Check another lead to confirm asystole

2

A client's blood pressure increases dramatically six hours after a femoral-popliteal bypass graft. Which priority concern motivates the nurse to inform the primary healthcare provider? 1 Hypertension may cause the graft to occlude. 2 Hypervolemia may be the cause of the hypertension. 3 Extremely high blood pressure may cause a brain attack. 4 Rapidly increasing blood pressure may rupture the graft.

4

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? 1 Check for a pulse 2 Start cardiac compressions 3 Prepare to defibrillate the client 4 Administer oxygen via an ambu bag

1

A low-dose intravenous dopamine hydrochloride infusion drip is prescribed for a client in acute renal failure (ARF). Which method is most appropriate for the nurse to administer this medication to the client? 1 Peripherally inserted central catheter (PICC) line 2 #20 angiocatheter in either antecubital area 3 Large-gauge butterfly needle in hand 4 Femoral line

1

A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report? 1 Feeling of heaviness in both legs 2 Intermittent claudication of the legs 3 Calf pain on dorsiflexion of the foot 4 Hematomas of the lower extremities

1

A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client? 1 The signs and symptoms of pericarditis 2 The signs and symptoms of heart failure 3 That cardiac surgery will have to be done eventually for the other valves 4 That cardiac surgery will have to be done every six months to replace the valve

2

A client is experiencing a myocardial infarction. What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion? 1 Arterial spasm 2 Heart muscle ischemia 3 Blocking of the coronary veins 4 Irritation of nerve endings in the cardiac plexus

2

On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority? 1 Prepare for blood transfusions. 2 Notify the surgeon immediately. 3 Make the client nothing by mouth (NPO). 4 Administer the prescribed preoperative sedative.

2

A client is admitted to the hospital with a diagnosis of laryngeal cancer. What is a common early sign of laryngeal cancer for which the nurse should assess in this client? 1 Aphasia 2 Dyspnea 3 Dysphagia 4 Hoarseness

4

An older client tells the nurse, "My legs begin to hurt after walking the dog for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition does the nurse consider as the most likely cause of the client's pain? 1 Spinal stenosis 2 Buerger disease 3 Rheumatoid arthritis 4 Intermittent claudication

4

The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear? 1 Stridor 2 Crackles 3 Wheezes 4 Friction rubs

2

A client is admitted to the hospital with atrial fibrillation. A diagnosis of mitral valve stenosis is suspected. The nurse concludes that it is most significant if the client presents with what history? 1 Cystitis as an adult 2 Pleurisy as an adult 3 Childhood strep throat 4 Childhood German measles

3

A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I'm ready for this move?" What should the nurse determine that the client most likely is experiencing based on this statement? 1 Fear 2 Depression 3 Dependency 4 Ambivalence

1

A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client? 1 Deficient fluid volume 2 Impaired skin integrity 3 Inadequate nutritional intake 4 Decreased participation in activities

1

A client's arterial blood gas report indicates that pH is 7.25, Pco2 is 60 mm Hg, and HCO3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? 1 A 65-year-old with pulmonary fibrosis 2 A 24-year-old with uncontrolled type 1 diabetes 3 A 45-year-old who has been vomiting for 3 days 4 A 54-year-old who takes sodium bicarbonate for indigestion

1

Which clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block? 1 Syncope 2 Headache 3 Tachycardia 4 Hemiparesis

1

A client is scheduled to have a cardiac catheterization via the femoral approach. The nurse teaches the client about postprocedure interventions that protect the catheter insertion site. What should the nurse inform the client of regarding the leg used for catheter insertion? 1 It should be elevated on a pillow. 2 It should be kept extended while on bed rest. 3 It will be positioned dependent to the level of the heart. 4 It will be put through range-of-motion exercises several times an hour.

2

A client is seen in the clinic with sickle cell anemia. A nurse teaches the client about sickle cell anemia. Which information from the client indicates a correct understanding of the condition? 1 "I have abnormal platelets." 2 "I have abnormal hemoglobin." 3 "I have abnormal hematocrit." 4 "I have abnormal white blood cells."

2

A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client? 1 Distended neck veins 2 Paradoxical respirations 3 Increasing amounts of purulent sputum 4 Absence of breath sounds over the affected area

4

Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with which autosomal recessive disorder? 1 Cerebral palsy 2 Cystic fibrosis 3 Muscular dystrophy 4 Multiple sclerosis

2

A client reports foot pain and is diagnosed with arterial insufficiency. The nurse provides teaching about what the client can do to increase arterial dilation and to decrease foot pain. Which client statement indicates to the nurse that further teaching is needed? 1 "I will wear socks." 2 "I will elevate my foot." 3 "I will increase fluid intake." 4 "I will drink a moderate amount of alcohol."

2

A client with squamous cell carcinoma of the tongue is to be treated with interstitially implanted radon seeds. Which consideration is priority when the nurse is planning room placement? 1 Assign the client to any type of room. 2 Place the client in a private room. 3 Assign the client to a semiprivate room. 4 Place the client with another client receiving the same type of therapy.

2

A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. Which reason for increased incidence of dysrhythmias in this client should the nurse monitor? 1 Metabolic alkalosis 2 Myocardial hypoxia 3 Decreased catecholamine secretion 4 Increased parasympathetic nervous system stimulation

2

A primary healthcare provider decides to omit a treatment that was part of a course of chemotherapy for a client because the client demonstrates myelosuppression. What information would be appropriate for the nurse to give to the client regarding myelosuppression? 1 Calcium carbonate and vitamin D must be increased in the diet because of the effects of myelosuppression. 2 Eating a balanced diet, resting, and trying to prevent bleeding and infections are appropriate at this time. 3 The development of myelosuppression explains why the client has nausea, vomiting, anorexia, and alopecia. 4 Frequent testing for restlessness, muscle control, and pupillary response is necessary because the meninges may be irritable.

2

An electrocardiogram (ECG) is performed before a client is to have a cardiac catheterization, and hypokalemia is suspected. What does the nurse expect the primary healthcare provider to prescribe to confirm the presence of hypokalemia? 1 A complete blood count 2 A serum electrolyte level 3 An arterial blood gas panel 4 An x-ray film of long bones

2

One week after admission to the cardiac care unit, a client displays an outburst of anger and tells the nurse to get out of the room. Which is the most appropriate nursing action? 1 Administer the prescribed sedative. 2 Return when the client has calmed down. 3 Point out that this behavior is inappropriate. 4 Notify the primary healthcare provider of the client's behavior.

2

The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selection by the client indicates to the nurse that dietary teaching about thiazide diuretics is successful? 1 Apples 2 Broccoli 3 Cherries 4 Cauliflower

2

The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response should be based on what principle about bed rest? 1 It prevents the further aggregation of platelets. 2 It enhances the peripheral circulation in the deep vessels. 3 It decreases the potential for further dislodgment of emboli. 4 It maximizes the amount of blood available to damaged tissues.

3

Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do? 1 Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. 2 Arrange for a supply of heparin for the client to take to the rehab center. 3 Explain to the client that anticoagulant therapy will no longer be needed. 4 Instruct the client to talk about anticoagulant needs with the healthcare provider at the rehabilitation center.

1

A client with a long history of cardiovascular problems, including angina and hypertension, is scheduled to have a cardiac catheterization. During preprocedure teaching, what does the nurse explains to the client is the major purpose for catheterization? 1 To obtain the pressures in the heart chambers 2 To determine the existence of congenital heart disease 3 To visualize the disease process in the coronary arteries 4 To measure the oxygen content of various heart chambers

3

The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain exhibits which characteristic? 1 Causes mild perspiration 2 Occurs after moderate exercise 3 Continues after rest and nitroglycerin 4 Precipitates discomfort in the arms and jaw

3

A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet (183 cm) tall and weighs 293 pounds (133 kg) puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply. 1 Age 2 Height 3 Weight 4 Smoking 5 Family history

3, 4

A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? Select all that apply. 1 Weight loss 2 Unusual fatigue 3 Dependent edema 4 Nocturnal dyspnea 5 Increased urinary output

2, 3, 4

A client has a pulse deficit. Which documentation by the nurse supports this finding? 1 Blood pressure of 130/70 mm Hg indicating pulse deficit of 60. 2 Capillary refill greater than 3 seconds indicating pulse deficit. 3 Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8. 4 Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10.

3

A client is admitted to the hospital for an emergency cardiac catheterization. What adaptation is the client most likely to complain of after this procedure? 1 Fear of dying 2 Skipped heartbeats 3 Pain at the insertion site 4 Anxiety in response to intensive monitoring

3

The nurse is caring for a client who is receiving therapy for vitamin B12 deficiency. Which finding indicates that the therapy is having the desired effect? 1 Normal serum electrolyte levels 2 Healthy skin integrity 3 Resolution of peripheral edema 4 Improved hemoglobin and hematocrit levels

4