Elevate module 2

What signs/symptoms would the nurse expect to assess in a client diagnosed with acute pericarditis? 1. Petechiae on trunk 2. Muffled heart sounds 3. Pericardial friction rub 4. Pulsus paradoxus 5. Chest pain on deep inspiration

2. Muffled heart sounds 3. Pericardial friction rub 5. Chest pain on deep inspiration

A client has sublingual (SL) nitroglycerin prn added to their medication regimen. Which statements made by this client indicates teaching has been effective? 1. "I will take this medication if I have an episode of chest pain." 2. "I will wait at least 1 hour after I take my erection agent before using Nitroglycerin." 3. "I can take up to 3 tablets every 10 minutes if my angina occurs." 4. "I know that I must put this tablet under my tongue for it to work." 5. "I will keep my medication handy, in a pocket."

1. "I will take this medication if I have an episode of chest pain." 4. "I know that I must put this tablet under my tongue for it to work."

A client who has been diagnosed with chronic venous insufficiency has received teaching regarding how to prevent venous stasis ulcerations. Which statements by the client indicate to the nurse that teaching has been effective? 1. "Stationary standing should be kept to a minimum." 2. "It is important to avoid wearing constricting clothes longer than 2 hours." 3. "Protecting my legs from trauma is very important." 4. "I will wear compression stockings every day." 5. "I will elevate the foot of my bed 6 inches (15.24 cm) when I sleep."

1. "Stationary standing should be kept to a minimum." 3. "Protecting my legs from trauma is very important." 4. "I will wear compression stockings every day." 5. "I will elevate the foot of my bed 6 inches (15.24 cm) when I sleep."

A nurse is caring for a client post heart catheterization with a left femoral stick. What signs and symptoms would indicate to the nurse that the primary healthcare provider should be notified? 1. Capillary refill of 6 seconds to left toes. 2. Epigastric discomfort 3. Paresthesia to left leg 4. Left pedal pulse 0/4; Right pedal pulse 2+/4 5. Temperature of 99.9º F (37.72º C)

1. Capillary refill of 6 seconds to left toes. 2. Epigastric discomfort (could indicate MI) 3. Paresthesia to left leg 4. Left pedal pulse 0/4; Right pedal pulse 2+/4

During the admission examination of a client diagnosed with acute pyelonephritis, what signs or symptoms would the nurse expect to find? 1. Dysuria 2. Costovertebral angle tenderness 3. Weight loss 4. Chills 5. Urinary frequency

1. Dysuria 2. Costovertebral angle tenderness 4. Chills 5. Urinary frequency (weight gain)

What information should a community health nurse include while planning an educational program on prevention of deep vein thrombus formation for a group of people who attend a senior citizens center? 1. Exercise legs hourly when traveling by plane 2. Stop smoking 3. Lose weight 4. Stop every 4 hours to walk when traveling by car 5. Exercise daily

1. Exercise legs hourly when traveling by plane 2. Stop smoking 3. Lose weight 5. Exercise daily

Which signs and symptoms experienced by the client correlate with chronic renal failure diagnosis? 1. Fatigue 2. Anorexia 3. Dark skin pigmentation 4. Swollen extremities 5. Hyperkalemia

1. Fatigue 2. Anorexia 4. Swollen extremities 5. Hyperkalemia

What potential contributing factors for transient urinary incontinence should a nurse assess in an elderly female client? 1. Fecal impaction 2. Diuretic use 3. Diabetic 4. Chronic urinary retention 5. Vaginitis

1. Fecal impaction 2. Diuretic use 3. Diabetic 5. Vaginitis

What should a nurse include when planning an educational program for a group of women on how to prevent a urinary tract infection (UTI)? 1. Increase daily intake to at least 9 cups (2160 mL) of water. 2. Urinate within one hour after sexual intercourse. 3. Take a low dose antibiotic. 4. Urinate at least twice a day.

1. Increase daily intake to at least 9 cups (2160 mL) of water.

A nurse is planning care for a newly admitted client diagnosed with acute nephrotic syndrome. What interventions would the nurse include in the plan of care? 1. Monitor triglyceride level 2. Educate client on a 3 gm sodium diet. 3. Auscultate lung sounds. 4. Monitor blood pressure. 5. Assess for venous thrombo-embolism (VTE).

1. Monitor triglyceride level 3. Auscultate lung sounds. 4. Monitor blood pressure. 5. Assess for venous thrombo-embolism (VTE).

A nurse, planning an educational seminar on chronic kidney disease, would invite clients with which medical conditions? 1. Polycystic kidney disease 2. Diabetes 3. Hypertension 4. Glomerulonephritis 5. Acute urinary tract infections (UTI)

1. Polycystic kidney disease 2. Diabetes 3. Hypertension 4. Glomerulonephritis

The client is being admitted for a myocardial infarction (MI). Which assessment finding is expected? 1. Reports of nausea and vomiting 2. Elevated temperature higher than 102 degrees F (38.89 degrees C) in the first 24 hours. 3. Pain relieved by two aspirin tablets. 4. Myoglobin will be negative.

1. Reports of nausea and vomiting

What would the nurse include in the teaching plan for a client with right sided heart failure? 1. There is a backup of blood in the right upper chamber of the heart. 2. There is swelling of lower extremities. 3. The heart rate decreases. 4. You may experience fatigue and depression. 5. You may have nausea and anorexia.

1. There is a backup of blood in the right upper chamber of the heart. 2. There is swelling of lower extremities. 4. You may experience fatigue and depression. 5. You may have nausea and anorexia.

What assessment finding would the nurse expect when evaluating whether treatment has been effective for a client hospitalized with systolic heart failure? 1. S3 heart sound 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.91 kg) 4. Hepatomegaly 5. Increasing BNP level 6. Urine output at 50 mL/hr

2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.91 kg) 6. Urine output at 50 mL/hr

In order to maintain asepsis, what would the nurse teach the client on home peritoneal dialysis? 1. Drink only bottled water. 2. Cap Tenckhoff catheter when not in use. 3. Soak the dialysate in warm water. 4. Clean the arteriovenous fistula with hydrogen peroxide twice a day. 5. Wash around the catheter insertion site daily.

2. Cap Tenckhoff catheter when not in use. 5. Wash around the catheter insertion site daily.

A client is admitted with arterial disease of the lower extremities. Which client teachings would the nurse initiate? 1. Elevate extremities above the level of the heart. 2. Discourage use of caffeine. 3. Protect extremities from cold exposure. 4. Maintain a warm environment at home. 5. Encourage isometric exercise.

2. Discourage use of caffeine. 3. Protect extremities from cold exposure. 4. Maintain a warm environment at home. 5. Encourage isometric exercise.

A client had a coronary artery bypass surgery (CABG) x 3 performed 24 hours ago. What assessment findings would make the nurse suspect cardiac tamponade? 1. Bradycardia with wet lungs 2. Increased central venous pressure 3. Distended bilateral neck veins 4. A widening pulse pressure 5. Decreasing blood pressure

2. Increased central venous pressure 3. Distended bilateral neck veins 5. Decreasing blood pressure

The nurse is caring for a client who is receiving enoxaparin after a diagnosis of deep vein thrombosis of the left leg. Which nursing interventions would be appropriate for this client? 1. Monitor PT and aPTT 2. Initiate bedrest 3. Elevate left leg 4. Monitor closely for bleeding 5. Monitor complete blood count

2. Initiate bedrest 3. Elevate left leg 4. Monitor closely for bleeding 5. Monitor complete blood count

A client arrives to the emergency department with reports of palpitations, chest discomfort, and light-headedness. The nurse connects the client to a cardiac monitor and notes a weak, thready pulse, and a BP of 90/50. What actions should the nurse take? EKG shows supraventricular tachycardia HR 188/min. 1. Administer Lidocaine 50 mg intravenous push (IVP). 2. Initiate oxygen at 2 liters per nasal cannula. 3. Apply oxygen saturation monitor to client. 4. Prepare for immediate synchronized cardioversion. 5. Perform carotid massage. 6. Begin cardiopulmonary resuscitation.

2. Initiate oxygen at 2 liters per nasal cannula. 3. Apply oxygen saturation monitor to client. 4. Prepare for immediate synchronized cardioversion.

What teaching points would the nurse include when educating a client how to prevent a venous stasis ulcer? 1. Dangle legs for 30 minutes, three times a day. 2. Perform leg exercises regularly. 3. Wear graduated compression stockings. 4. Avoid crossing the legs. 5. Minimize stationary standing.

2. Perform leg exercises regularly. 3. Wear graduated compression stockings. 4. Avoid crossing the legs. 5. Minimize stationary standing.

As a member of the emergency preparedness planning team at the hospital, which action should the nurse encourage the team to implement? 1. Develop a response plan for each potential disaster. 2. Provide education to employees on the response plan. 3. Practice the response plan on a regular basis. 4. Evaluate the hospital's level of preparedness. 5. Coordinate with neighboring hospitals regarding different emergency response plans.

2. Provide education to employees on the response plan. 3. Practice the response plan on a regular basis. 4. Evaluate the hospital's level of preparedness. 5. Coordinate with neighboring hospitals regarding different emergency response plans.

A small community has experienced a mudslide that hit a restaurant causing mass casualties. What would the nurse do first? 1. Assess the immediate area for electrical wires on the ground. 2. Attend to victim injuries as they are encountered. 3. Activate the community emergency response team. 4. Triage and tag victims according to injury.

3. Activate the community emergency response team.

The nurse sees the following rhythm on the cardiac monitor for a client recovering from a myocardial infarction. What would be the nurse's first action upon entering the client's room? 1. Attempt defibrillation 2. Begin CPR 3. Assess for carotid pulse 4. Administer lidocaine

3. Assess for carotid pulse

The nurse is caring for a client with acute renal failure. The morning assessment findings indicate the client has become confused and irritable. Which finding is most likely responsible for the change in behavior? 1. Hyperkalemia 2. Hypernatremia 3. Elevated blood urea nitrogen (BUN) 4. Limited fluid intake

3. Elevated blood urea nitrogen (BUN)

A construction worker comes into the occupational health nurse's clinic reporting chest heaviness. The nurse should assess for what additional signs and symptoms? 1. Headache 2. Dry, flushed skin 3. Lightheadedness 4. Dyspnea 5. Irregular pulse

3. Lightheadedness 4. Dyspnea 5. Irregular pulse