Final Study Guide

A nurse is reinforcing teaching about self-management strategies with a client who has emphysema. Which of the following client statements indicates that the client understands the instructions?

I will follow a diet high in calories and protein.

A nurse is reinforcing teaching with a class about preventing deep-vein thrombosis. The nurse should include in the teaching that which of the following is a risk factor for this disorder? (Select all that apply.)

Dehydration Oral contraceptive use Immobility

hypertension drug therapy

Diuretics (e.g. Furosemide) Adrenergic Inhibitors (e.g. Clonidine) Angiotensin II Receptor Blockers (e.g. Valsartan) B-Adrenergic Blockers (e.g. Metoprolol) Angiotensin-Converting Enzyme Inibitors (ACE) (e.g. Enalapril) Calcium Channel Blockers (e.g. Diltiazem)

A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain. The client states that his chest pain is relieved but now he has a headache. which of the following responses by the nurse is appropriate?

"A headache is a common adverse effect of this medication, but it will probably occur less often over time."

A nurse is reinforcing teaching with a client who has genital herpes caused by herpes simple virus type 2 (HSV2)?

"I can transmit the infection to another person even when I don't have symptoms"

A nurse in a clinic is caring for a client who has heart failure and is taking digoxin. Which of the following statements by the client indicates the client is experiencing digoxin toxicity?

"My vision seems yellow."

A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax?

Absence of breath sounds

A patient is admitted with herpes zoster. The health care provider orders an antiviral medication to slow the progression of the virus.

Acyclovir (Zovirax)

Before each periodic debridement of the burn wound using hydrotherapy, what nursing interventions is essential?

Administer a prescribed analgesic

When a previously negative client has a positive reaction to a tuberculin skin test, what action is taken next?

Antituberculosis drugs will be prescribed.

When a client reports pruritus from dry skin, what nursing suggestions is most appropriate for consistently relieving the client discomfort?

Avoid using stringent on skin

A 54 year old client is being treated for gout. When the nurse examines the client, what body part is usually affected by gout?

Great toe

A nurse is collecting data for a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?

Barrel

A nurse is collecting data from a client who has chronic bronchitis. Which of the following findings should the nurse expect?

Barrel chest

A nurse is caring for a client who has a respiratory infection. The nurse should have the client sit in a high-Fowler's position to help mobilize secretions from which of the following lung segments?

Both upper lobes

A nurse reinforcing infection control practices for hand hygiene with a group of unit nurse. Which of following information should the nurse reinforce in the teaching?

Change glove's between tasks on the same patient

What is prescribed to be given hour until the client's pain is relieved during an acute attack of gout?

Colchicine

A nurse notes a small section of bowel protruding from the abdominal incision of a client who's postoperative. Which of the following action should the nurse take first?

Cover client wound with a moist sterile dressing

A nurse is collecting data from a client who has a respiration and display manifestation of hypoxia. Which of the following findings should the nurse expect?

Cyanosis

Hypertension nonpharmacological therapy and nursing intervention.

DASH DIET: increase fruits, veggies, low fat dairy, decrease salt & fat weight reduction smoking cessation stress limit alcohol consumption

A nurse is reinforcing teaching with client about he risk factors for skin cancer.

Excessive exposure to UV light

A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultate the client's chest, the nurse should expect to hear which of the following sounds?

Expiratory wheeze

A nurse is reinforcing teaching for a client who has angina pectoris and a new prescription to apply a nitroglycerin transdermal patch daily at home. Which of the following instructions should the nurse give the client?

Fold used patch with medication area to the inside and discard in a closed receptacle.

The nurse witnesses a client sustain a fall and suspects that clients leg may be fractured. Which action is the priority?

Immobilized the leg before moving the client

nurse is collecting data from a client who has right-sided heart failure. Which of the following nurse expect?

Peripheral edema

A nurse is collecting data from a client who has herpes zoster (shingles).

painful vesicles following a nerve pathway

Hypertension risk factors: Non modifiable Risk Factors and Modifiable Risk Factors

Non modifiable: sex, age, genetics, ethnicity Modifiable: body weight, smoking, exercise, sodium intake, diet

Blood pressure normal range and abnormal

Normal 120/80 Abnormal elevated 120-129/ less than 80 or less on systolic and diastolic

A nurse is reinforcing teaching with a client who has atelectasis. The nurse tells the client how to position herself to promote drainage or the apical in a segments. which of the following statements by my client should tell the nurse identify as understanding of the teaching?

"I will sit up on the side of the bed with my legs dangling."

A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching?

"I will wear stockings with elastic tops."

A nurse is reinforcing teaching with a client who has angina pectoris about starting therapy with nitroglycerin. Which of the following statements by the client indicates an understanding of the teaching?

"I'II dial 911 if one tablet does not relieve my pain."

A nurse is caring for a client who has a deep vein thrombosis who received IV heparin for the past 5 days, and now has a new prescription for oral warfarin in addition to the heparin. The client asks the nurse if both medications are necessary. Which of the following is an appropriate response by the nurse?

'Heparin will be continued until the warfarin reaches a therapeutic level."

A nurse in a provider's office is reviewing the laboratory results of four clients who take digoxin. Which of the foliowing clients is at risk for developing digoxin toxicity?

A client who take furosemide for hypertension

A nurse is reinforcing teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. The nurse should include which of the following instructions in the teaching? (Select all that apply.)

Apply the patch to a hairless area. Apply a new patch each morning. Remove the patch for 10 to 12 hr daily.

What client symptom indicates that the nurse should withhold the medication until checking with the prescriber even if the client's pain is relieved?

Dont know ?

Methotrexate is prescribed for client with severe rheumatoid arthritis. What client teaching is essential when beginning Methotrexate therapy?

Drink 2-3L of water per day. Promotes excretion of the medication

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to thin client's respiratory secretions?

Encourage the client to drink more fluids.

A nurse is caring for a client who has COPD. Which of the following nursing actions should the nurse take?

Encourage the client to eat most of the daily calories at breakfast.

A nurse in a provider's office is collecting data from a client who reports dyspnea and fatigue. The nurse determines that the client has tachycardia and edema. Which of the following disorder should the nurse suspect?

Heart failure

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous infusion of heparin. The client ask the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse make?

Heparin prevents new clots from forming rather than dissolving established clots.

A patient complains of burning pain on his lower thoracic area. On inspection, the area is found to be erythematous and edematous with a cluster of vesicles. What condition is most likely to be diagnosed?

Herpes zoster

A nurse is assisting with teaching a client who has a history of smoking about recognizing early manifestations of laryngeal cancer. The nurse should instruct the client to monitor and report which of the following manifestations of laryngeal cancer?

Hoarseness

A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When collecting data from this client, the nurse should expect to find which of the following early indications of hypoxia?

Hypertension

A nurse is reinforcing nutritional teaching with a client who has COPD. Which of the following instructions by the nurse is appropriate?

Increase protein intake.

A nurse is caring for a client who is postoperative and has develop atelectasis. Which of the following finding should the nurse expect?

Increasing dyspnea

A nurse at a provider's office receives a telephone call from a client who reports nausea and has unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?

Instruct the client to call 911.

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

Instruct the client to use pursed-lip breathing.

A nurse is caring for a client who has been admitted with asthma exacerbation and is experiencing increased wheezing and has an oxygen saturation of 91%. The client is scheduled for his next breathing treatment in 1hr. Which of the following actions should the nurse take?

Instructing respiratory therapy to administer a PRN albuterol aerosol

A nurse is preparing to administer digoxin to a client who has heart failure which of the following actions should the nurse take?

Measure the client's apical pulse.

A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan?

Monitor platelet levels

a nurse stops to give first aid to a burn victim running from a home that is on fire. The nurse rolls the victim on the ground to smother the flames. The chest and the neck of the victim are burned. What is the next priority for the nurse?

Monitor victim for respiratory distress

Based on etiology of pressure injuries, what nursing interventions is best for promoting integrity?

Move patient every 2 hour

The nurse is checking the casted extremity of a client. The nurse needs to check for which sign indicative of infection.

Presence of "hot spot" on the cast

Whats the difference between essential and secondary hypertension?

Primary: family history, increase sodium intake, obesity, stress, hyperlipidemia Secondary: disease/meds cause increase blood pressure, kidney disease, hyperthyroidism, crushing disease pheochromocytes

The nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its purpose. The nurse would tell the client that the primary purpose of pursed lip breathing is which?

Promote carbon dioxide elimination

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects?

Protamine sulfate

What finger joints would the nurse expect to be most affected by the client's rheumatoid arthritis?

Proximal finger joint

A nurse is caring for a client who is postoperative for 3 days following a cholecystectomy. The client wound is infected because the drainage from the dressing is yellow and thick.

Purulent

A nurse is reinforcing teaching with a client who has herpes zoster. The nurse should include which of the following statements in the teaching?

Recurrence of infection can be triggered by stress or trauma

The nurse planning the care for a patient who has impetigo expects to administer which topical drug to the patient?

Retapamulin

A nurse is collecting data about a client's pulmonary system. While auscultating the client's lungs, the nurse hears continuous gurgling, low-pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?

Rhonchi

A nurse is collecting data from a client who has severe burn injuries. How can the nurse determine the percentage of the body affected by a burn injury?

Rules of nines

Which method of assessing bum size apples only to adults?

Rules of nines

The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding?

Serous drainage

When examining skin of a client with psoriasis, what finding would the nurse expect to observe?

Silvery, white scaly lesions

A nurse is collecting data from a client who has basal cell carcinoma on her nose. What finding should the nurse expect?

Small translucent nodule

What are some effects of long term on the body organs if hypertension if left untreated?

Stroke, kidney failure, heart failure, acute infraction, renal ischemia

A nurse is reinforcing teaching with a client who uses a nitroglycerine patch to treat angina. The client now has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?

Take the medication at the first indication of chest pain.

Upon inspection of a client's skin, a nurse identifies a stage 3 pressure ulcer on the sacrum.

There is a full thickness skin loss with a crater

A nurse is collecting data from a client who is postoperative following abdominal surgery. Which of the following findings should cause the nurse to suspect deep-vein thrombosis (DVT)?

Unilateral leg edema

A middle-aged client asks the nurse about methods for preventing or delaying the onset of osteoporosis. What nursing assessment finding most likely indicates that a client has osteoporosis?

Using glucocorticoid for 10 years because of a chronic lung disorder

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious lung sounds?

Wheezes

15.A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily for heart failure. The client's current vital signs are: BP 144/96, heart rate 54/min. respirations 18/min, and temperature 37 degrees C & 98.6 F. Which of the following action should the nurse take?

Withhold the digoxin dose for decreased heart rate.

A nurse is reinforcing instructions with a client who is scheduled for a cardiac catheterization with angiography. Which of the following statements should the nurse include in the instructions?

You might have to lie in bed for 6 hr after the procedure.