Med Surg

Which assessment finding does the nurse expect in a client diagnosed with aortic stenosis? a. Bounding arterial pulse b. Slow, faint arterial pulse c. Narrowed pulse pressure d. Elevated systolic and diastolic pressures

C In aortic stenosis, the client presents with a narrowed pulse pressure when the blood pressure is assessed.

The client with moderate heart failure is being discharged. Which is of priority to teach the client? a. "Avoid drinking more than 3 quarts of liquids each day." b. "Stop your activity and rest at the first sign of chest pain." c. "Weigh yourself every day in the morning before breakfast." d. "Do not take a double dose if you forget to take your digoxin."

C Weight gain is the most reliable indicator of fluid retention associated with heart failure. The client should weigh himself or herself early in the morning, before breakfast. The client should be instructed to limit fluid; 3 quarts is too much fluid for the client.

The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea, pink, frothy sputum, and crackles throughout the lung fields. Which prescription should the nurse carry out first? A. Enalapril B. Heparin C. Furosemide D. I & O

Furosemide

The nurse is assessing a client in the emergency department. Which client statement alerts the nurse to the occurrence of heart failure?

I get short of breath when I climb stairs

The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure. The nurse questions the client about the use of which medication because it raises an index of suspicion as to the cause of heart failure? A. Ibuprofen (Motrin) B. Hydrochlorothiazide (HydroDIURIL) C. NPH Insulin D. Levothyroxine (Synthroid)

Ibuprofen (Motrin)

the nurse is caring for a client with a nasogastric tube that is attached to low suction. the client is at risk for which acid base disorder? respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis

metabolic alkalosis

the nurse is caring for a pt with a chest tube drainage system. the nurse notes constant bubbling in the water seal chamber. which of the following nursing actions is most appropriate? reposition the client change the chest tube drainage system notify physician this is a normal expected finding; no action is necessary

notify the physician

A client asks the nurse why it is important to be weighed every day if he or she has right-sided heart failure. How will the nurse respond? a. "Weight is the best indication that you are gaining or losing fluid." b. "Weighing you every day will help us make sure that you're eating properly." c. "The hospital requires that all inpatients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."

A Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds.

A client with a history of heart failure is being discharged. Which instruction will assist the client in the prevention of complications associated with heart failure? a. "Drink at least 2 L of fluids daily." b. "Eat six small meals daily instead of three larger meals." c. "When you feel short of breath, take an additional diuretic." d. "Weigh yourself daily wearing the same amount of clothing."

D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure are increasing dyspnea, exercise intolerance, cold symptoms, and nocturia.

A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). Which assessment finding alerts the nurse to a serious side effect? a. Cough b. Headache c. Bradycardia d. Hypokalemia

D Hypokalemia is a side effect of both thiazide and loop diuretics. The client loses electrolytes with fluid. Coughing is not a typical side effect of this medication. Headaches may occur with any medication, and is not a serious side effect. Bradycardia is not likely to occur with this medication.

A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. Which primary collaborative intervention should the nurse perform? a. Maintain the head of the bed in a high Fowler's position. b. Keep the client on bedrest, with passive range of motion. c. Limit visitors and activity to a minimum. d. Administer loop diuretics.

D The client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention. Administering the diuretics will decrease the fluid overload, thereby decreasing the incidence of pulmonary edema.

The nurse is caring for a client who is being treated for hypertensive emergency. Which medication prescribed for the client should the nurse question? A. Enalapril (Vasotec) B. Sodium nitroprusside (Nipride) C. Dopamine (Intropin) D. Clevidipine (butyrate)

Dopamine (Intropin)

When obtaining a client's vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse's best intervention?:

Teach the patient lifestyle modifications to decrease blood pressure

the nurse is caring for a client with a chest tube drainage system. the nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube system. which nursing action is appropriate? no action necessary encourage coughing &deep breathing suction the client increase the suction

no action is necessary

The nurse checks the lab results for a secrum digoxin level that was drawn on a client earlier in the day. the result is 2.4 ng/ml. Which of the following is the most important action of the part of the nurse? record the normal value on the client's flow sheet administer the next dose of the med as scheduled check the client's last pulse rate Notify the physician

notify the physician

The client with a diagnosis of chronic ovstructive pulmonary disease (COPD) is most likely to experience what type of acid base imbalance? respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis

respiratory acidosis

The nurse is caring for a client with pneumonia. Blood gas results indicate pH of 7.45, PCO2 of 30 mmHg and HCO3 of 22 mEq/L metabolic acidosis, compensated metabolic alkalosis, uncompensated respiratory alkalosis, compensated respiratory acidosis, uncompensated

respiratory alkalosis, compensated

The nurse is teaching the client precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective? A. "I can use an electric razor or a regular razor." B. "Eating foods like green beans won't interfere with my Coumadin therapy." C. "If I notice I am bleeding a lot, I should stop taking Coumadin right away." D. "When taking Coumadin, I may notice some blood in my urine."

"Eating foods like green beans won't interfere with my Coumadin therapy."

the nurse is caring for the client who is immunosuppressed with a diagnosis of cancer. the nurse would consider implementing neuropenic precaustions if the client's WBC count was 2000 5800 8400 11,500

2000

Which client is most at risk of developing left-sided heart failure? a. Middle-aged woman with aortic stenosis b. Middle-aged man with pulmonary hypertension c. Older woman who smokes two packs of cigarettes daily d. Older man who has had a right ventricular myocardial infarction

A Although most individuals with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, CAD (coronary artery disease), and hypertension.

The client with heart failure is prescribed enalapril (Vasotec). What is the nurse's focus for teaching? a. Avoiding salt substitutes b. Taking medication with food c. Avoiding aspirin or aspirin-containing products d. Holding this medication if the pulse rate is below 74 beats/min

A Angiotensin-converting enzyme (ACE) inhibitors inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride.

Which conditions are caused by left-sided heart failure? (Select all that apply.) a. Hypertensive disease b. Crackles heard c. Enlarged liver and spleen d. Confusion e. Pulmonary hypertension f. Dependent edema g. S3/S4 gallop h. Cough worsens at night

A, B, D, G, H Left-sided failure occurs with decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided failure occurs with problems from the pulmonary vasculature on. Signs will be noted before the right atrium or ventricle.

Which laboratory results does the nurse expect in the client with heart failure? (Select all that apply.) a. Hemoglobin, 14.2 g/dL; hematocrit (Hct), 32.8% b. Serum sodium, 130 mEq/L c. Serum potassium, 4.0 mEq/L d. Serum creatinine, 1.0 mg/dL e. Proteinuria f. Microalbuminuria

A, B, E, F The hematocrit is low (should be 42.6%), indicating a dilutional ratio of RBCs to fluid. The serum sodium is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. This is an early warning sign of decreased compliance of the heart.

A client with systolic dysfunction has an ejection fraction of 38%. The nurse expects to observe which physiologic change? a. An increase in stroke volume b. A decrease in tissue perfusion c. An increase in oxygen saturation d. A decrease in arterial vasoconstriction

ANS: B In systolic dysfunction, the ventricle is unable to contract with enough force to eject blood effectively during systole. As the ejection fraction decreases (50% to 70% is normal), tissue perfusion decreases and the client develops activity intolerances.

Which is the priority intervention for a client who has received the first dose of captopril (Capoten)? a. Administer this medication 1 hour before meals to aid absorption. b. Instruct the client to ask for assistance when arising from bed. c. Give the medication with milk to prevent stomach upset. d. Monitor the potassium level for hypokalemia.

B Administration of the first dose of ACE inhibitors is associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension.

A nurse is instructing a client with heart failure on energy conservation. Which is the best instruction? a. "Walk until you become short of breath and then walk back home." b. "Gather everything you need for a chore before you begin." c. "Pull rather than push or carry items heavier than 5 pounds." d. "Take a walk after dinner every day."

B Gathering all supplies needed for a chore at one time decreases the amount energy needed.

Which statement made by a client would alert the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight." c. "I wake up coughing every night." d. "I have trouble catching my breath."

B Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing could all be results of left-sided heart failure.

The nurse notes that the client's apical pulse is displaced to the left. What conclusion can be drawn from this assessment? a. This is a normal finding. b. The heart is hypertrophied. c. The left ventricle is contracted. d. The client has pulsus alternans.

B The client with heart failure typically has an enlarged heart that displaces the apical pulse to the left.

Which client statement alerts the nurse to possible heart failure? a. "I am drinking more water than usual." b. "I have been awakened by the need to urinate at night." c. "I have to stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."

C Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living as well as difficulty breathing, or "catching their breath." This occurs as fluid moves into the alveoli.

The nurse recognizes that which medication when given in heart failure may improve morbidity and mortality? A. Dobutamine (Dobutrex) B. Carvedilol (Coreg) C. Digoxin (Lanoxin) D. Bumetamide (Bumex)

Carvedilol (Coreg)

How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? A. Ejection fraction is 25%. B. Client states that she is able to sleep on one pillow. C. Client was hospitalized five times last year with pulmonary edema. D. Client reports that she experiences palpitations.

Client states that she is able to sleep on one pillow.

The nurse suspects that the client has developed an acute arterial occlusion of the right lower extremity based on which of the following? Select all that apply. A. Hypertension B. Tachycardia C. Bounding right pedal pulses D. Cold right foot E. Numbness and tingling of right foot F. Mottling of right foot and lower leg

Cold right foot Numbness and tingling of right foot Mottling of right foot and lower leg

Which assessment finding supports a diagnosis of impaired tissue perfusion in the client with heart failure? a. Carotid bruit b. A dry hacking cough c. A positive Allen's test d. Dyspnea on exertion

D Indications of poor tissue perfusion are activity intolerance, which includes dyspnea on exertion.

The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, "I feel so tired and short of breath." Which action should the nurse take first? A. Assess the client for peripheral edema. B. Listen to the client's posterior breath sounds. C. Notify the physician about the client's weight gain. D. Remind the client about dietary sodium restrictions.

Listen to the client's posterior breath sounds.

The client is receiving unfractionated heparin by infusion. Of which finding should the nurse notify the provider? A. Partial thromboplastin time (PTT) 60 seconds B. Platelets 32,000 C. White blood cells (WBCs) 11,000 D. Hemoglobin 12.2 g/dL

Platelets 32,000

The professional nurse and the nursing student are caring for a group of clients with hypertension. Which of these problems identified by the nursing student correctly identifies the client at risk for secondary hypertension? A. Psychiatric disturbance B. High sodium intake C. Physical inactivity D. Renal failure

Renal failure

A client with heart failure has furosemide (Lasix). Which finding would concern the nurse with this new prescription? A. Serum sodium level of 135 mEq/L B. Serum potassium level of 2.8 mEq/L C. Serum creatinine of 1.0 mg/dL D. Serum magnesium level of 1.9 mEq/L

Serum potassium level of 2.8 mEq/L

The nurse caring for the client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply. A. Hypokalemia B. Sinus bradycardia C. Fatigue D. Serum digoxin level of 1.5 E. Anorexia

Sinus bradycardia Fatigue Anorexia

The nurse is beginning to transfuse a client with a unit of blood. just prior to starring the infusion, it is most important for the nurse to assess: skin color oxygen saturation vital signs latest hematocrit

vital signs

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? A. Client ambulates around the nursing unit with a walker. B. The nurse monitors the client's pulse and blood pressure frequently. C. The nurse obtains a bedside commode before administering furosemide. D. The nurse returns the client to bed when he becomes tachycardic.

The nurse obtains a bedside commode before administering furosemide.

The client begins therapy with lisinopril (Prinivil, Zestril). What should the nurse consider at the start of therapy with this medication? A. The client's ability to understand medication teaching B. The risk for hypotension C. The potential for bradycardia D. Liver function tests (LFTs)

The risk for hypotension

the nurse has finished infusing a unit of granulocytes to an assigned client. the nurse notes the results of which follow up lab study to evaluate the effectiveness of this therapy hemoglobin hematocrit WBC count platelet count

WBC count

Which teaching should the nurse include for a client with peripheral arterial disease (PAD)? A. Elevate your legs above heart level to prevent swelling. B. Inspect your legs daily for brownish discoloration around the ankle. C. Walk to the point of leg pain, then rest, resuming when pain stops. D. Apply a heating pad to the legs if they feel cold.

Walk to the point of leg pain, then rest, resuming when pain stops.

the nurse is caring for a client hospitalized with acute exacervation of chronic ovstructive pumonary disease. which of the following does the nurse expect to note in assessing this client? increased oxygen sat with exercise a shortened expiratory phase of respiration a hyperinflated chest on the xray film a widened diaphragm noted on the chest x ray film

a hyperinflated chest on the xray film

the community nurse is conducting an educational session to community members regarding tuberculosis. the first symptom associated with tuberculosis is bloody, productive cough morning cough with expectoration of mucoid sputum chest pain dyspnea

a morning cough with expectoration of mucoid sputum

the client in hemorrhagic shock requires rapid transfusion with multiple units of blood. the nurse uses which of the following devices to prevent cardiac dysrhythmias during the transfusion? blood warming device electronic infusion device noninvasive BP monitor continuous cardiac monitor

blood warming device

The nurse is assessing an older adult client who is experiencing a myocardial infarction. What clinical manifestation does the nurse expect in this client?

disoriented and confusion

the nurse is monitoring the chest tube drainage system in a client with a chest tube. the nurse notes intermittent bubbling in the water seal compartment. which of the following is the most appropriate action? change the chest tube drainage system document the findings check for an airleak notify the physician

document the findings

the client receiving a blood transfusion begins to exhibit flushing, stridor and a drop in BP. the nurse initially obtains which of the following meds from the emergency cart to have ready for use as ordered? aminophylline lidocaine norepinephrine epinephrine

epinephrine

the adult female client has a hgb level of 10.8 g/dL. the nurse interprets that this result is most likely due to which of the following factors in the clients history? COPD heart failure dehydration iron deficiency anemia

iron deficiency anemia

the nurse is caring for a client following a bronchoscopy and biopsy. which of the following signs, if noted in the client, should be reported immediately to the physician? blood streaked sputum dry cough hematuria laryngeal stridor

laryngeal stridor

The nurse is assessing a client newly admitted to the medical unit. Which statement made by the client alerts the nurse to the presence of edema?

my shoes fit tighter at the end of the day

The nurse reviews the blood gas results of a client with Guillain-Barre syndrome. the nurse analyzes the results and determines that the client is experiencing respiratory acidosis. which of the following validates the nurse's finding? pH 7.40, PCO 52mmHg pH 7.35, PCO 40mmHg pH 7.25, PCO 50mmHg pH 7.50, PCO 30mmHg

pH 7.25, PCO 50mmHg

The nurse is caring for a client with adult respiratory distress syndrome (ARDS). Blood gas results indicate a pH of 7.50 and PCO2 of 30mmHg. the nurse has determined that the client is experiencing respiratory alkalosis. which of the following lab values would the nurse expect to note? Sodium 145 mEq/L Potassium 3.2mEq/L Magnesium 2.0mEq/L Phosphorus 2.3mEq/L

potassium 3.2

The nurse is caring for a client with renal failure Blood gas results indicate a pH of 7.30, PCO 32mmHg, HCO 20 mEq/L. the nurse has determined that the client is experiencing metabolic acidosis. which of the following laboratory values would the nurse note? Sodium 145 mEq/L Magnesium 2.0 mEq/L Potassium 5.2 mEq/L Phosphorus 2.3 mEq/L

potassium 5.2

aminophylline is administered to a client with acute bronchitis. the primary action of this medication is to promote expectoration suppress the cough relax smooth muscles of the bronchial airway prevent infection

relax smooth muscles of the bronchial airway

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on the documentation, which of the following did the nurse observe? 1.respirations that are abnormally deep, regular and increased in rate 2.respirations that are regular but abnormally slow 3.respirations that are labored and increased in depth and rate 4.respirations that cease for several seconds

respirations that are abnormally deep, regular and increased in rate