Midterm: Ch 27, 32, 35, 38, 40, 68

A client weighing 174 pounds had thrombolytic therapy followed by a one-time dose of IV Lovenox 30 mg. The physician prescribes Lovenox 1 mg/kg subcutaneously after the IV administration. The nurse will give ____ mg of Lovenox to the client.

79

The nurse is teaching a client with newly diagnosed anemia about conserving energy. What does the nurse tell the client? Select all that apply. a. "Allow others to perform your care during periods of extreme fatigue." b. "Drink small quantities of protein shakes and nutritional supplements daily." c. "Perform a complete bath daily to reduce your chance of getting an infection." d. "Provide yourself with four to six small, easy-to-eat meals daily." e. "Perform your care activities in groups to conserve your energy." f. "Stop activity when shortness of breath or palpitations are present."

a. "Allow others to perform your care during periods of extreme fatigue." b. "Drink small quantities of protein shakes and nutritional supplements daily." d. "Provide yourself with four to six small, easy-to-eat meals daily." f. "Stop activity when shortness of breath or palpitations are present." It is critical to have others help the anemic client who is extremely tired. Although it may be difficult for him or her to ask for help, this practice should be stressed to the client. Drinking small protein or nutritional supplements will help rebuild the client's nutritional status. Having four to six small meals daily is preferred over three large meals; this practice conserves the body's expenditure of energy used in digestion and assimilation of nutrients. Stopping activities when strain on the cardiac or respiratory system is noted is critical. A complete bath should be performed only every other day; on days in between, the client can be taught to take a "mini" sponge bath, which will conserve energy and still be safe in preventing the risks for infection. Care activities should be spaced every hour or so rather than in groups to conserve energy; the time just before and after meals should be avoided.

The nurse is assessing a middle-aged patient who reports a decreased tolerance for exercise and that she must work harder to breathe. Which questions assist the nurse in determining what these changes are related to? Select all that apply. a. "Do you have anemia?" b. "When did you first notice these symptoms?" c. "Do you or have you ever smoked cigarettes?" d. "How often do you exercise?" e. "Are you coughing up any colored sputum?"

a. "Do you have anemia?" b. "When did you first notice these symptoms?" c. "Do you or have you ever smoked cigarettes?" e. "Are you coughing up any colored sputum?"

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching? a. "I should avoid eating hamburgers." b. "I must cut out bacon and canned foods." c. "I shouldn't put the salt shaker on the table anymore." d. "I should avoid lunchmeats but may cook my own turkey."

a. "I should avoid eating hamburgers." Cutting out beef or hamburgers made at home is not necessary; however, fast-food hamburgers are to be avoided owing to higher sodium content. Bacon, canned foods, lunchmeats, and processed foods are high in sodium, which promotes fluid retention; these are to be avoided. The client correctly understands that adding salt to food should be avoided.

You're providing discharge teaching to a patient about pernicious anemia. Which statement by the patient indicates they did NOT understand the discharge teaching? a. "Pernicious anemia is caused by not consuming enough Vitamin B12." b. "Pernicious anemia causes the red blood cells to appear very large and oval." c. "Treatment for pernicious anemia includes a series of intramuscular injections of Vitamin B12." d. "A red, smooth tongue can be a sign of pernicious anemia."

a. "Pernicious anemia is caused by not consuming enough Vitamin B12." The patient lacking intrinsic factor which helps with the absorption of vitamin B12. The patient can consume supplements or foods with vitamin B12, but they will not absorb B12 because they lack intrinsic factor.

A client with unstable angina has received education about acute coronary syndrome. Which statement indicates that the client has understood the teaching? a. "This is a big warning; I must modify my lifestyle or risk having a heart attack in the next year." b. "Angina is just a temporary interruption of blood flow to my heart." c. "I need to tell my wife I've had a heart attack." d. "Because this was temporary, I will not need to take any medications for my heart."

a. "This is a big warning; I must modify my lifestyle or risk having a heart attack in the next year." Among people who have unstable angina, 10% to 30% have a myocardial infarction within 1 year. Although anginal pain is temporary, it reflects underlying coronary artery disease (CAD), which requires attention, including lifestyle modifications. Unstable angina reflects tissue ischemia, but infarction represents tissue necrosis. Clients with underlying CAD may need medications such as aspirin, lipid-lowering agents, anti-anginals, or antihypertensives.

The nurse teaches a patient about the impact of cigarette smoking on the lower respiratory tract. Which statement by the patient indicates an understanding of the information? a. "Using nicotine replacement therapy will increase my chances of success." b. "If I stop smoking, the damage to my lungs will be reversed." c. "Cigarette smoke affects my ability to cough out secretions from the lungs." d. "Smoking makes the large and small airways get bigger."

a. "Using nicotine replacement therapy will increase my chances of success."

A patient comes to the health care provider's office for an annual physical. The patient reports having a persistent, nagging cough. Which question does the nurse ask first about this symptom? a. "When did the cough start?" b. "Do you have a family history of lung cancer?" c. "Have you been running a fever?" d. "Do you have sneezing and congestion?"

a. "When did the cough start?"

A patient reports having chest discomfort that started during exercise. The patient is currently pain-free, but is "concerned." What questions must the nurse ask to assess the patient's pain episode? Select all that apply. a. "When did the pain start and how long did it last?" b. "What were you doing when the pain started?" c. "What did you do alleviate the pain?" d. "How did you feel about the pain?" e. "Did the pain radiate to other locations?" f. "On a scale of 0 to 10 with 10 as the worst pain, what number would you use to categorize the pain?"

a. "When did the pain start and how long did it last?" b. "What were you doing when the pain started?" c. "What did you do alleviate the pain?" e. "Did the pain radiate to other locations?" f. "On a scale of 0 to 10 with 10 as the worst pain, what number would you use to categorize the pain?"

Which of the following patients are MOST at risk for developing endocarditis? Select all that apply. a. 25 year old male who reports using intravenous drugs on a daily basis b. 55 year old male who is post-opt from aortic valve replacement c. 63 year old female who is newly diagnosed with hyperparathyroidism and is taking Aspirin d. 66 year old female who recently had an invasive dental procedure performed 1 month ago and is having a fever

a. 25 year old male who reports using intravenous drugs on a daily basis b. 55 year old male who is post-opt from aortic valve replacement d. 66 year old female who recently had an invasive dental procedure performed 1 month ago and is having a fever Remember that any thing that allows entry of bacteria into the system can potentially cause endocarditis

Which client has the highest risk for developing a pulmonary embolism (PE)? a. 25-year-old woman who frequently flies to different countries b. 67-year-old man who works on a farm c. 45-year-old man admitted for a heart attack d. 23-year-old woman with a bleeding disorder

a. 25-year-old woman who frequently flies to different countries People who engage in prolonged and frequent air travel are at higher risk for PE. A 67-year-old man who works on a farm is not at high risk because he has an active lifestyle. A heart attack is usually caused by a thrombus or occlusion of the coronary arteries, not of the legs; if on prolonged bedrest, the client's risk is increased. PE is a clotting disorder, not a bleeding disorder.

Which client is at greatest risk for having a hemolytic transfusion reaction? a. 34-year-old client with type O blood b. 42-year-old client with allergies c. 58-year-old immune-suppressed client d. 78-year-old client

a. 34-year-old client with type O blood Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood that contains antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. Type O is considered the universal donor, but not the universal recipient. The client with allergies would be most susceptible to an allergic transfusion reaction. The immune-suppressed client would be most susceptible to a transfusion-associated graft-versus-host disease. The older adult client would be most susceptible to circulatory overload.

An RN from pediatrics has "floated" to the medical-surgical unit. Which client is assigned to the float nurse? a. 42-year-old with sickle cell disease receiving a transfusion of packed red blood cells b. 50-year-old with pancytopenia needing assessment of risk factors for aplastic anemia c. 55-year-old with folic acid deficiency anemia caused by alcohol abuse who needs counseling d. 60-year-old with newly diagnosed polycythemia vera who needs teaching about the disease

a. 42-year-old with sickle cell disease receiving a transfusion of packed red blood cells Because sickle cell disease is commonly diagnosed during childhood, the pediatric nurse will be familiar with the disease and with red blood cell transfusion; therefore, he or she should be assigned to the client with sickle cell disease. Aplastic anemia, folic acid deficiency, and polycythemia vera are problems more commonly seen in adult clients who should be cared for by nurses who are more experienced in caring for adults.

After receiving change-of-shift report about these four clients, which client should the nurse assess first? a. 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions b. 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% c. 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths d. 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min

a. 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions The 46-year-old's premature ventricular contractions may be indicative of digoxin toxicity; further assessment for clinical manifestations of digoxin toxicity should be done and the health care provider notified about the dysrhythmia. The 55-year-old is stable and can be assessed after the client with aortic stenosis. The 68-year-old may be assessed after the client with aortic stenosis; this type of pain is expected in pericarditis. Tachycardia is expected in the 79-year-old because rejection will cause signs of decreased cardiac output, including tachycardia; this client may be seen after the client with aortic stenosis.

Which of the following patients are MOST at risk for developing heart failure? Select-all-that-apply. a. 69 year old male with a history of alcohol abuse and is recovering from a myocardial infarction b. 55 year old female with a health history of asthma and hypoparathyroidism c. 30 year old male with a history of endocarditis and has severe mitral stenosis d. 45 year old female with lung cancer stage 2 e. 58 year old female with uncontrolled hypertension and is being treated for influenza

a. 69 year old male with a history of alcohol abuse and is recovering from a myocardial infarction c. 30 year old male with a history of endocarditis and has severe mitral stenosis e. 58 year old female with uncontrolled hypertension and is being treated for influenza FAILURE: Faulty heart valves, Arrhythmias, Infarction, Lineage, Uncontrolled hypertension, Recreational drug usage, Evaders

Select the patient below who is at MOST risk for pernicious anemia: a. 75 year old male who recently had surgery on the ileum b. 25 year old female who reports craving ice and clay c. 66 year old male whose peripheral blood smear showed hypochromic red blood cells d. all the patients above are at risk for pernicious anemia

a. 75 year old male who recently had surgery on the ileum Patients who've had GI surgery (the ileum is part of the GI system), have endocrine disorders (like Addison's Disease, Diabetes Type 1 etc.), or GI disease are at risk for pernicious anemia. This reason is because as the person ages GI secretions decrease along with intrinsic factor and with GI surgery the parietal cells can be damaged (which are responsible for secreting intrinsic factor).

The closing of the atrioventricular valves (tricuspid valve--right ventricle, and the mitral valve--left ventricle) produces which heart sound? a. S1 b. S2 c. S3 d. S4

a. S1

Which finding in the first 24 hours after kidney transplantation requires immediate intervention? a. abrupt decrease in urine output b. blood-tinged urine c. incisional pain d. increase in urine output

a. abrupt decrease in urine output An abrupt decrease in urine output may indicate complications such as rejection, acute kidney injury, thrombosis, or obstruction. Blood-tinged urine, incisional pain, and an increase in urine output are expected findings after kidney transplantation.

A 30 year old female is being treated for infective endocarditis with IV antibiotics. At the beginning of the hospitalization, the patient's symptoms were severe and sudden with a high fever but are now controlled. She has no significant health history other than 2 cesarean sections in the past. She is being prepped for a central line placement so she can be discharged home with home health to continue the 4 week antibiotic regime. What is type of infective endocarditis this classified as based on the information listed? a. acute infective endocarditis b. subacute infective endocarditis c. non-infective endocarditis d. pericarditis

a. acute infective endocarditis This is acute infective endocarditis. The key clues in this question are patient has no significant health history and signs and symptoms were sudden/severe. In subacute infective endocarditis, the patient will have a pre-existing condition that caused them to develop the IE and the symptoms are gradual and subtle.

The nurse has just received a patient from the recovery room who is somewhat drowsy, but is capable of following instructions. Pulse oximetry has dropped from 95% to 90%. What is the priority nursing intervention? a. administer oxygen at 2 L/min by nasal cannula, then reassess b. have the patient perform coughing and deep-breathing exercises, then reassess c. administer naloxone (Narcan) to reverse narcotic sedation effect d. withhold narcotic pain medication to reduce sedation effect

a. administer oxygen at 2 L/min by nasal cannula, then reassess

In order to assist a patient in the prevention of osteodystrophy, which intervention does the nurse perform? a. administer phosphate binders with meals b. encourage high-quality protein foods c. administer iron supplements d. encourage extra milk at mealtimes

a. administer phosphate binders with meals

The nurse is caring for a patient with AKI who does not have signs or symptoms of fluid overload. A fluid challenge is performed to promote kidney perfusion by doing what? a. administering normal saline 500 to 1000 mL infused over 1 hour b. administering drugs to suppress aldosterone release c. instilling warm, sterile normal saline into the bladder d. having the patient drink several large glasses or water

a. administering normal saline 500 to 1000 mL infused over 1 hour

A client with asthma reports shortness of breath. What is the nurse assessing when auscultating this client's chest? a. adventitious breath sounds b. fremitus c. oxygenation status d. respiratory excursion

a. adventitious breath sounds Adventitious sounds are additional breath sounds superimposed on normal sounds. They indicate pathologic changes in the lung. Fremitus is vibration and is not detected by auscultation. Oxygenation status cannot be detected specifically by auscultation. Respiratory excursion is detected by both observation of the movement of the chest and palpation as the client inhales and exhales.

A patient is admitted for unstable angina. The patient is currently asymptomatic and all vital signs are stable. Which position does the nurse place the patient in? a. any position of comfort b. supine c. sitting in a chair d. fowler's

a. any position of comfort

The nurse is evaluating a patient's treatment response to erythropoietin (Epogen). Which hemoglobin reading indicates that the goal is being met? a. around 10 g/dL b. greater than 20 g/dL c. upward trend d. at baseline for gender

a. around 10 g/dL

After receiving report at the beginning of her shift, a nurse enters her client's room to begin her duties. The client is intubated and requires a mechanical ventilator with supplemental oxygen as treatment for pneumonia. Upon entering the client's room and starting the assessment, which action should the nurse perform first? a. assess the client's skin color b. ensure the ventilator alarms are set c. obtain pulse oximetry reading d. check the ventilator settings

a. assess the client's skin color

After a bronchoscopy procedure, the patient coughs up sputum which contains blood. What is the best nursing action at this time? a. assess vital signs and respiratory status and notify the provider of the findings b. monitor the patient for 24 hours to see if blood continues in the sputum c. send the sputum to the lab for cytology for possible lung cancer d. reassure the patient this is a normal response after a bronchoscopy

a. assess vital signs and respiratory status and notify the provider of the findings

A client with chronic kidney disease reports chest pain. The nurse notes tachycardia and low-grade fever. Which additional assessment is warranted? a. auscultate for pericardial friction rub b. assess for crackles c. monitor for decreased peripheral pulses d. determine if the client is able to ambulate

a. auscultate for pericardial friction rub The client with uremia is prone to pericarditis; symptoms include inspiratory chest pain, low-grade fever, and ST-segment elevation. Crackles and tachycardia are symptomatic of fluid overload; fever is not present. Although the nurse will monitor pulses, and ambulation is important to prevent weakness and deep vein thrombosis, these are not pertinent to the constellation of symptoms of pericarditis that the client presents with.

A patient is receiving digoxin therapy for heart failure. What assessment does the nurse perform before administering the medication? a. auscultate the apical pulse rate and heart rhythm b. assess for nausea and abdominal distention c. auscultate the lungs for crackles d. check for increased urine output

a. auscultate the apical pulse rate and heart rhythm

A patient has an ejection fraction of less than 30%. The nurse prepares to provide patient education about which potential treatment? a. automatic implantable cardio-defibrillator b. heart transplant c. mechanical implanted pump d. ventricular reconstructive procedures

a. automatic implantable cardio-defibrillator

A client with a recently created vascular access for hemodialysis is being discharged. In planning discharge instructions, which information does the nurse include? a. avoiding venipuncture and blood pressure measurements in the affected arm b. modifications to allow for complete rest of the affected arm c. how to assess for a bruit in the affected arm d. how to practice proper nutrition

a. avoiding venipuncture and blood pressure measurements in the affected arm Compression of vascular access causes decreased blood flow and may cause occlusion; if this occurs, dialysis will not be possible. The arm should be exercised to encourage venous dilation, not rested. The client can palpate for a thrill; a stethoscope is not needed to auscultate the bruit at home. The nurse should take every opportunity to discuss nutrition, even as it relates to wound healing, but loss of the graft or fistula by compression or occlusion must take priority because lifesaving dialysis cannot be performed.

People involved in which occupations or activities are encouraged to wear masks and to have adequate ventilation? Select all that apply. a. bakers b. coal miners c. electricians d. furniture refinishers e. plumbers f. potters

a. bakers b. coal miners d. furniture refinishers f. potters Being exposed to flour as a baker for prolonged periods of time may cause a condition called occupational asthma. Coal miners are at risk to develop pneumoconiosis as the result of inhalation of coal dust. Owing to the chemicals used to refinish furniture (paint strippers, solvents), masks and adequate ventilation are essential for furniture refinishers. One of the main solvents involved will metabolize in the body to carbon monoxide and will impair the ability of the tissue to extract oxygen. Silicosis or inhalation of silica dust is a hazard for professional and recreational potters. Except in unique situations, electricians and plumbers do not need to wear masks or utilize special ventilation for their jobs.

The nurse is providing postdialysis care for a patient. In comparing vital signs and weight measurements to the predialysis data, what does the nurse expect to find? a. blood pressure and weight are reduced b. blood pressure is increased and weight is reduced c. blood pressure and weight are slightly increased d. blood pressure is low and weight is the same

a. blood pressure and weight are reduced

The nurse is caring for a patient receiving gentamicin. Because this drug has potential for nephrotoxicity, which laboratory results does the nurse monitor? Select all that apply. a. blood urea nitrogen b. creatinine c. drug peak and trough levels d. prothrombin time (PT) e. platelet count f. hemoglobin and hematocrit

a. blood urea nitrogen b. creatinine c. drug peak and trough levels

What are the risk factors for the development of leukemia? Select all that apply. a. bone marrow hypoplasia b. chemical exposure c. down syndrome d. ionizing radiation e. multiple blood transfusions f. prematurity at birth

a. bone marrow hypoplasia b. chemical exposure c. down syndrome d. ionizing radiation Reduced production of blood cells in the bone marrow is one of the risk factors for developing leukemia. Exposure to chemicals through medical need or by environmental events can also contribute. Certain genetic factors contribute to the development of leukemia; Down syndrome is one such condition. Radiation therapy for cancer or other exposure to radiation, perhaps through the environment, also contributes. There is no indication that multiple blood transfusions are connected to clients who have leukemia. Although some genetic factors may influence the incidence of leukemia, prematurity at birth is not one of them.

A 56-year-old client admitted with a diagnosis of acute myelogenous leukemia is prescribed IV cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. What is the major side effect of this therapy? a. bone marrow suppression b. liver toxicity c. nausea d. stomatitis

a. bone marrow suppression Intravenous cytosine arabinoside and daunorubicin are a commonly prescribed course of aggressive chemotherapy, and bone marrow suppression is a major side effect. The client is even more at risk for infection than before treatment began. Liver toxicity, nausea, and stomatitis are not the major problems with this therapy.

The nurse is caring for a patient with AKI and notes a trend of increasingly elevated BUN levels. HOw does the nurse interpret this information? a. breakdown of muscle for protein which leads to an increase in azotemia b. sign of urinary retention and decreased urinary output c. expected trend that can be reversed by increasing dietary d. ominous sign of impending irreversible kidney failure

a. breakdown of muscle for protein which leads to an increase in azotemia

Which component of a client's family history is of particular importance to the home health nurse who is assessing a new client with asthma? a. brother is allergic to peanuts b. father is obese c. mother is diabetic d. sister is pregnant

a. brother is allergic to peanuts Clients with asthma often have a family history of allergies; it will be important to assess whether this client has any allergies that may serve as triggers for an asthma attack. Obesity, diabetes, and pregnancy are not correlated with asthma.

A patient is hypertensive and continues to have angina despite therapy with beta blockers. The nurse anticipates which type of drug will be prescribed for this patient? a. calcium channel blocker b. digoxin c. angiotensin-converting enzyme (ACE) d. dopamine

a. calcium channel blocker

A patient with CKD has a potassium level of 9 mEq/L. The nurse notifies the health care provider after assessing for which sign/symptom? a. cardiac dysrhythmias b. respiratory depression c. hypercalcemia d. hypokalemia

a. cardiac dysrhythmias

The nurse is caring for a patient requiring PD. In order to monitor the patient's weight, what does the nurse do? a. check the weight after a drain and before the next fill to monitor the patient's "dry weight" b. calculate the "dry weight" by weighing the patient every day and comparing the patient's weight to a standard weight chart based on height and age c. weigh the patient each day and count fluid intake and dialysate volume to determine the patient's "dry weight"

a. check the weight after a drain and before the next fill to monitor the patient's "dry weight"

The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? Select all that apply. a. chest discomfort or pain b. tachycardia c. expectorating thick, yellow sputum d. sleeping on back without a pillow e. fatigue

a. chest discomfort or pain b. tachycardia e. fatigue Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure. Presence of a cough or dyspnea results as pulmonary venous congestion ensues. Clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Thick, yellow sputum is indicative of infection. Position for sleeping isn't a symptom; Clients usually find it difficult to lie flat because of dyspnea symptoms.

The nurse is interviewing a patient reporting chest discomfort that occurs with moderate to prolonged exertion. The patient describes the pain as being "about the same over the past several months and going away with nintroglycerin or rest." Based on the patient's description of symptoms, what does the nurse suspect in this patient? Select all that apply. a. chronic stable angina (CSA) b. unstable angina c. acute coronary sndrome (ACS) d. acute myocardial infraction (MI) e. coronary artery disease (CAD)

a. chronic stable angina (CSA) e. coronary artery disease (CAD)

The medical-surgical unit nurse should call the Rapid Response Team to assess which client? a. client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis b. client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain c. client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry of 94% d. client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs

a. client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis The client with a diagnosed pulmonary embolism is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin; this indicates a significant decline in status and warrants activation of the Rapid Response Team. The client with deep vein thrombosis requires ongoing monitoring and is receiving appropriate treatment; calf pain is expected in this situation. The client with a right pneumothorax requires ongoing monitoring but has normal oxygen saturation. The client who was extubated 3 days ago requires ongoing monitoring or nursing intervention, but does not have evidence of acute deterioration or severe complications.

Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurse's immediate attention? a. client with acute allergic reaction b. client with dyspnea on exertion c. client with lung cancer with cough d. client with sinus infection and fever

a. client with acute allergic reaction An acute allergic reaction can lead to immediate respiratory distress; this is an emergent situation that requires the immediate attention of the nurse. Dyspnea on exertion is a condition that will need further evaluation by the nurse, but is not usually an emergency. Coughing is a frequent symptom of lung cancer; although coughing may be related to something not associated with the client's cancer, this situation is not an emergency. Sinus infections are not considered emergencies.

The RN has received report about all of these clients. Which client needs the most immediate assessment? a. client with acute asthma who has an oxygen saturation of 89% by pulse oximetry b. client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes c. client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago d. client with pleural effusion who has decreased breath sounds at the right base

a. client with acute asthma who has an oxygen saturation of 89% by pulse oximetry An oxygen saturation level less than 91% indicates hypoxemia and requires immediate assessment and intervention to improve blood and tissue oxygenation. The client who is scheduled for a thoracentesis will be able to receive teaching and will have the opportunity to ask questions and have them answered before the procedure is performed, if this was not already completed. The client who had a bronchoscopy 3 hours ago and has returned to the floor does not require the most immediate attention at this moment. It would not be unusual to have diminished breath sounds at the base of the lung of the client with pleural effusion.

After receiving change-of-shift report in the coronary care unit, which client does the nurse assess first? a. client with acute coronary syndrome who has a 3-pound weight gain and dyspnea b. client with percutaneous coronary angioplasty who has a dose of heparin scheduled c. client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min d. client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction

a. client with acute coronary syndrome who has a 3-pound weight gain and dyspnea Dyspnea and weight gain are symptoms of left ventricular failure and pulmonary edema; this client needs prompt intervention. A scheduled heparin dose does not take priority over dyspnea; it can be administered after the client with dyspnea is taken care of. The client with a pacemaker and a normal heart rate is not in danger. First-degree heart block is rarely symptomatic, and the client has a normal heart rate; the client with dyspnea should be seen first.

The nurse is caring for a group of clients. Which clients should be monitored closely for respiratory failure? Select all that apply. a. client with brainstem tumor b. client with acute pancreatitis c. client with a T3 spinal cord injury d. client using patient-controlled analgesia e. client experiencing cocaine intoxication

a. client with brainstem tumor b. client with acute pancreatitis c. client with a T3 spinal cord injury d. client using patient-controlled analgesia Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome; abdominal distention also ensues, which can limit respiratory excursion. Clients with cervical and thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect intercostal muscles are affected. Opiates, which can depress the brainstem, present risk factors for respiratory failure. All of these clients should be monitored closely for respiratory failure. Cocaine is a stimulant, which would not cause respiratory failure unless a stroke ensued.

The home health nurse is assigned to visit all of these clients when a change in agency staffing requires that one of the clients be rescheduled for a visit on the following day. Which client would be best to reschedule? a. client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% b. client with history of a cough, weight loss, and night sweats who has just had a positive Mantoux test c. client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment d. client with percutaneous lung biopsy yesterday who called in to report increased dyspnea

a. client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% The client with emphysema has an appropriate SpO2 for home oxygen use. A positive Mantoux test, in addition to a history of cough, weight loss, and night sweats, is highly suspicious for tuberculosis and needs follow-up and reporting, because this becomes a public and a personal health issue. A client with a newly diagnosed pleural effusion needs a complete and thorough admission and intake assessment to ensure that he has adequate respiratory function to meet his basic oxygenation needs. Although a percutaneous lung biopsy may be an outpatient procedure, pneumothorax or hemothorax is a possible life-threatening complication of this procedure that would cause dyspnea and requires assessment in a timely manner by the home health nurse.

The nurse auscultates popping, discontinuous sounds over the client's anterior chest. How does the nurse classify these sounds? a. crackles b. rhonchi c. pleural friction rub d. wheeze

a. crackles Crackles are described as a popping, discontinuous sound caused by air moving into previously deflated airways. The airways have been deflated due to the presence of fluids in the lungs, and crackles should be considered to be a sign of fluid overload. Rhonchi are low-pitched, coarse snoring sounds caused by fluid or secretions in larger airways. A pleural friction rub sounds grating, loud, or scratchy as inflamed surfaces of the pleura rub together. Wheezes are frequently referred to as musical or squeaky; they may occur on inspiration or on expiration and may be heard without a stethoscope as air rushes through narrowed airways.

The nurse is teaching a client with vitamin B12 deficiency anemia about dietary intake. Which type of food does the nurse encourage the client to eat? a. dairy products b. grains c. leafy vegetables d. starchy vegetables

a. dairy products Dairy products such as milk, cheese, and eggs will provide the vitamin B12 that the client needs. Grains, leafy vegetables, and starchy vegetables are not a source of vitamin B12.

Which problems occur with acute kidney injury (AKI)? Select all that apply. a. decreased peristalsis b. anemia c. metabolic acidosis d. hypokalemia e. peripehral edema

a. decreased peristalsis b. anemia c. metabolic acidosis e. peripehral edema

A patient sustained extensive burns and depletion of vascular volume. The nurse expects which changes in vital signs and urinary function? a. decreased urine output, hypotension, tachycardia b. increased urine output, hypertension, tachycardia c. bradycardia, hypotension, polyuria d. dysrhythmias, hypertension, oliguria

a. decreased urine output, hypotension, tachycardia

A patient with heart failure is being treated for exacerbation of symptoms. The physician has ordered a dose of milrinone to be given IV. Which best describes a property of this type of medication? a. decreasing afterload b. regulating heart arrhythmia c. decreasing contractility d. increasing preload

a. decreasing afterload Milrinone increases the size of blood vessels, which reduces the pressure the heart must work against during contractions. Therefore, afterload is decreased and blood flow is improved. Milrinone is used for short-term management of heart failure.

Which intervention for a client in the intensive care unit (ICU) will decrease the incidence of "ICU psychosis?" a. decreasing nighttime disruptions b. keeping the lights on to promote orientation c. administering sedation d. providing television or radio for stimulation

a. decreasing nighttime disruptions ICU psychosis can be minimized not only by encouraging sleep, but also by keeping to a regular routine. Keeping the lights on or providing TV or radio will not encourage sleep. Sedation can promote confusion and disorientation.

The nurse is assessing a patient with right-sided heart failure. Which assessment findings does the nurse expect to see in this patient? Select all that apply. a. dependent edema b. weight loss c. polyuria at night d. hypotension e. hepatomegaly f. angina

a. dependent edema c. polyuria at night e. hepatomegaly

A nurse is preparing a client for coronary artery bypass graft surgery. Which preop interventions would the nurse use that would help with prevention of bleeding after the surgery? Select all that apply. a. determining whether the patient has a clotting factor deficiency b. stopping warfarin administration 12 hours before surgery c. performing a P2Y12 assay d. checking if the patient has had bleeding with prior surgeries e. administering clopidogrel prior to surgery

a. determining whether the patient has a clotting factor deficiency c. performing a P2Y12 assay d. checking if the patient has had bleeding with prior surgeries

The community health nurse is designing programs to reduce kidney problems and kidney injury among the general public. In order to do so, the nurse targets health promotion and compliance with therapy for people with which conditions? a. diabetes mellitus and hypertension b. frequent episodes of sexually transmitted disease c. osteoporosis and other bone diseases d. gastroenteritis and poor eating habits

a. diabetes mellitus and hypertension

The nurse is caring for a client with congestive heart failure. This client regularly takes a vasodilator. The nurse understands that this type of drug helps congestive heart failure in what ways? Select all that apply. a. dilate the kidney's arterioles b. reduce cardiac afterload c. increase cardiac preload d. increase blood pressure e. enhance skeletal muscle circulation

a. dilate the kidney's arterioles b. reduce cardiac afterload e. enhance skeletal muscle circulation n general, a vasodilator benefits the client in heart failure by dilating blood vessels so that cardiac afterload is reduced. When peripheral blood vessels are dilated, circulation is enhanced which means that both skeletal and coronary circulation is increased. The kidney's arterioles are also dilated which promotes blood filtration. Vasodilation decreases the forward flow of blood, which decreases cardiac preload and afterload and decreases blood pressure.

The nurse is assessing a patient with left-sided heart failure. Which assessment findings does the nurse expect to see in this patient? Select all that apply. a. displacement of the apical impulse to the left b. S3 heart sound c. paroxysmal nocturnal dyspnea d. jugular venous distention e. oliguria during the day f. wheezes or crackles

a. displacement of the apical impulse to the left b. S3 heart sound c. paroxysmal nocturnal dyspnea e. oliguria during the day f. wheezes or crackles

The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms should the nurse assess? Select all that apply. a. dizziness and fainting b. shortness of breath (SOB) worsening over the last 2 weeks c. inspiratory chest pain d. productive cough e. pink, frothy sputum

a. dizziness and fainting c. inspiratory chest pain Syncope, hypotension, and fainting are symptoms associated with PE. Sharp, pleuritic, inspiratory chest pain is also characteristic of PE. Sudden, not gradual, SOB occurs with PE. Productive cough is associated with infection; PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema; PE may cause hemoptysis.

A patient has received thrombolytic therapy for treatment of acute MI. What are postadministration nursing responsibilities for this treatment? (Select all that apply.) a. document the patient's neurologic status b. observe all IV sites for bleeding and patency c. monitor white blood cell (WBC) count and differential d. monitor clotting studies e. monitor hemoglobin and hematocrit f. test stools, urine, and emesis for occult blood

a. document the patient's neurologic status b. observe all IV sites for bleeding and patency d. monitor clotting studies e. monitor hemoglobin and hematocrit f. test stools, urine, and emesis for occult blood

You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? a. document your findings as normal b. assess for an air leak due to bubbling noted in the suction chamber c. notify the physician about the drainage d milk the tubing to ensure patency of the tubes

a. document your findings as normal

A patient with heart failure has a new prescription for digoxin (Lanoxin). The nurse is giving this patient more information. What should be included as part of teaching this patient about digoxin? Select all that apply. a. drug may not be well absorbed if the patient has a high-fiber meal b. drug could cause serious side effects, such as cardiac arrhythmias c. common signs of drug toxicity include petechiae on the chest and hair loss d. patient should not take the drug if his pulse is less than 60 or over 100 bpm e. digoxin may be affected by concurrent intake of St. John's wort

a. drug may not be well absorbed if the patient has a high-fiber meal b. drug could cause serious side effects, such as cardiac arrhythmias d. patient should not take the drug if his pulse is less than 60 or over 100 bpm e. digoxin may be affected by concurrent intake of St. John's wort Digoxin is a cardiac medication that must be carefully monitored with patient use because of its effects. The patient should know his heart rate before taking digoxin, as the drug can cause changes in the rate. Other items may affect absorption of digoxin, including a high-fiber meal or intake of some types of supplements. Common signs of drug toxicity are irregular heart rate, vision changes and confusion, among others.

For which problem does the nurse assess the client who cannot breathe through the nose because of a severe septal deviation? a. dry respiratory tract membranes b. frequent episodes of tonsillitis c. development of nasal polyps d. difficulty swallowing

a. dry respiratory tract membranes When inspired air passes through the nose, it is filtered, warmed, and humidified. When a person is unable to breathe through the nose because of an anatomical obstruction, he or she is at risk for excessive drying of the respiratory mucous membranes. This anatomical problem does not influence the development of tonsillitis or difficulty swallowing. Nasal polyps can contribute to nasal obstruction but is not caused by a septal deviation.

Which test is the best tool for diagnosing heart failure? a. echocardiography b. pulmonary artery catheter c. radionuclide studies d. multigated angiographic (MUGA) scan

a. echocardiography

When assisting with dietary protein needs for a client on peritoneal dialysis, the nurse recommends that the client select which food? a. eggs b. ham c. eggplant d. macaroni

a. eggs Suggested protein-containing foods for a client on peritoneal dialysis are milk, meat, and eggs. Although a protein, ham is high in sodium, which should be avoided. Vegetables and pasta contain mostly carbohydrates. Peritoneal dialysis clients are allowed 1.2 to 1.5 g of protein/kg/day because protein is lost with each exchange.

The nurse is managing a post-op CABG patient assess a sudden drop in BP, distended neck veins, muffled heart tones, minimal chest tube output, and a systolic pressure that fluctuates with breathing pattern. The patient most likely needs: a. emergent return to the OR b. clamping of the chest tube c. transfusion of PRBCs d. high-dose dopamine

a. emergent return to the OR

The nurse is taking a history of a patient at risk for kidney failure. What does the nurse ask the patient about during the interview? Select all that apply. a. exposure to nephrotoxic chemicals b. increased appetite c. history of diabetes mellitus, hypertension, systemic lupus erythematosus d. recent surgery, trauma, or transfusions e. leakage of urine when coughing or laughing f. recent or prolonged use of antibiotics and NSAIDs

a. exposure to nephrotoxic chemicals c. history of diabetes mellitus, hypertension, systemic lupus erythematosus d. recent surgery, trauma, or transfusions f. recent or prolonged use of antibiotics and NSAIDs

A patient is newly diagnosed with cardiovascular disease. What psychosocial reactions does the nurse assess for? Select all that apply. a. fear b. anxiety c. anger d. suspicion e. denial f. depression

a. fear b. anxiety c. anger e. denial f. depression

Which clients are at risk for acute kidney injury (AKI)? Select all that apply. a. football player in preseason practice b. client who underwent contrast dye radiology c. accident victim recovering from a severe hemorrhage d. accountant with diabetes e. client in the intensive care unit on high doses of antibiotics f. client recovering from gastrointestinal influenza

a. football player in preseason practice b. client who underwent contrast dye radiology c. accident victim recovering from a severe hemorrhage e. client in the intensive care unit on high doses of antibiotics f. client recovering from gastrointestinal influenza To prevent AKI, all people should be urged to avoid dehydration by drinking at least 2 to 3 liters of fluids daily, especially during strenuous exercise or work associated with diaphoresis, or when recovering from an illness that reduces kidney blood flow, such as influenza. Contrast media may cause acute renal failure, especially in older clients with reduced kidney function. Recent surgery or trauma, transfusions, or other factors that might lead to reduced kidney blood flow may cause AKI. Certain antibiotics may cause nephrotoxicity. Diabetes may cause acute kidney failure superimposed on chronic kidney failure.

A 56-year-old client is suffering from interstitial nephritis and is seen in the hospital for care. The client's creatinine levels are elevated and the client has poor skin turgor and dry mucous membranes upon exam. The nurse ensures that the client does not receive any nephrotoxic medications that would worsen the condition. Which medication should be avoided? a. gentamicin b. combivir c. amantadine d. abilify

a. gentamicin

What are the typical signs and symptoms of infective endocarditis? Select all that apply. a. hyperthermia b. S4 gallop c. enlarged spleen d. hyperkalemia e. substernal pain that radiates to the back f. heart failure g. cardiac murmur

a. hyperthermia c. enlarged spleen f. heart failure g. cardiac murmur

An older adult patient with heart failure is volume-depleted and has a low sodium level. The health care provider has ordered valsartan (Diovan), and angiotensin-receptor blocker (ARB). After the initial dose, for what complication does the nurse carefully monitor in this patient? a. hypotension b. cough c. fluid retention d. chest pain

a. hypotension

The nurse is caring for a patient in the intensive care unit who sustained blood loss during a traumatic accident. For early identification of signs and symptoms that would suggest the development of kidney dysfunction, what does the nurse observe for? Select all that apply. a. hypotension b. bradycardia c. decreased urine output d. decreased cardiac output e. increased central venous pressure

a. hypotension c. decreased urine output d. decreased cardiac output

The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client's HF? a. ibuprofen (Motrin) b. hydrochlorothiazide (HydroDIURIL) c. nph insulin d. levothyroxine (Synthroid)

a. ibuprofen (Motrin) Long-term use of nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin) causes fluid and sodium retention, which can worsen a client's HF. A diuretic may be used in the treatment of HF and hypertension. Although diabetes may be a risk factor for cardiovascular disease, it does not directly cause HF. In proper doses, Synthroid replaces thyroid hormone for those with hypothyroidism; it does not cause HF.

A patient is receiving treatment for stable coronary artery disease. The doctor prescribes the patient Plavix. What important information will you include in the patient's teaching? Select-all-that-apply. a. if you are scheduled for any planned surgical procedures, let your doctor know you are taking Plavix because this medication will need to be discontinued 5-7 days prior to the procedure b. normal side effect of this medication is a dry cough c. avoid green leafy vegetables while taking Plavix d. notify the doctor, immediately, if you develop bruising, problems urinating, or fever

a. if you are scheduled for any planned surgical procedures, let your doctor know you are taking Plavix because this medication will need to be discontinued 5-7 days prior to the procedure d. notify the doctor, immediately, if you develop bruising, problems urinating, or fever

A patient who has recovered from ARDS in the ICU is now malnourished and has lost a significant amount of weight. The physician orders TPN to add nutrition for the patient, who then develops re-feeding syndrome. Which of the following signs or symptoms would the nurse expect to see with re-feeding syndrome? Select all that apply. a. impaired mental status b. constipation c. insulin resistance d. seizures e. persistent weight loss

a. impaired mental status c. insulin resistance d. seizures

It is best for the nurse to auscultate for heart murmurs by listening: a. in the direction of the blood flow, at the intercostal spaces b. in the four auscultation areas directly over each valve c. at the base and apex of the heart d. along the bony ridge of the sternal angle

a. in the direction of the blood flow, at the intercostal spaces

The nurse reviews the complete blood count results for the patient who has chronic obstructive pulmonary disease (COPD) and lives in a high mountain area. What lab results does the nurse expect to see for this patient? a. increased red blood cells b. decreased neutrophils c. decreased eosinophils d. increased lymphocytes

a. increased red blood cells

A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system? a. intermittent bubbling may be noted in the water seal chamber b. 200 cc of drainage per hour is expected during recovery of a pneumothorax c. chest tube is positioned at the patient's chest level to facilitate drainage d. all of these options are appropriate findings

a. intermittent bubbling may be noted in the water seal chamber It is normal to find intermittent (NOT CONTINUOUS) bubbling in the water seal chamber if the patient is recovery from a pneumothorax. Remember that a pneumothorax is an AIR leak between the lung and chest wall....therefore air will escape into the water seal chamber causing intermittent bubbles.

The home health nurse is reviewing the medication list of a patient with CKD. The nurse calls the health care provider as a reminder that the patient might need which nutritional supplements? Select all that apply. a. iron b. magnesium c. phospohrus d. calcium e. vitamin D f. water-soluble vitamins

a. iron d. calcium e. vitamin D f. water-soluble vitamins

A patient is being evaluated for thrombolytic therapy. What are absolute contraindications for this procedure? Select all that apply. a. ischemic stroke within 3 months b. pregnancy c. suspected aortic aneurysm d. major trauma in the last 12 months e. intracranial hemorrhage f. malignant intracranial neoplasm

a. ischemic stroke within 3 months c. suspected aortic aneurysm e. intracranial hemorrhage f. malignant intracranial neoplasm

All of the following are true of an S3 heart sound except: a. it can be heard best using the diaphragm of the stethoscope at the right of the sternum, at the 2nd intercostal space b. it can be heard best with the patient sitting forward or in the left lateral position c. absence of S3 does not rule out the diagnosis of heart failure d. it is heard immediately following closure of the semi-lunar valves

a. it can be heard best using the diaphragm of the stethoscope at the right of the sternum, at the 2nd intercostal space

When blood passes through the lungs, what happens to oxygen? a. it diffuses from the alveoli into the red blood cells b. it diffuses from the red blood cells into the alveoli c. it decreases concentration in the blood d. it increases concentration in the alveoli

a. it diffuses from the alveoli into the red blood cells

The ED nurse, caring for a patient with severe chest pain and ECG changes, gives supplemental oxygen to the patient as ordered. Which other medications does the nurse anticipate giving to this patient? Select all that apply. a. iv nitroglycerin b. beta blocker c. iv morphine d. oral aspirin e. ace inhibitor

a. iv nitroglycerin b. beta blocker c. iv morphine d. oral aspirin

All of these nursing actions are included in the plan of care for a client who has just been extubated. Which action should the nurse delegate to unlicensed assistive personnel (UAP)? a. keep the head of the bed elevated b. teach about incentive spirometer use c. monitor vital signs every 5 minutes d. adjust the nasal oxygen flow rate

a. keep the head of the bed elevated Positioning of clients is included in UAP education and scope of practice and can be delegated. Client teaching is an activity performed by the professional nurse. Although taking vital signs is an activity of the UAP, monitoring a potentially unstable client is done by the professional nurse. Adjusting oxygen flow rates requires complex decision making and should be done by the RN.

The emergency department (ED) nurse is assessing an 86-year-old patient with acute confusion, increased respiratory rate, anxiety, and chest pain. The nurse finds a respiratory rate of 36/min with crackles and wheezes on auscultation. How does the nurse interpret these findings? a. left ventricular heart failure b. atypical angina c. cad d. unstable angina

a. left ventricular heart failure

The patient with CKD reports chronic fatigue and lethargy with weakness and mild shortness of breath with dizziness when rising to a standing position. In addition, the nurse note pale mucous membranes. Based on the patient's illness and the presenting symptoms, which laboratory result does the nurse expect to see? a. low hemoglobin and hematocrit b. low white cell count c. low blood glucose d. low oxygen saturation

a. low hemoglobin and hematocrit

A nurse is caring for a 49-year-old client who is recovering from valve replacement surgery. Three days after the surgery, the nurse suspects that the client has developed infective endocarditis. Which of the following signs or symptoms would indicate that this condition has developed in the client? a. low-grade fever, splinter hemorrhages b. nausea, vomiting, and diarrhea causing electrolyte imbalances c. slapped-cheek appearance and profuse sweating d. red, beefy tongue and difficulty swallowing

a. low-grade fever, splinter hemorrhages Infective endocarditis is a serious infection of bacteria or fungi that affects the heart valves and surrounding structures. The client may develop weight loss, fever, a cardiac murmur, splenomegaly, and skin changes. The characteristic skin changes associated with infective endocarditis are generalized rashes and small hemorrhages in the nail beds, known as splinter hemorrhages.

A patient is undergoing a dialysis treatment and exhibits a progression of symptoms which include headache, nausea, and vomiting; and fatigue. How does the nurse interpret these symptoms? a. mild dialysis disequilibrium syndrome b. expected manifestations in ESKD c. transient symptoms in a new dialysis patient d. adverse reaction to the dialysate

a. mild dialysis disequilibrium syndrome

When the nurse auscultates a murmur at the apex, it may be related to a: a. mitral valve defect b. tricuspid valve defect c. stenotic aortic valve d. regurgitant pulmonic valve

a. mitral valve defect

A patient is receiving an infusion of nesiritide (Natrecor) for treatment of heart failure. What is the priority nursing assessment while administering this medication? a. monitor hypotension b. assess for cardiac dysrhythmias c. observe for respiratory depression d. monitor for peripheral vasoconstriction

a. monitor hypotension

A patient with heart failure has inadequate tissue perfusion. Which nursing interventions are included in the plan of care for this patient? Select all that apply. a. monitor respiratory rate, rhythm, and quality every 1 to 4 hours b. auscultate breath sounds every 4 to 8 hours c. provide supplemental oxygen to maintain oxygen saturation at 90% or greater d. place the patient in a supine position with pillows under each leg e. assist the patient in performing coughing and deep-breathing exercises every 2 hours

a. monitor respiratory rate, rhythm, and quality every 1 to 4 hours b. auscultate breath sounds every 4 to 8 hours c. provide supplemental oxygen to maintain oxygen saturation at 90% or greater e. assist the patient in performing coughing and deep-breathing exercises every 2 hours

When planning care for a client in the emergency department, which interventions are needed in the acute phase of myocardial infarction? Select all that apply. a. morphine sulfate b. oxygen c. nitroglycerin d. naloxone e. acetaminophen f. verapamil (Calan, Isoptin)

a. morphine sulfate b. oxygen c. nitroglycerin Morphine is needed to reduce oxygen demand, preload, pain, and anxiety, and nitroglycerin is used to reduce preload and chest pain. Administering oxygen will increase available oxygen for the ischemic myocardium. Naloxone is a narcotic antagonist that is used for overdosage of opiates, not for MI. Acetaminophen may be used for headache related to nitroglycerin. Because of negative inotropic action, calcium channel blockers such as verapamil are used for angina, not for MI.

Mr. Z has hypoxemia without hypercapnia because carbon dioxide: a. much more soluble than oxygen b. equally as soluble as oxygen c. much less soluble than oxygen d. retained because of obstructive processes

a. much more soluble than oxygen

A patient is currently pain -and symptom-free, but reports having intermittent episodes of chest pain over the past week. The nurse asks about which associated symptoms? Select all that apply. a. nausea b. diarrhea c. diaphoresis d. dizziness e. joint pain f. shortness of breath

a. nausea c. diaphoresis d. dizziness f. shortness of breath

A patient with CKD is taking digoxin (Lanoxin). Which signs of digoxin toxicity does the nurse vigilantly monitor for? Select all that apply. a. nausea and vomiting b. visual changes c. respiratory depression d. restlessness or confusion e. headache or fatigue f. tachycardia

a. nausea and vomiting b. visual changes d. restlessness or confusion e. headache or fatigue f. tachycardia

Which statement best describes the renin-angiotensin-aldosterone system? a. net result is the retention of sodium and water b. renin is released form the juxtaglomerular cells in response to systemic hypertension c. angiotensinogen causes the conversion of angiotensin I to angiotensin II in the renal tubules d. angiotensin converting enzyme causes the conversion of angiotensinogen to angiotensin I

a. net result is the retention of sodium and water

The nurse teaches a client who is recovering from acute kidney disease to avoid which type of medication? a. nonsteroidal anti-inflammatory drugs (NSAIDs) b. angiotensin-converting enzyme (ACE) inhibitors c. opiates d. calcium channel blockers

a. nonsteroidal anti-inflammatory drugs (NSAIDs) NSAIDs may be nephrotoxic to a client with acute kidney disease, and should be avoided. ACE inhibitors are used for treatment of hypertension and to protect the kidneys, especially in the diabetic client, from progression of kidney disease. Opiates may be used by clients with kidney disease if severe pain is present; however, excretion may be delayed. Calcium channel blockers can improve the glomerular filtration rate and blood flow within the kidney.

An 84-year-old male client is being admitted after surgery to remove a section of his bowel (colectomy) following a diagnosis of colon cancer. His urine output from an indwelling urinary catheter after 3 hours in the postanesthesia care unit plus the amount in the bag on admission to the medical-surgical unit totals 100 mL. The urine is cloudy and dark yellow. He also has a history of hypertension. After evaluating the patency of the collection device, what is the most appropriate action for the nurse to perform? a. notify the health care provider of the low urine output b. increase the rate of intravenous fluids until urine output is 0.5 mL/kg/hr c. continue to assess the client and re-evaluate urine output in 4 hours d. ask about his typical voiding patterns and about any previous episodes of urinary problems

a. notify the health care provider of the low urine output The lowest acceptable urine output to avoid acute kidney injury (AKI) is 0.5 mL/kg/hr, which, in this 70-kg man, is about 35 mL/hr or a total of at least 105 mL. Surgery places clients at risk for both hypo- and hypervolemia. Waiting an additional 4 hours to obtain 6-hour trend data delays the prompt assessment and intervention necessary to avoid AKI. It is not appropriate to increase fluid rate, and it is unlikely the client is ready to take oral fluid this soon after surgery on the gastrointestinal tract. Voiding is not an issue with a urinary collection device.

The nurse caring for a client who is intubated and receiving mechanical ventilation notes that her oxygen saturation is 89%, her heart rate is 120 beats/min, and she is increasingly agitated and restless. On auscultation, the nurse finds the lung sounds are diminished on one side. Which action does the nurse perform first? a. notify the provider and prepare for re-intubation or repositioning the tube b. document the findings and request sedation from the provider c. call respiratory therapy to obtain a set of arterial blood gasses d. reposition the tube, and call radiology for a stat chest x-ray

a. notify the provider and prepare for re-intubation or repositioning the tube With the decreased oxygen saturation and decreased breath sounds on one side, the endotracheal tube is incorrectly positioned into one bronchus. For effective gas exchange, the tube must be repositioned, which is a health care provider function, not a nursing function.

While managing care for a client with chronic kidney disease, which actions does the registered nurse (RN) plan to delegate to unlicensed assistive personnel (UAP)? Select all that apply. a. obtain the client's pre-hemodialysis weight b. check the arteriovenous (AV) fistula for a thrill and bruit c. document the amount the client drinks throughout the shift d. auscultate the client's lung sounds every 4 hours e. explain the components of a low-sodium diet

a. obtain the client's pre-hemodialysis weight c. document the amount the client drinks throughout the shift Obtaining the client's weight and documenting oral fluid intake are routine tasks that can be performed by UAP. Assessment skills (checking the AV fistula and auscultating lung sounds) and client education (explaining special diet) require more education and are in the legal scope of practice of the RN.

Which are characteristics of angina? Select all that apply. a. pain is precipitated by exertion or stress b. pain occurs without cause, usually in the morning c. pain is relieved only by opioids d. pain is relieved by nitroglycerin or rest e. nausea, diaphoresis, feelings of fear, and dyspnea may occur f. pain lasts less than 15 minutes

a. pain is precipitated by exertion or stress d. pain is relieved by nitroglycerin or rest f. pain lasts less than 15 minutes

The nurse identifies a priority problem of fatigue and weakness for the patient with heart failure. After ambulating 200 feet down the hall, the patient's blood pressure change is more than 20 mm Hg. How does the nurse interpret this data? a. patient is building endurance b. activity is too stressful c. patient could walk farther d. activity is appropriate

a. patient is building endurance

A 25-year-old patient in the ICU is being treated for acute respiratory distress syndrome (ARDS). The patient is on a ventilator and requires 80 percent FiO2. Which information would the nurse most likely need to report about the patient to the respiratory therapist working with her? a. patient needs an arterial blood gas drawn b. patient needs endotracheal suctioning c. patient needs more oxygen because of his saturations d. patient needs a hemoglobin level drawn

a. patient needs an arterial blood gas drawn

A patient has returned to the medical-surgical unit after having a dialysis treatment. The nurse notes that the patient is also scheduled for an invasive procedure on the same day. What is the primary rationale for delaying the procedure for 4 to 6 hours? a. patient was heparinized during dialysis b. patient will have cardiac dysrhythmias after dialysis c. patient will be incoherent and unable to give consent d. patient needs routine medications that were delayed

a. patient was heparinized during dialysis

Which statements are true about the use of thrombolytic agents for a patient with an acute MI? Select all that apply. a. patient who has received a thrombolytic agent must be continuously monitored before and after the medication is given b. thrombolytic therapy is indicated for chest pain of longer than 30 minutes duration that is unrelieved by other medications c. there are no contraindications to thrombolytic therapy if the patient is having an acute MI as evidenced by cardiac enzymes and ECG d. bleeding is a risk for patients receiving thrombolytic therapy e. nurse need only monitor clotting studies of the patient who has received thrombolytic therapy. No further assessment is needed

a. patient who has received a thrombolytic agent must be continuously monitored before and after the medication is given b. thrombolytic therapy is indicated for chest pain of longer than 30 minutes duration that is unrelieved by other medications d. bleeding is a risk for patients receiving thrombolytic therapy

Which patient has the highest risk for death because of ventricular failure and dysrhythmias related to damage to the left ventricle? a. patient with an anterior wall MI (AWMI) b. patient with a posterior wall MI (PWMI) c. patient with a lateral wall MI (LWMI) d. patient with an infferior wall MI (IWMI)

a. patient with an anterior wall MI (AWMI)

Which patients with CKD are candidates for intermittent hemodialysis? (Select all that apply.) a. patient with fluid overload who does not respond to diuretics b. patient with injury stage according to the RIFLE classification c. patient with symptomatic toxin ingestion d. patient with uremic manifestations, such as decreased cognition e. patient with symptomatic hyperkalemia and calciphylaxis

a. patient with fluid overload who does not respond to diuretics c. patient with symptomatic toxin ingestion d. patient with uremic manifestations, such as decreased cognition e. patient with symptomatic hyperkalemia and calciphylaxis

The nurse is caring for a postoperative patient and is evaluating the patient's intake and output as a measure to prevent AKI. The patient weighs 60 kilograms and has produced 180 mL of urine in the past 4 hours. What should the nurse do? a. perform other assessments related to fluid status and record the output b. call the health care provider and obtain an order for a fluid bolus c. encourage the patient to drink more fluid, so that the output is increased d. compare the patient's weight to baseline to determine fluid retention

a. perform other assessments related to fluid status and record the output

A nurse is caring for a patient who underwent open-heart surgery 12 hours ago. While recovering in his room, the patient develops chest pain and becomes very restless. After testing, the physician determines that the patient has developed cardiac tamponade. Which describes the most likely treatment for this condition? a. pericardiocentesis b. swan-Ganz insertion c. electrocardiogram d. echocardiogram

a. pericardiocentesis

A patient with CKD develops severe chest pain, an increased pulse, low-grade fever, and a pericardial friction rub with a cardiac dysrhythmia and muffled heart tones. The nurse immediately alerts the health care provider and prepares for which emergency procedure? a. pericardiocentesis b. CVVH c. kidney dialysis d. endotracheal intubation

a. pericardiocentesis

Which intervention will be most effective in reducing anxiety in a client with a pulmonary embolism (PE)? a. remain with the client and provide oxygen in a calm manner b. have the client breathe into a brown paper bag using pursed lips c. offer the client a mild sedative d. allow a family member to remain in the room

a. remain with the client and provide oxygen in a calm manner The underlying cause for anxiety with a PE is hypoxemia, which will be alleviated by oxygen; remaining with the client in distress is appropriate. Rebreathing from a brown paper bag is an intervention that increases PaCO2 during hyperventilation, as in a panic attack; it will not provide needed oxygen. Sedation and/or allowing a family member to stay may calm the client, but will not improve oxygenation.

Which characteristics are associated with ESKD? Select all that apply. a. severe fluid overload b. renal osteodystrophy c. nephrons compensate d. dialysis or transplant needed to maintain homeostasis e. excessive waste products

a. severe fluid overload b. renal osteodystrophy d. dialysis or transplant needed to maintain homeostasis e. excessive waste products

A patient is treated for acute pulmonary edema. Which medications does the nurse prepare to administer to this patient? Select all that apply. a. sublingual nitroglycerin b. iv lasix c. iv morphine sulfate d. iv beta blocker e. iv nitroglycerine

a. sublingual nitroglycerin b. iv lasix c. iv morphine sulfate e. iv nitroglycerine

What observations does the nurse make when performing a general assessment of a patient's lungs and thorax? Select all that apply. a. symmetry of chest movement b. rate, rhythm, and depth of respirations c. use of accessory muscles for breathing d. comparison of the anteroposterior diameter with the lateral diameter e. measurement of the length of the chest cavity f. assessment of chest expansion and respiratory excursion

a. symmetry of chest movement b. rate, rhythm, and depth of respirations c. use of accessory muscles for breathing d. comparison of the anteroposterior diameter with the lateral diameter f. assessment of chest expansion and respiratory excursion

The nurse is providing care for a patient who would like to quit smoking. Which important teaching points must be included when teaching this patient? Select all that apply. a. talk with your health care provider about nicotine replacement therapies b. ask for help from family and friends who have quit smoking c. smoking while using a nicotine patch is acceptable as long as you are gradually decreasing how much you smoke d. remove all ashtrays, cigarettes, pipes, cigars, and lighters from your home to decrease the temptation to smoke e. f you are used to having a cigarette after eating, get up from the table as soon as you are finished eating f. avoid starting an exercise program at the same time you quit smoking because making two big changes at the same time is setting yourself up for failure

a. talk with your health care provider about nicotine replacement therapies b. ask for help from family and friends who have quit smoking d. remove all ashtrays, cigarettes, pipes, cigars, and lighters from your home to decrease the temptation to smoke e. f you are used to having a cigarette after eating, get up from the table as soon as you are finished eating

The nursing student is assisting in the care of a patient with advanced right-sided heart failure. In addition to bringing a stethoscope, what additional piece of equipment does the student bring in order to assess this patient? a. tape measure b. glasgow coma scale c. portable Doppler d. bladder ultrasound scanner

a. tape measure

A nurse is caring for a client on a ventilator. The client's family is visiting, so the nurse teaches the family about what alarms mean on the ventilator. Which best describes the rationale for this intervention? a. to reduce the family's anxiety b. to educate the family about medical equipment c. to prevent the client from developing an infection d. to protect the safety of the client by avoiding a fire

a. to reduce the family's anxiety

The nurse is preparing to teach a client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome should the nurse include in the discussion? Select all that apply. a. truncal obesity b. hypercholesterolemia c. elevated homocysteine levels d. glucose intolerance e. client taking losartan (Cozaar)

a. truncal obesity b. hypercholesterolemia d. glucose intolerance e. client taking losartan (Cozaar) A large waist size (excessive abdominal fat causing central obesity)—40 inches (102 cm) or greater for men, 35 inches (88 cm) or greater for women—is a sign of metabolic syndrome. Decreased high-density lipoprotein cholesterol (HDL-C) (usually with high low-density lipoprotein cholesterol)—HDL-C less than 40 mg/dL for men or less than 50 mg/dL for women—or taking an anticholesterol drug is a sign of metabolic syndrome. Increased fasting blood glucose (caused by diabetes, glucose intolerance, or insulin resistance) is included in the constellation of metabolic syndrome. Blood pressure greater than 130/85 mm Hg or taking antihypertensive medication indicates metabolic syndrome. Although elevated homocysteine levels may predispose to atherosclerosis, they are not part of metabolic syndrome.

The nurse is caring for a patient who had hypovolemic shock secondary to trauma in the emergency department (ED) 2 days ago. Based on the pathophysiology of hypovolemia and prerenal azotemia, what does the nurse assess at least every hour? a. urinary output b. presence of edema c. urine color d. presence of pain

a. urinary output

Which intervention is most important for the nurse to teach the client with polycythemia vera to prevent injury as a result of the increased bleeding tendency? a. use a soft-bristled toothbrush b. drink at least 3 liters of liquids per day c. wear gloves and socks outdoors in cool weather d. exercise slowly and only on the advice of your physician

a. use a soft-bristled toothbrush The other interventions focus on preventing venous stasis, clot formation, and myocardial infarction. Using a soft-bristled toothbrush minimizes trauma to the gums and prevents bleeding.

A patient can develop intrarenal kidney injury from which causes? Select all that apply. a. vasculitis b. pyelonephritis c. strenuous exercise d. exposure to nephrotoxins e. bladder cancer

a. vasculitis b. pyelonephritis d. exposure to nephrotoxins

What conditions below can result in an increased cardiac afterload? Select all that apply. a. vasoconstriction b. aortic stenosis c. vasodilation d. dehydration e. pulmonary hypertension

a. vasoconstriction b. aortic stenosis e. pulmonary hypertension Vasoconstriction increases systemic vascular resistance which will increase cardiac afterload. It will increase the pressure the ventricle must pump against to open the semilunar valves to get blood out of the heart. Aortic stenosis creates an outflow of blood obstruction for the ventricle (specifically the left ventricle) and this will increase the pressure the ventricle must pump against to get blood out through the aortic valve. Pulmonary hypertension increases pulmonary vascular resistance which will increase the pressure the right ventricle must overcome to open the pulmonic valve to get blood out of the heart....all of this increase cardiac afterload.

A nurse is conducting a pre-op screening on a client preparing for a coronary artery bypass graft procedure. Which substance used by the client can indicate that the client is at higher risk of post-op bleeding? a. vitamin E supplements b. omeprazole c. loperamide d. bisacodyl

a. vitamin E supplements

Which description best defines preload? a. volume of blood returning to the heart and filling the ventricles at the end of diastole b. pressure the ventricles must press against to pump blood into the aorta c. closing of the mitral and tricuspid valves at the end of systole d. ability of the heart's muscle fibers to stretch enough to force blood into pulmonary circulation

a. volume of blood returning to the heart and filling the ventricles at the end of diastole

The nurse is assessing the endurance level of a client in a long-term care facility. What question does the nurse ask to get this information? a. "Are your feet or hands cold, even when you are in bed?" b. "Do you feel more tired after you get up and go to the bathroom?" c. "How much exercise do you get?" d. "What is your endurance level?"

b. "Do you feel more tired after you get up and go to the bathroom?" Asking about feeling tired after using the bathroom is pertinent to the client's activity and provides a comparison. The specific activity helps the client relate to the question and provide needed answers. Asking about cold feet or hands does not address the client's endurance. The hospitalized client typically does not get much exercise; this would be a difficult assessment for a client in long-term care facility to make. Asking the client about his or her endurance level is too vague; the client may not know how to answer this question.

The nurse is educating a group of young women who have sickle cell disease (SCD). Which comment from a class member requires correction? a. "Frequent handwashing is an important habit for me to develop." b. "Getting an annual 'flu shot' would be dangerous for me." c. "I must take my penicillin pills as prescribed, all the time." d. "The pneumonia vaccine is protection that I need."

b. "Getting an annual 'flu shot' would be dangerous for me." The client with SCD should receive annual influenza and pneumonia vaccinations; this helps prevent the development of these infections, which could cause a sickle cell crisis. Handwashing is a very important habit for the client with SCD to develop because it reduces the risk for infection. Prophylactic penicillin is given to clients with SCD orally twice a day to prevent the development of infection.

You're providing education to a patient about how to take their prescribed iron supplement. Which statement by the patient requires you to re-educate the patient on how to take this supplement? a. "I will take this medication on an empty stomach." b. "I will avoid taking this medication with orange juice." c. "I will wait and take my calcium supplements 2 hours after I take my iron supplement." d. "This medication can cause constipation. So, I will drink plenty of fluids and take a stool softer as needed."

b. "I will avoid taking this medication with orange juice." The patient should be encouraged to take their iron supplement with Vitamin C (hence orange juice) because Vitamin C increases the absorption of iron.

A client who recently had a heart valve replacement is taking warfarin (Coumadin) as prescribed. What statement by the client indicates that the nurse will need to do additional health teaching? a. "I will take my pulse every day, and call my doctor if it is below 60." b. "I will eat foods that are high in vitamin K, such as kale and spinach." c. "I will weigh myself every day in the morning using the same scale." d. "I will take my blood pressure every day and call if it is too high or low."

b. "I will eat foods that are high in vitamin K, such as kale and spinach." Patients taking warfarin (Coumadin) should be taught to avoid foods that are high in vitamin K, as well as herbs such as ginger, ginseng, goldenseal, Ginkgo biloba, and St. John's wort, because all of these may interfere with the drug's action. Spinach and kale are high in vitamin K.

The nurse is overseeing a nursing student who is administering medications to a group of clients with pulmonary disorders. Which statement by the student nurse indicates a correct understanding about thrombolytic therapy? a. "You will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days." b. "Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3." c. "Once the health care provider orders warfarin (Coumadin), we will discontinue the intravenous heparin." d. "If bleeding develops, we will give you platelets to reverse the anticoagulant."

b. "Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3." The international normalized ratio (INR), a measurement of anticoagulation with warfarin, is in the therapeutic range between 2 and 3. Enoxaparin (Lovenox) is a low-molecular-weight heparin that is usually given by the subcutaneous route. Heparin and warfarin are overlapped until the INR is in the therapeutic range, then the heparin can be discontinued. Fresh-frozen plasma is used as an antidote for anticoagulant therapy, not platelets.

A patient with angina is prescribed nitroglycerin tablets. What information does the nurse include when teaching the patient about this drug? Select all that apply. a. "If one tablet does not relieve the angina after 5 minutes, take two pills." b. "You can tell the pills are active when your tongue feels a tingling sensation." c. "Keep your nitroglycerin with you at all times." d. "The prescription should last about 6 months before a refill is necessary." e. "If pain doesn't go away, just wait; the medication will eventually take effect." f. "The medication can cause a temporary headache."

b. "You can tell the pills are active when your tongue feels a tingling sensation." c. "Keep your nitroglycerin with you at all times." f. "The medication can cause a temporary headache."

A client awaiting kidney transplantation states, "I can't stand this waiting for a kidney, I just want to give up." Which statement by the nurse is most therapeutic? a. "I'll talk to the health care provider and have your name removed from the waiting list." b. "You sound frustrated with the situation." c. "You're right, the wait is endless for some people." d. "I'm sure you'll get a phone call soon that a kidney is available."

b. "You sound frustrated with the situation." Acknowledging the client's frustration reflects the feelings the client is having and offers assistance and support. Talking to the health care provider and removing the client from the waiting list does not allow the nurse to hear more and perhaps offer therapeutic listening or a solution to the problem. Telling the client that the wait is endless for some people cuts the client off from sharing his or her concerns and accentuates the negative aspects of the situation. The waiting time for kidney matches is increasing due to a shortage of organs; the nurse should not offer false hope by suggesting that the client will get a phone call soon.

Select all the patients who are at MOST risk for iron-deficiency anemia: a. 55 year old male who reports taking Ferrous Sulfate regularly b. 25 year old female who was recently diagnosed with Celiac Disease c. 35 year old female who is 36 weeks pregnant that reports craving ice d. 67 year old female with a Hemoglobin level of 14

b. 25 year old female who was recently diagnosed with Celiac Disease c. 35 year old female who is 36 weeks pregnant that reports craving ice Patients who have GI issues, such as Celiac Disease, are at risk for iron-deficiency anemia due to damage to the intestines, which play a huge role in absorbing iron. In addition, females who are pregnant are at risk for this condition because of fetal demands on the body for iron. Also, this patient is craving ice which is a sign that the body is low on iron.

Which client does the nurse assign as a roommate for the client with aplastic anemia? a. 23-year-old with sickle cell disease who has two draining leg ulcers b. 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol) c. 30-year-old with leukemia who is receiving induction chemotherapy d. 34-year-old with idiopathic thrombocytopenia who is taking steroids

b. 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol) Because clients with aplastic anemia usually have low white blood cell counts that place them at high risk for infection, roommates such as the client with G6PD deficiency anemia should be free from infection or infection risk. The client with sickle cell disease has two draining leg ulcer infections that would threaten the diminished immune system of the client with aplastic anemia. The client with leukemia who is receiving induction chemotherapy and the client with idiopathic thrombocytopenia who is taking steroids are at risk for development of infection, which places the client with aplastic anemia at risk, too.

Which patient(s) are most at risk for developing coronary artery disease? Select-all-that-apply. a. 25 year old patient who exercises 3 times per week for 30 minutes a day and has a history of cervical cancer b. 35 year old male with a BMI of 30 and reports smoking 2 packs of cigarettes a day c. 45 year old female that reports her father died at the age of 42 from a myocardial infraction d. 29 year old that has type I diabetes

b. 35 year old male with a BMI of 30 and reports smoking 2 packs of cigarettes a day c. 45 year old female that reports her father died at the age of 42 from a myocardial infraction d. 29 year old that has type I diabetes

Which client needs immediate attention by the nurse? a. 40-year-old who is receiving continuous positive airway pressure and has intermittent wheezing b. 54-year-old who is mechanically ventilated and has tracheal deviation c. 57-year-old who was recently extubated and is reporting a sore throat d. 60-year-old who is receiving O2 by facemask and whose respiratory rate is 24 breaths/min

b. 54-year-old who is mechanically ventilated and has tracheal deviation The 54-year-old client is showing signs of a tension pneumothorax that could lead to decreased cardiac output and shock if not addressed promptly. The 40-year-old client has intermittent adventitious breath sounds, but is not in immediate danger or distress. The 57-year-old client has mild discomfort, but is not in danger of a life-threatening situation. The 60-year-old client has mild tachypnea, but is not in immediate distress or danger.

People should seek treatment for symptoms of MI rather than delay because physical changes will occur approximately how many hours after an infarction? a. 3 hours b. 6 hours c. 12 hours d. 24 hours

b. 6 hours

A patient reports smoking a pack of cigarettes a day for 9 years. He then quit for 2 years, and then smoked 2 packs a day for the last 30 years. What are the pack-years for this patient? a. 39 years b. 69 years c. 19.5 years d. 41 years

b. 69 years

Patients with heart failure can experience episodes of exacerbation. All of the patients below have a history of heart failure. Which of the following patients are at MOST risk for heart failure exacerbation? a. 55 year old female who limits sodium and fluid intake regularly b. 73 year old male who reports not taking Amiodarone for one month and is experiencing atrial fibrillation c. 67 year old female who is being discharged home from heart valve replacement surgery d. 78 year old male who has a health history of eczema and cystic fibrosis

b. 73 year old male who reports not taking Amiodarone for one month and is experiencing atrial fibrillation Patients who are in an arrhythmia (especially a-fib) are at risk for developing heart failure because the heart is not contracting properly and blood is pooling in the chambers.

A 74 year old female presents to the ER with complaints of dyspnea, persistent cough, and unable to sleep at night due to difficulty breathing. On assessment, you note crackles throughout the lung fields, respiratory rate of 25, and an oxygen saturation of 90% on room air. Which of the following lab results confirm your suspicions of heart failure? a. K+ 5.6 b. BNP 820 c. BUN 9 d. troponin <0.02

b. BNP 820 BNP (b-type natriuretic peptide) is a biomarker released by the ventricles when there is excessive pressure in the heart due to heart failure. <100 no failure, 100-300 present, >300 pg/mL mild, >600 pg/mL >moderate, 900 pg/mL severe.

A patient comes to the ED extremely anxious, tachycardic, struggling for air, and with a moist cough productive of frothy, blood-tinged sputum. What is the priority nursing intervention? a. apply a pulse oximeter and cardiac monitor b. administer high-flow oxygen therapy via facemask c. prepare for continuous positive airway pressure ventilation d. prepare for intubation and mechanical ventilation

b. administer high-flow oxygen therapy via facemask

Where does gas exchange occur? a. acinus b. alveolus c. bronchus d. carina

b. alveolus The alveolus is the structural unit of the lung where gas exchange occurs. The acinus is a structural unit that includes a bronchiole, an alveolar duct, and an alveolar sac. The bronchus (plural, bronchi) is similar in structure to the trachea, which allows passage of air into the lungs. The carina is the junction where the trachea branches into the left and right bronchi.

Which description best explains residual volume (RV)? a. amount of air in the lungs at the end of maximal inhalation b. amount of air remaining in lungs at the end of full forced exhalation c. amount of air remaining in the lungs after normal exhalation d. maximal amount of forced air that can be exhaled after maximal inspiration

b. amount of air remaining in lungs at the end of full forced exhalation

Which statement below best describes the term cardiac preload? a. pressure the ventricles stretch at the end of systole b. amount the ventricles stretch at the end of diastole c. pressure the ventricles must work against to pump blood out of the heart d. strength of the myocardial cells to shorten with each beat

b. amount the ventricles stretch at the end of diastole Cardiac preload is the amount the ventricles stretch at the end of diastole (the filling or relaxation phase of the heart).

The nurse is caring for a group of clients who have sustained myocardial infarction (MI). The nurse observes the client with which type of MI most carefully for the development of left ventricular heart failure? a. inferior wall b. anterior wall c. lateral wall d. posterior wall

b. anterior wall Due to the large size of the anterior wall, the amount of tissue infarction may be large enough to decrease the force of contraction, leading to heart failure. The client with an inferior wall MI is more likely to develop right ventricular heart failure. Clients with obstruction of the circumflex artery may experience a lateral wall MI and sinus dysrhythmias or a posterior wall MI and sinus dysrhythmias.

A ventilated client in the intensive care unit (ICU) begins to pick at the bedcovers. Which action should the nurse take next? a. increase the sedation b. assess for adequate oxygenation c. explain to the client that he has a tube in his throat to help him breathe d. request that the family leave to decrease the client's agitation

b. assess for adequate oxygenation Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia. Increasing sedation is not indicated for this client and may mask symptoms such as hypoxemia or worsening respiratory failure. Although the nurse may explain to the client that he or she is intubated, it does not take priority over assessing for hypoxemia. The presence of family members may decrease the chances of "ICU psychosis" and anxiety, but it does not take priority over assessing for hypoxemia.

The nurse coming on shift prepares to perform an initial assessment of a sedated, ventilated client. Which are priorities for the nurse to carry out? Select all that apply. a. ask visitors to leave b. assess the client's color and respirations c. confirm alarms and ventilator settings d. ensure that the tube cuff is inflated and is in the proper position e. listen for bilateral breath sounds f. provide routine tracheotomy and endotracheotomy and mouth care

b. assess the client's color and respirations c. confirm alarms and ventilator settings d. ensure that the tube cuff is inflated and is in the proper position e. listen for bilateral breath sounds The first priority when caring for a critically ill client is to assess airway and breathing. Alarm settings should be confirmed each shift, more frequently if necessary. Confirming that the client cannot speak ensures that air is going through the endotracheal tube and not around it. Auscultating for equal bilateral breath sounds assists in confirming that the tube is above the carina. Having visitors remain with the client may promote comfort and prevent confusion. Routine tracheostomy care is performed according to schedule, not necessarily as part of an initial assessment.

You are assisting a patient up from the bed to the bathroom. The patient has swelling in the feet and legs. The patient is receiving treatment for heart failure and is taking Hydralazine and Isordil. Which of the following is a nursing priority for this patient while assisting them to the bathroom? a. measure and record the urine voided b. assist the patient up slowing and gradually c. place the call light in the patient's reach while in the bathroom d. provide privacy for the patient

b. assist the patient up slowing and gradually All the options are important for the nurse to perform. However, Hydralazine (vasodilator) and Isordil (nitrate) can cause orthostatic hypotension. The patient should transfer slowly and gradually to decrease dizziness and the risk of falling.

A 77-year-old patient is suffering from heart failure. The nurse has given him a nursing diagnosis of Fluid Volume Excess related to heart failure as evidenced by weight gain and peripheral edema. Which of the following interventions should the nurse employ with this nursing diagnosis? a. onitor the patients intake and output every 24 hours b. auscultate breath sounds at least every 2 hours c. place the patient on a low-magnesium diet d. keep the patients legs in the dependent position

b. auscultate breath sounds at least every 2 hours Fluid volume excess develops when the patient has excess circulating volume in the bloodstream or the body is retaining enough fluid that the excess is in the tissues outside of circulation. It may be manifested by such signs or symptoms as swelling, wet breath sounds, and weight gain. Nursing interventions include reducing edema, checking breath sounds regularly for changes, and monitoring intake and output at least every 4 hours. Placing the legs in the dependent position would allow for further fluid accumulation in the extremities.

When caring for a client with a left forearm arteriovenous fistula created for hemodialysis, which actions must the nurse take? Select all that apply. a. check brachial pulses daily b. auscultate for a bruit every 8 hours c. teach the client to palpate for a thrill over the site d. elevate the arm above heart level e. ensure that no blood pressures are taken in that arm

b. auscultate for a bruit every 8 hours c. teach the client to palpate for a thrill over the site e. ensure that no blood pressures are taken in that arm A bruit or swishing sound, and a thrill or buzzing sensation upon palpation should be present in this client, indicating patency of the fistula. No blood pressure, venipuncture, or compression, such as lying on the fistula, should occur. Distal pulses and capillary refill should be checked, and for a forearm fistula, the radial pulse is checked—the brachial pulse is proximal. Elevating the arm increases venous return, possibly collapsing the fistula.

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 does the nurse take first? a. assess the client for peripheral edema b. auscultate the client's posterior breath sounds c. notify the health care provider about the client's weight gain d. remind the client about dietary sodium restrictions

b. auscultate the client's posterior breath sounds Because the client is at risk for pulmonary edema and hypoxemia, the first action should be to assess breath sounds. Assessment of edema may be delayed until after breath sounds are assessed. After a full assessment, the nurse should notify the health care provider. After physiologic stability is attained, then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.

The night shift nurse sees a patient with kidney failure sitting up in bed. The patient states, "I feel a little short of breath at night or when I get up to walk to the bathroom." What assessment does the nurse do? a. check for orthostatic hypotension because of potential volume depletion b. auscultate the lungs for crackles, which indicate fluid overload c. check the pulse and blood pressure for possible decreased cardiac output d. assess for normal sleep pattern and need for a prn sedative

b. auscultate the lungs for crackles, which indicate fluid overload

Which medication, when given in heart failure, may improve morbidity and mortality? a. dobutamine (Dobutrex) b. carvedilol (Coreg) c. digoxin (Lanoxin) d. bumetanide (Bumex)

b. carvedilol (Coreg) Beta-adrenergic blocking agents such as carvedilol reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure; this category of pharmacologic agents improves morbidity, mortality, and quality of life. Dobutamine and digoxin are inotropic agents used to improve myocardial contractility but have not been directly associated with improving morbidity and mortality. Bumetanide is a high-ceiling diuretic that promotes fluid excretion; it does not improve morbidity and mortality.

Postrenal kidney injury can result from which conditions? Select all that apply. a. septic shock b. cervical cancer c. nephrolithiasis or ureterolithiasis d. heart failure e. neurogenic bladder f. prostate cancer

b. cervical cancer c. nephrolithiasis or ureterolithiasis e. neurogenic bladder f. prostate cancer

The home health nurse receives a call from a patient with CAD who reports having new onset of chest pain and shortness of breath. What does the nurse instruct the patient to do? a. rest quietly until the nurse can arrive at the house to check the patient. b. chew 325 mg of aspirin and immediately call 911 c. use supplemental home oxygen until symptoms resolve d. take three nitroglycerin tablets and have family drive the patient to the hospital

b. chew 325 mg of aspirin and immediately call 911

When the above patient, Mrs. Jones, has an exacerbation of her heart failure, she develops jugular venous distention (JVD), peripheral edema, and abdominal discomfort. These are clinical signs specific to: a. acute left ventricular failure b. chronic left right ventricular failure c. acute right ventricular failure d. chronic dehydration

b. chronic left right ventricular failure

The nurse in the coronary care unit is caring for a group of clients who have had myocardial infarction. Which client does the nurse see first? a. client with dyspnea on exertion when ambulating to the bathroom b. client with third-degree heart block on the monitor c. client with normal sinus rhythm and PR interval of 0.28 second d. client who refuses to take heparin or nitroglycerin

b. client with third-degree heart block on the monitor Third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system are involved, so the client with the third-degree heart block should be seen first. Third-degree heart block usually requires pacemaker insertion. A normal rhythm with prolonged PR interval indicates first-degree heart block, which usually does not require treatment. The client with dyspnea on exertion when ambulating to the bathroom is not at immediate risk. The client's uncooperative behavior when refusing to take heparin or nitroglycerin may indicate fear or denial; he should be seen after emergency situations have been handled.

A client who has been admitted for the third time this year for heart failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? a. calls the family to lift the client's spirits b. considers further assessment for depression c. sedates the client to decrease myocardial oxygen demand d. tells the client that things will get better

b. considers further assessment for depression This client is at risk for depression because of the diagnosis of heart failure, and further assessment should be done. Calling the family to help distract the client does not address the core issue. Sedation is inappropriate in this situation because it ignores the client's feelings. Telling the client that things will get better may give the client false hope, and ignores the client's feelings.

Which components belong to the ventilator bundle approach to prevent ventilator-associated pneumonia (VAP)? Select all that apply. a. administering antibiotic prophylaxis b. continuous removal of subglottic secretions c. elevating the head of the bed at least 30 degrees whenever possible d. handwashing before and after contact with the client e. placing a nasogastric tube f. placing the client in a negative-airflow room

b. continuous removal of subglottic secretions c. elevating the head of the bed at least 30 degrees whenever possible d. handwashing before and after contact with the client Continuous removal of subglottic secretions, elevating the head of the bed at least 30 degrees whenever possible, and handwashing before and after contact with a client are all part of a VAP bundle. Antibiotics are not given prophylactically; they are given on the basis of cultures to prevent an increase in drug-resistant organisms. A nasogastric tube is not part of the VAP bundle. If a client is going to be mechanically ventilated for a prolonged period of time, postpyloric or gastrostomy tubes are preferred over nasogastric tubes for nutrition. Placing a client in a negative-airflow room is not part of the VAP bundle. The client does not require this room.t

The nurse is concerned that a client who had myocardial infarction (MI) has developed cardiogenic shock. Which findings indicate shock? Select all that apply. a. bradycardia b. cool, diaphoretic skin c. crackles in the lung fields d. respiratory rate of 12 breaths/min e. anxiety and restlessness f. temperature of 100.4° F

b. cool, diaphoretic skin c. crackles in the lung fields e. anxiety and restlessness The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles. Because of poor tissue perfusion, a change in mental status, anxiety, and restlessness are expected. All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea. Cardiogenic shock does not present with low-grade fever; this would be more likely to occur in pericarditis.

A client is diagnosed with left-sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply. a. peripheral edema b. crackles in both lungs c. breathlessness d. ascites e. tachypnea

b. crackles in both lungs c. breathlessness e. tachypnea Clients with left-sided heart failure will exhibit symptoms such as fatigue, dyspnea or breathlessness, and crackles on auscultation of breath sounds. Peripheral edema and ascites are associated with right-sided heart failure.

The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure? a. urine output of 1500 mL on the preceding day b. crackles in the lung fields c. pedal edema d. expectoration of yellow sputum

b. crackles in the lung field Manifestations of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields. A urine output of 1500 mL is normal. Edema is a sign of right ventricular heart failure. Yellow sputum indicates the presence of white blood cells and possible infection.

Which signs and symptoms indicate rejection of a transplanted kidney? Select all that apply. a. blood urea nitrogen (BUN) 21 mg/dL, creatinine 0.9 mg/dL b. crackles in the lung fields c. temperature of 98.8° F (37.1° C) d. blood pressure of 164/98 mm Hg e. 3+ edema of the lower extremities

b. crackles in the lung fields d. blood pressure of 164/98 mm Hg e. 3+ edema of the lower extremities Signs and symptoms of fluid retention (e.g., crackles in the lung fields and 3+ edema of the lower extremities) indicate transplant rejection. Increased blood pressure is also a symptom of transplant rejection. Increasing BUN and creatinine are symptoms of rejection; a BUN of 21 mg/dL and a creatinine of 0.9 mg/dL reflect normal values. Fever, not normothermia, is symptomatic of transplant rejection.

Your patient has suffered an acute kidney injury. Which of the following nursing interventions are important for this patient? Select all that apply. a. 1 gm NaCl tabs q6hrs b. daily weights c. head CT with contrast d. monitor I&O e. fluid restriction

b. daily weights d. monitor I&O e. fluid restriction

Which aspect of PFTs would be considered a normal result in the older adult? a. increased forced vital capacity b. decline in forced expiratory volume in 1 second c. decrease in diffusion capacity of carbon monoxide d. increased functional residual capacity

b. decline in forced expiratory volume in 1 second

A patient has a blood pressure of 220/140. The physician prescribes a vasodilator. This medication will? a. decrease the patient's blood pressure and increase cardiac afterload b. decrease the patient's blood pressure and decrease cardiac afterload c. decrease the patient's blood pressure and increase cardiac preload d. increase the patient's blood pressure but decrease cardiac output

b. decrease the patient's blood pressure and decrease cardiac afterload The patient has a high systemic vascular resistance...as evidence by the patient's blood blood....there is vasoconstriction and this is resulting in the high blood pressure. Therefore, right now, the cardiac afterload is high because the ventricle must overcome this high pressure in order to pump blood out of the heart. If a vasodilator is given, it will decrease the blood pressure (hence the systemic vascular resistance) and this will decrease the cardiac afterload. The amount of the pressure the ventricle must pump against will decrease (cardiac afterload decrease) because the blood pressure will go down (hence the systemic vascular resistance).

A nurse must position the patient prone after his diagnosis of acute respiratory distress syndrome (ARDS). Which of the following is a benefit of using this position? Select all that apply. a. reduced need for endotracheal intubation b. decreased atelectasis c. mobilization of secretions d. increased response to corticosteroid therapy e. decreased pleural pressure

b. decreased atelectasis c. mobilization of secretions e. decreased pleural pressure

The blood of a client who has chronic myelogenous leukemia shows a high percentage of blast cells and promyelocytes. What is the nurse's correct interpretation of this test result? a. client's risk for infection is decreasing b. disease has become more aggressive c. drug therapy for the disease is effective d. type of leukemia is now lymphocytic rather than myelogenous

b. disease has become more aggressive The leukemia is progressing and the drug therapy is no longer effective. CML has three phases: The chronic phase is often a slowly progressing (indolent) course during which the patient may have mild symptoms and respond to standard treatments. The bone marrow usually shows less than 10% blast cells at this time. The accelerated phase features spleen enlargement and progressive manifestation, such as intermittent fevers, night sweats, and unexplained weight loss. The patient usually does not respond to standard treatment, and the bone marrow may contain 10% to 30% blast cells and promyelocytes. The blast phase indicates transformation to a very aggressive acute leukemia. The bone marrow contains more than 30% blast cells. The promyelocytes and blast cells commonly spread to other tissues and organs. The leukemia becomes more similar to acute leukemia than chronic leukemia but does not change from myelogenous to lymphocytic. With so many blast cells that are immature and do not function properly, the client is now at greatly increased risk for infection.

What type of chest tube system does this statement describe? This chest drainage system has no water column to control suction but uses a suction monitor bellow that balances the wall suction and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems. a. mediastinal chest tube system b. dry suction chest tube system c. wet suction chest tube system d. dry-Wet suction chest tube system

b. dry suction chest tube system

Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? Select all that apply. a. sharp, inspiratory chest pain b. dyspnea c. dizziness d. extreme fatigue e. anorexia

b. dyspnea c. dizziness d. extreme fatigue Many women who experience an MI present with dyspnea, light-headedness, and fatigue. Sharp, pleuritic pain is more consistent with pericarditis or pulmonary embolism. Anorexia is neither a typical nor an atypical sign of MI.

What are the typical clinical manifestations of anemia? Select all that apply. a. decreased breath sounds b. dyspnea on exertion c. elevated temperature d. fatigue e. pallor f. tachycardia

b. dyspnea on exertion d. fatigue e. pallor f. tachycardia Difficulty breathing—especially with activity—is common with anemia. Lower levels of hemoglobin carry less O2 to the cells of the body. Fatigue is a classic symptom of anemia; lowered O2 levels contribute to a faster pulse (i.e., cardiac rate) and tend to "wear out" a client's energy. Lowered O2 levels deliver less oxygen to all cells, making clients with anemia pale—especially their ears, nail beds, palms, and conjunctivae and around the mouth. Respiratory problems with anemia do not include changes in breath sounds; dyspnea and decreased oxygen saturation levels are present. Skin is cool to the touch, and an intolerance to cold is noted; elevated temperature would signify something additional, such as infection.

The nurse is assessing a middle-aged woman with diabetes who denies any history of known heart problems. However, on auscultation of the heart the nurse hears an S4 heart sound. The nurse alerts the physician and obtains an order for which diagnostic test? a. blood glucose level b. electrocardiogram c. chest x-ray d. echocardiogram

b. electrocardiogram

A patient taking Zocor is reporting muscle pain. You are evaluating the patient's lab work and note that which of the following findings could cause muscle pain? a. elevated potassium level b. elevated CPK (creatine kinase level) c. decreased potassium level d. decreased CPK (creatine kinase level)

b. elevated CPK (creatine kinase level) Zocor (a statin medication used for lowering cholestorl) can cause increased CPK levels which will lead to a patient experiencing muscle pain. Therefore, CPK levels must be monitored while a patient is taking this medication.

The nurse hears fine crackles during a lung assessment of the patient who is in the initial postoperative period. Which nursing intervention helps relieve this respiratory problem? a. monitor the patient with a pulse oximeter b. encourage coughing and deep-breathing c. obtain an order for a chest x-ray d. obtain an order for high-flow oxygen

b. encourage coughing and deep-breathing

The nurse is caring for a patient with an arteriovenous fistula. What is included in the nursing care for this patient? Select all that apply. a. keep small clamps handy by the bedside b. encourage routine range-of-motion exercises c. avoid venipuncture or IV administration on the arm with the access device d. instruct the patient to carry heavy objects to build muscular strength e. assess for manifestations of infection of the fistula f. instruct the patient to sleep on the side with the affected arm in the dependent position

b. encourage routine range-of-motion exercises c. avoid venipuncture or IV administration on the arm with the access device e. assess for manifestations of infection of the fistula

In assessing the client's respiratory status, arterial blood gas (ABG) test results reveal pH of 7.50, PaO2 of 99 mm Hg, PaCO2 of 29 mm Hg, and HCO3- of 22 mEq/L. What action does the nurse need to take first? a. call the health care provider b. encourage the client to slow his breathing rate c. nothing; these results are within the normal range d. provide oxygen support

b. encourage the client to slow his breathing rate The ABGs indicate respiratory alkalosis, which is commonly caused by hyperventilation; encouraging the client to slow down his breathing rate may help the client return to normal breathing and may correct this abnormality. This situation is not an emergency condition and does not require that the health care provider be called or that oxygen be given. The client's PaO2 is within normal limits, but it is important for the nurse to assess the client and not just look at the numbers.

The nurse is caring for an older adult who uses a wheelchair and spends over half of each day in bed. Which intervention is important in promoting pulmonary hygiene related to age and decreased mobility? a. obtain an order for prn (as-needed) oxygen via nasal cannula b. encourage the patient to turn, cough, and deep-breathe c. reassure the patient that immobility is temporary d. monitor the respiratory rate and check pulse oximetry readings

b. encourage the patient to turn, cough, and deep-breathe

Which intervention most effectively protects a client with thrombocytopenia? a. avoiding the use of dentures b. encouraging the use of an electric shaver c. taking rectal temperatures d. using warm compresses on trauma sites

b. encouraging the use of an electric shaver The client with thrombocytopenia should be advised to use an electric shaver instead of a razor. Any small cuts or nicks can cause problems because of the prolonged clotting time. Dentures may be used by clients with thrombocytopenia as long as they fit properly and do not rub. To prevent rectal trauma, rectal thermometers should not be used. Oral or tympanic temperatures should be taken. Ice (not heat) should be applied to areas of trauma.

The nurse is caring for a client with congestive heart failure. This client regularly takes a vasodilator. The nurse understands that this type of drug helps congestive heart failure in what ways? Select all that apply. a. increase blood pressure b. enhance skeletal muscle circulation c. increase cardiac preload d. dilate the kidney's arterioles e. reduce cardiac afterload

b. enhance skeletal muscle circulation c. increase cardiac preload e. reduce cardiac afterload

Which is an example of third-hand passive smoking? a. sitting in a car with a person who is smoking b. exposure to smoke on the clothes of a smoker c. walking through a group of people smoking outside d. entering a room where several people have been smoking

b. exposure to smoke on the clothes of a smoker

After thrombolytic therapy, the nurse working in the cardiac catheterization laboratory would be alarmed to notice which sign? a. 1-inch backup of blood in the IV tubing b. facial drooping c. partial thromboplastin time (PTT) 68 seconds d. report of chest pressure during dye injection

b. facial drooping During and after thrombolytic administration, the nurse observes for any indications of bleeding, including changes in neurologic status, which may indicate intracranial bleeding. A 1-inch backup of blood in the IV tubing may be related to IV positioning. If heparin is used, PTT reflects a therapeutic value. Reports of chest pressure during dye injection or stent deployment are considered an expected result of the procedure.

As a patient with ESKD experiences isosthenuria, what must the nurse be alert for? a. diuretic stage b. fluid volume overload c. dehydration d. alkalosis

b. fluid volume overload

The nurse is caring for a client with sickle cell disease. Which action is most effective in reducing the potential for sepsis in this client? a. administering prophylactic drug therapy b. frequent and thorough handwashing c. monitoring laboratory values to look for abnormalities d. taking vital signs every 4 hours, day and night

b. frequent and thorough handwashing Prevention and early detection strategies are used to protect the client in sickle cell crisis from infection. Frequent and thorough handwashing is of the utmost importance. Drug therapy is a major defense against infections that develop in the client with sickle cell disease, but is not the most effective way that the nurse can reduce the potential for sepsis. Continually assessing the client for infection and monitoring the daily complete blood count with differential white blood cell count is early detection, not prevention. Taking vital signs every 4 hours will help with early detection of infection, but is not prevention.

Your patient has been diagnosed with heart failure. During your assessment you note that the patient has pitting edema, shortness of breath and which heart sound? a. rubbing b. gallop c. swooshing d. clicking

b. gallop When listening to heart sounds, if you hear a rubbing noise, it means there is inflammation in the pericardium (pericarditis). Clicks are often heard with mitral valve prolapse or aortic stenosis (and also someone with a prosthetic valve). Murmurs make a swooshing sound. If you hear a gallop sound (S3) you are hearing the blood prematurely rushing into the ventrical which can be from either pulmonary hypertension, heart failure or coronary artery disease.

A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-all-that-apply. a. educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed b. gather supplies needed which will include a petroleum gauze dressing per physician preference c. place the patient in Semi-Fowler's position d. have the patient take a deep breath, exhale, and bear down during removal of the tube e. pre-medicate prior to removal as ordered by the physician f. place the patient is prone position after removal

b. gather supplies needed which will include a petroleum gauze dressing per physician preference c. place the patient in Semi-Fowler's position d. have the patient take a deep breath, exhale, and bear down during removal of the tube e. pre-medicate prior to removal as ordered by the physician

A patient with pericarditis is being evaluated for dizziness and shortness of breath. His heart rate on the monitor demonstrates supraventricular tachycardia. Which of the following interventions is most appropriate in this situation? a. administer a vasopressor medication, such as epinephrine b. have the patient perform the Valsalva maneuver c. give the patient 8 oz. of water to drink d. start CPR at a rate of 100 compressions per minute

b. have the patient perform the Valsalva maneuver Supraventricular tachycardia (SVT) is a type of cardiac arrhythmia in which the heart beats rapidly. The rhythm originates in the atria of the heart and can cause a heart rate of up to 300 bpm. The patient becomes lightheaded and dizzy because his heart is not effectively pumping blood due to the rapid rate. The initial method of management is to ask the patient to "bear down", known as the Valsalva maneuver. The maneuver can also be achieved by having the patient close their mouth, pinch their nose and blow against closed airways. This causes increased intrathoracic pressure, blood pressure and heart rate shifts, and may convert the arrhythmia back into a normal rhythm.

A 60-year-old African-American client is newly diagnosed with mild chronic kidney disease (stage 2 CKD). She has a history of diabetes, and her current A1C is 8.0%. She asks the nurse whether any of the following factors could have caused this problem. Which factor should the nurse indicate may have influenced the development of CKD? a. she heavily salted her food as a child and teenager but added no extra salt to her food as an adult b. her chronic hyperglycemia caused blood vessel changes in the kidney that can damage kidney tissue c. her paternal grandparents had type 2 diabetes and hypertension d. she drinks 2 cups of coffee water daily

b. her chronic hyperglycemia caused blood vessel changes in the kidney that can damage kidney tissue Diabetic nephropathy is the most common cause of end-stage renal disease (ESRD) needing dialysis. Managing hyperglycemia delays the onset and progression of CKD. This level of caffeine intake would not lead to either kidney damage or hypertension. The fact that she has reduced her salt intake during adulthood would only help prevent hypertensive kidney disease. The family history of type 2 diabetes and hypertension is a potential risk factor, but her own diabetes and lack of glycemic control manifested by the elevated A1C have a more direct and great adverse effect on kidney function.

A 32-year-old client is recovering from a sickle cell crisis. His discomfort is controlled with pain medications and he is to be discharged. What medication does the nurse expect to be prescribed for him before his discharge? a. heparin (Heparin) b. hydroxyurea (Droxia) c. tissue plasminogen activator (t-PA) d. warfarin (Coumadin)

b. hydroxyurea (Droxia) Hydroxyurea (Droxia) has been used successfully to reduce sickling of cells and pain episodes associated with sickle cell disease (SCD). Clients with SCD are not prescribed anticoagulants such as heparin or warfarin (Coumadin). t-PA is used as a "clot buster" in clients who have had ischemic strokes.

The nurse is transfusing 2 units of packed red blood cells to a postoperative client. What post-transfusion electrolyte imbalance does the nurse want to rule out? a. hypercalcemia b. hyperkalemia c. hypomagnesemia d. hyponatremia

b. hyperkalemia During transfusion, some cells are damaged. These cells release potassium, thus raising the client's serum potassium level (hyperkalemia). This complication is especially common with packed cells and whole-blood products. High serum calcium levels, low magnesium levels, or low sodium levels are not expected with blood transfusions.

Mr. B., a 67-year-old, is admitted with a diagnosis of COPD and left upper lobe pneumonia, which has been confirmed with a chest x-ray. He has the following arterial blood gas results pH 7.35 O2 62 mmHg CO2 59 mmHg HCO3 32 mEq/L Upon percussing the lungs of Mr. B., the nurse may find: a. clear undiminished bilateral breath sounds b. hyperresonance with air trapping c. pleural friction rub d. audible split S3

b. hyperresonance with air trapping

The physician orders a patient with suspected iron-deficiency anemia a blood smear test to assess the quality of the red blood cells. How would the red blood cells appear if the patient had iron- deficiency anemia? a. hyperchromic and macrocytic b. hypochromic and microcytic c. hyperchromic and macrocytic d. hypochromic and macrocytic

b. hypochromic and microcytic The RBCs would appear pale (hypochromic) and small (microcytic).

The nurse is reviewing a patient's laboratory results. In the early phase of CKD, the patient is at risk for which electrolyte abnormality? a. hyperkalemia b. hyponatremia c. hypercalcemia d. hypokalemia

b. hyponatremia

The client with which condition is in greatest need of immediate intubation? a. difficulty swallowing oral secretions b. hypoventilation and decreased breath sounds c. O2 saturation of 90% d. thick, purulent secretions and crackles

b. hypoventilation and decreased breath sounds Intubation may be indicated for the client who is hypoventilating and has decreased breath sounds. Suctioning, rather than intubation, is indicated for difficulty swallowing secretions, as well as for thick, purulent secretions and crackles (consistent with pneumonia). Intubation is indicated for the client with an O2 saturation of less than 90% and other symptoms of hypoxemia or hypercarbia.

What are common causes of prerenla kidney injury? Select all that apply. a. urethral cancer b. hypovolemic shock c. enlarged prostate gland d. sepsis e. severe burns

b. hypovolemic shock d. sepsis e. severe burns

The client returns to the medical unit after a therapeutic bronchoscopy. Which intervention does the nurse apply first? a. assess the puncture site for drainage b. implement nothing-by-mouth (NPO) status c. monitor for signs of anaphylaxis d. perform aggressive chest physiotherapy

b. implement nothing-by-mouth (NPO) status Until the client has a gag reflex and is fully alert, he or she should be maintained on NPO status to prevent aspiration. No external puncture site is needed for bronchoscopy. Although the client will have received medications during the bronchoscopy, an anaphylactic reaction will occur immediately, not in a client who has returned to the medical unit. Aggressive chest physiotherapy is not indicated in a client who has had a bronchoscopy and may cause bleeding if biopsies have been obtained.

The nurse requests a dietary consult to address the patient's high rate of catabolism. Which nutritional element is directly related to this metabolic process? a. carbohydrates b. inability to excrete excess electrolytes c. conversion of body fat into glucose d. presence of retained nitrogenous wastes

b. inability to excrete excess electrolytes

A patient with hypovolemic shock is given IV fluids. IV fluids will help _________ cardiac output by: a. decrease; decreasing preload b. increase, increasing preload c. increase, decreasing afterload d. decrease, increasing contractility

b. increase, increasing preload IV fluids will increase venous return to the heart. This will increase the amount of fluid that will fill the ventricles at the end of diastole...hence increasing preload and increasing cardiac output.

As a result of kidney failure, excessive hydrogen ions cannot be excreted. With acid retention, the nurse is most likely to observe what type of respiratory compensation? a. cheyne-stokes respiratory pattern b. increased depth of breathing c. decreased respiratory rate and depth d. increased arterial carbon dioxide levels

b. increased depth of breathing

In which situation would the oxygen dissociation curve shift to the left? a. decreased pH (acidosis) b. increased pH (alkalosis) c. increased body temperature d. increased body carbon dioxide concentration

b. increased pH (alkalosis)

A client has been admitted for a pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? a. teach the client to avoid using dental flos b. monitor the platelet count daily c. ensure adequate staffing for the unit d. notify radiology of an impending scan

b. monitor the platelet count daily Daily platelet counts are a safety priority in assessing for thrombocytopenia; heparin-induced thrombocytopenia is a possible side effect. Avoiding the use of dental floss is important during anticoagulation therapy, but it is not the priority. Adequate staffing and notifying radiology are not the priority.

A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? a. administers oxygen therapy b. obtains the client's description of the chest discomfort c. provides pain relief medication d. remains calm and stays with the client

b. obtains the client's description of the chest discomfort A description of the chest discomfort must be obtained first, before further action can be taken. Neither oxygen therapy nor pain medication is the first priority in this situation; an assessment is needed first. Remaining calm and staying with the client are important, but are not matters of highest priority.

When caring for a client with pulmonary embolism (PE), which arterial blood gas results does the nurse anticipate early in the course of the disease? a. pH 7.24, PaCO2 55 mm Hg, HCO3- 26 mEq/L, PaO2 56 mm Hg b. pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L, PaO2 68 mm Hg c. pH 7.35, PaCO2 45 mm Hg, HCO3- 24 mEq/L, PaO2 80 mm Hg d. pH 7.47, PaCO2 35 mm Hg, HCO3- 30 mEq/L, PaO2 75 mm Hg

b. pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L, PaO2 68 mm Hg Hyperventilation triggered by hypoxia and pain first leads to respiratory alkalosis, indicated by a low partial pressure of arterial carbon dioxide (PaCO2 of 30 mm Hg) and a high pH (7.46). No compensation is present as the bicarbonate (HCO3-) (26 mEq/L) is normal, and hypoxemia is present, consistent with PE. A pH of 7.24 is acidotic, a partial pressure of arterial oxygen (PaO2) of 56 mm Hg reflects hypoxemia, and no compensation is present with a normal HCO3- (26 mEq/L); this blood would be found in a person in acute respiratory failure owing to hypoventilation and hypoxemia. A pH between 7.35 and 7.45, PaCO2 of 35 to 45 mm Hg, HCO3- of 22 to 26 mEq/L, and PaO2 greater than 75 mm Hg all reflect normal blood gas results. A pH of 7.47 and an HCO3- of 30 mEq/L are alkalotic, indicating metabolic alkalosis; a PaCO2 of 35 mm Hg is normal (indicating lack of compensation) and a PaO2 of 75 mm Hg is normal.

Prompt pain management with myocardial infarction is essential for which reason? a. discomfort will increase client anxiety and reduce coping b. pain relief improves oxygen supply and decreases oxygen demand c. relief of pain indicates that the MI is resolving d. pain medication should not be used until a definitive diagnosis has been established

b. pain relief improves oxygen supply and decreases oxygen demand The focus of pain relief is on reducing myocardial oxygen demand. Chest discomfort will increase anxiety, but it may not affect coping. Relief of pain is secondary to the use of opiates or indicates that the tissue infarction is complete. Although it used to be true that pain medication was not to be used for undiagnosed abdominal pain, this does not relate to MI.

Select ALL the signs and symptoms that can present in pernicious anemia: a. erythema b. paresthesia of hands and feet c. racing thoughts d. extreme hunger e. depression f. unsteady gait g. shortness of breath with activity

b. paresthesia of hands and feet e. depression f. unsteady gait g. shortness of breath with activity

Before a bronchoscopy procedure, the patient received benzocaine spray as a topical anesthetic to numb the oropharynx. The nurse is assessing the patient after the procedure. Which finding suggests that the patient is developing methemoglobinemia? a. patient has a decreased hematocrit level b. patient does not respond to supplemental oxygen c. blood sample is a bright cherry-red color d. patient experiences sedation and amnesia

b. patient does not respond to supplemental oxygen

The nurse is assessing a patient's extremity with an areriovenous graft. The nurse notes a thrill and a bruit, and the patient reports numbness and a cool feeling in the fingers. How does the nurse interpret this information in regard to the graft? a. graft is functional and these symptoms are expected b. patient has "steal syndrome" and may need surgical intervention c. graft is patent, but the blood is flowing in the wrong direction d. patient needs to increase active use of hands and fingers

b. patient has "steal syndrome" and may need surgical intervention

The nurse reads in the patient's chart that he has acute-on-chronic kidney disease. How does the nurse interpret this information? a. kidney disease has progressed to the need for dialysis or transplant b. patient has chronic kidney disease and has sustained an acute kidney injury c. acute kidney injury requires aggressive management to prevent chronic disease d. condition could by acute or chronic; further diagnostic testing is needed

b. patient has chronic kidney disease and has sustained an acute kidney injury

During an annual physical exam, a patient receives an ECG and has an abnormal Q wave in several leads. What is the nurse's best interpretation of this result? a. patient is experiencing a silent MI b. patient has experienced an MI in the past c. patient is having an acute MI at the moment d. patient is experiencing ischemia at the moment

b. patient has experienced an MI in the past

A patient with prerenal azotemia is administered a fluid challenge. In evaluating response to the therapy, which outcome indicates that the goal was met? a. patient reports feeling better and indicates an eagerness to go home b. patient produces urine soon after the initial bolus c. therapy is completed without adverse effects d. health care provider orders a diuretic when the challenge is completed

b. patient produces urine soon after the initial bolus

Which patients are likely to be excluded from receiving a transplant? Select all that apply. a. patient who had breast cancer 6 years ago b. patient with advanced and uncorrectable heart disease c. patient with a chemical dependency d. patient who is 70 years old and has a living related donor e. patient with diabetes mellitus

b. patient with advanced and uncorrectable heart disease c. patient with a chemical dependency

Select all the correct statements about educating the patient with heart failure. a. it is important patients with heart failure notify their physician if they gain more than 6 pounds in a day or 10 pounds in a week b. patients with heart failure should receive an annual influenza vaccine and be up-to-date with the pneumonia vaccine c. heart failure patients should limit sodium intake to 2-3 grams per day d. heart failure is exacerbated by illness, too much fluid or sodium intake, and arrhythmias e. patients with heart failure should limit exercise because of the risks

b. patients with heart failure should receive an annual influenza vaccine and be up-to-date with the pneumonia vaccine c. heart failure patients should limit sodium intake to 2-3 grams per day d. heart failure is exacerbated by illness, too much fluid or sodium intake, and arrhythmias

Which of the following are NOT typical signs and symptoms of right-sided heart failure? Select-all-that-apply. a. jugular venous distention b. persistent cough c. weight gain d. crackles e. nocturia f. orthopnea

b. persistent cough d. crackles f. orthopnea Persistent cough, crackles (also called rales), and orthopnea are signs and symptoms of LEFT-sided heart failure...not right-sided heart failure.

7. While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention? a. stay with the patient and monitor their vital signs while another nurse notifies the physician b. place a sterile dressing over the site and tape it on three sides and notify the physician c. attempt to re-insert the tube d. keep the site open to air and notify the physician

b. place a sterile dressing over the site and tape it on three sides and notify the physician

A patient comes to the walk-in clinic reporting left anterior chest discomfort with mild shortness of breath. The patient is alert, oriented, diaphoretic, and anxious. What is the priority action for the nurse? a. obtain a complete cardiac history to include a full description of the presenting symptoms b. place the patient in Fowler's position and start supplemental oxygen c. instruct the patient to go immediately to the closest full-service hospital d. immediately alert the physician and establish IV access

b. place the patient in Fowler's position and start supplemental oxygen

A patient with CKD is restless, anxious, and short of breath. The nurse hears crackles that begin at the base of the lungs. The pulse rate is increased and the patient has frothy, blood-tinged sputum. What does the nurse do first? a. facilitate transfer to the ICU for aggressive treatment b. place the patient in a high-Fowler's position c. continue to monitor vital signs and assess breath sounds d. administer a loop diuretic such as furosemide (Lasix)

b. place the patient in a high-Fowler's position

Which statement about CAD is accurate? a. ischemia that occurs with angina lasts more than 30 minutes and does not cause permanent damage of myocardial tissue b. postmenopausal women in their 70s have the same incidence of MI as men c. many patients suffering sudden cardiac arrest die before reaching the hospital due to atrial fibrillation d. studies have shown that CAD in women manifests with the same symptoms as with men

b. postmenopausal women in their 70s have the same incidence of MI as men

The nurse is talking to an older adult male patient who is reasonably healthy for his age, but has benign prostatic hyperplasia (BPH). Which conditioin does the BPH potentially place him at risk for? a. prerenal acute kidney injury b. postrenal acute kidney injury c. polycystic kidney disease d. acute glomerulonephritis

b. postrenal acute kidney injury

he ED nurse is caring for a patient with acute pain associated with MI. What are the purposes of collaborative management that address the patient's pain? Select all that apply. a. return the vital signs and cardiac rhythm to baseline, so the patient can resume activities of daily living b. prevent further damage to the cardiac muscle by decreasing myocardial oxygen demand and increasing myocardial oxygen supply c. aggressively diagnose and treat life-threatening cardiac dysrhythmias and restore pulmonary wedge pressure d. closely monitor the patient for accompanying symptoms such as nausea and vomiting or indigestion e. eliminate discomfort by providing pain relief modalities, decrease myocardial oxygen demand, and increase myocardial oxygen supply

b. prevent further damage to the cardiac muscle by decreasing myocardial oxygen demand and increasing myocardial oxygen supply e. eliminate discomfort by providing pain relief modalities, decrease myocardial oxygen demand, and increase myocardial oxygen supply

The nurse assesses multiple clients who are receiving transfusions of blood components. Which assessment indicates the need for the nurse's immediate action? a. partial thromboplastin time (PTT) that is 1.2 times normal in a client who received a transfusion of fresh-frozen plasma (FFP) b. respiratory rate of 36 breaths/min in a client receiving red blood cells c. sleepiness in a client who received diphenhydramine (Benadryl) as a premedication d. temperature of 99.1° F (37.3° C) for a client with a platelet transfusion

b. respiratory rate of 36 breaths/min in a client receiving red blood cells An increased respiratory rate indicates a possible hemolytic transfusion reaction; the nurse should quickly stop the transfusion and assess the client further. Because FFP is not usually given until the PTT is 1.5 times above normal, a PTT that is 1.2 times normal indicates that the FFP has had the desired response. Sleepiness is expected when Benadryl is administered. Temperature elevations are not an indication of an allergic reaction to a platelet transfusion, although the nurse may administer acetaminophen (Tylenol) to decrease the fever.

A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? a. client's ability to understand medication teaching b. risk for hypotension c. potential for bradycardia d. liver function tests

b. risk for hypotension Angiotensin-converting enzyme (ACE) inhibitors are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years. Although desirable, understanding of teaching is not essential. ACE inhibitors are vasodilators; they do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.

A patient is prescribed diuretics for treatment of heart failure. Because of this therapy, the nurse pays particular attention to which laboratory test level? a. peak and trough of medication b. serum potassium c. serum sodium d. prothrombin time (PT) and partial thromboplastin time (PTT)

b. serum potassium

A client with heart failure is taking furosemide (Lasix). Which finding concerns 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

b. serum potassium level of 2.8 mEq/L Clients taking loop diuretics should be monitored for potassium deficiency from diuretic therapy. A serum sodium level of 135 mEq/L is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L represents a normal value.

Select all the correct statements about the pharmacodynamics of Beta-blockers for the treatment of heart failure: a. these drugs produce a negative inotropic effect on the heart by increasing myocardial contraction b. side effect of these drugs include bradycardia c. these drugs are most commonly prescribed for patients with heart failure who have COPD d. beta-blockers are prescribed with ACE or ARBs to treat heart failure

b. side effect of these drugs include bradycardia d. beta-blockers are prescribed with ACE or ARBs to treat heart failure

The nurse caring for a 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

b. sinus bradycardia c. fatigue e. anorexia Digoxin toxicity may cause bradycardia. Fatigue and anorexia are symptoms of digoxin toxicity. Hypokalemia causes increased sensitivity to the drug and toxicity, but it is not a symptom of toxicity. A serum digoxin level between 0.8 and 2.0 is considered normal and is not a symptom.

What is the characteristic of normal lung sounds that should be heard throughout the lung fields? a. short inspiration, long expiration, loud, harsh b. soft sound, long inspiration, short quiet expiration c. mixed sounds of harsh and soft, long inspiration and long expiration d. loud, long inspiration and short, loud expiration

b. soft sound, long inspiration, short quiet expiration

A patient demonstrates labored, shallow respirations and a respiratory rate of 32/min with a pulse oximetry reading of 85%. What is the priority nursing intervention? a. notify respiratory therapy to give the patient a breathing treatment b. start oxygen via nasal cannula at 2 L/min c. obtain an order for a stat arterial blood gas (ABG) d. encourage coughing and deep-breathing exercises

b. start oxygen via nasal cannula at 2 L/min

The nurse who just came on duty observes that the client, whose blood type is AB negative, is receiving a transfusion with type O negative packed red blood cells. What is the nurse's best first action? a. call the blood bank b. take and record the client's vital signs c. stop the transfusion and keep the IV open d. document the observation as the only action

b. take and record the client's vital signs Clients with AB negative blood types can receive O negative blood because they do not have antibodies against this type of blood. Therefore, the transfusion does not need to be stopped nor does the blood bank need to be notified. The transfusion can proceed. Because the nurse is seeing the client for the first time since the transfusion was initiated, the client's vital signs need to be assessed rather than just documenting the observation.

When caring for a client with acute kidney injury and a temporary subclavian hemodialysis catheter, which assessment finding does the nurse report to the provider? a. mild discomfort at the insertion site b. temperature 100.8° F c. 1+ ankle edema d. anorexia

b. temperature 100.8° F Infection is a major complication of temporary catheters. All symptoms of infection, including fever, must be reported to the provider because the catheter may have to be removed. Mild discomfort at the insertion site is expected with a subclavian hemodialysis catheter. During acute injury, oliguria with resulting fluid retention is expected. Rising blood urea nitrogen may result in anorexia, nausea, and vomiting.

What is the function of the turbinates? a. they decrease the weight of the skull on the neck b. they increase the surface area of the nose for heating and filtering c. they move inspired particles from nose to throat for removal d. they separate two nasal passages down the middle

b. they increase the surface area of the nose for heating and filtering The turbinates increase the surface area of the nose, so that more heating, filtering, and humidifying of inspired air can occur before air passes into the nasopharynx. The paranasal sinuses are air-filled cavities that decrease the weight of the skull. The cilia are responsible for moving inspired particles to the throat so they can be swallowed or expectorated. The septum is the cartilage that separates the nasal cavity into two passages.

An older client has a history of coronary artery disease. Which modifiable risk factors will the nurse assess to guide the client's teaching plan? Select all that apply. a. older age b. tobacco use c. female d. high-fat diet e. family history f. obesity

b. tobacco use d. high-fat diet f. obesity Modifiable risk factors are those in which the patient can actively make changes to control. The patient can modify tobacco use, dietary selection, and obesity. Being an older adult, being female, and having a family history are nonmodifiable risks.

The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure. Which findings would cause the nurse to suspect a left-sided tension pneumothorax? a. chest caves in on inspiration and "puffs out" on expiration b. trachea is deviated to the right side and cyanosis is present c. left lung field is dull to percussion with crackles present on auscultation d. client has bloody sputum and wheezes

b. trachea is deviated to the right side and cyanosis is present Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention, cyanosis, and hyperresonance to percussion over the affected area. Flail chest is manifested by paradoxical chest movement, which consists of "sucking inward" of the loose chest area during inspiration and "puffing out" of the same area during expiration. Open pneumothorax presents with decreased breath sounds, hyperresonance, and poor respiratory excursion on the affected side. Pulmonary contusion presents with hemoptysis, dullness to percussion, and crackles or wheezes.

What are the characteristics of continuous venovenous hemofiltration (CVVH)? Select all that apply. a. requires placement of arterial and venous access b. uses a pump to drive blood from the patient catheter into the dialyzer c. risk of air embolus d. more commonly used for patients who are critically ill e. most convenient method for home care patients

b. uses a pump to drive blood from the patient catheter into the dialyzer c. risk of air embolus d. more commonly used for patients who are critically ill

A hematology unit is staffed by RNs, LPN/LVNs, and unlicensed assistive personnel (UAP). When the nurse manager is reviewing documentation of staff members, which entry indicates that the staff member needs education about his or her appropriate level of responsibility and client care? a. "Abdominal pain relieved by morphine 4 mg IV; client resting comfortably and denies problems. B.C., RN" b. "Ambulated in hallway for 40 feet and denies shortness of breath at rest or with ambulation. T.Y., LPN" c. "Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" d. "Vital signs 37.0° C, heart rate 60, respiratory rate 20, blood pressure 110/68, and oximetry 98% on room air. L.D., UAP"

c. "Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" Determination of the need for oxygen and administration of oxygen should be done by licensed nurses who have the education and scope of practice required to administer it. All other documentation entries reflect appropriate delegation and assignment of care.

A client with leukemia is being discharged from the hospital. After hearing the nurse's instructions to keep regularly scheduled follow-up provider appointments, the client says, "I don't have transportation." How does the nurse respond? a. "A pharmaceutical company might be able to help." b. "I might be able to take you." c. "The local American Cancer Society may be able to help." d. "You can take the bus."

c. "The local American Cancer Society may be able to help." Many local units of the American Cancer Society offer free transportation to clients with cancer, including those with leukemia. Suggesting a pharmaceutical company is not the best answer; drug companies typically do not provide this type of service. Although the nurse offering to take the client is compassionate, it is not appropriate for the nurse to offer the client transportation. Telling the client to take the bus is dismissive and does not take into consideration the client's situation (e.g., the client may live nowhere near a bus route).

The nurse is taking a history on a patient recently diagnosed with heart failure. The patient admits to "sometimes having trouble catching my breath," but is unable to provide more specific details. What question does the nurse ask to gather more data about the patient's symptoms? a. "Do you have any medical problems, such as high blood pressure?" b. "What did your doctor tell you about your diagnosis?" c. "What was your most strenuous activity in the past week?" d. "How do you feel about being told that you have heart failure?"

c. "What was your most strenuous activity in the past week?"

The nurse is caring for a patient with CKD. The family asks about when renal replacement therapy will begin. What is the nurse's best response? a. "As early as possible to prevent further damage in stage I." b. "When there is reduced kidney function and metabolic wastes accumulate." c. "When the kidneys are unable to maintain a balance in body functions." d. "It will be started with diuretic therapy to enhance the remaining function."

c. "When the kidneys are unable to maintain a balance in body functions."

A client admitted to the medical unit with a history of vomiting and diarrhea and an increased blood urea nitrogen requires 1 liter of normal saline infused over 2 hours. Which staff member should be assigned to care for the client? a. RN who has floated from pediatrics for this shift b. LPN/LVN with experience working on the medical unit c. RN who usually works on the general surgical unit d. new graduate RN who just finished a 6-week orientation

c. RN who usually works on the general surgical unit The nurse with experience in taking care of surgical clients will be most capable of monitoring the client receiving rapid fluid infusions, who is at risk for complications such as pulmonary edema and acute kidney failure. The pediatric float RN and the new graduate RN will have less experience in caring for this type of client. The LPN/LVN should not be assigned to a client requiring IV therapy and who is at high risk for complications.

The nurse is assessing a patient with kidney injury and notes a marked increase in the rate and depth of breathing. The nurse recognizes this as Kussmaul respiration, which is the body's attempt to compensate for which condition? a. hypoxia b. alkalosis c. acidosis d. hypoxemia

c. acidosis

A client who had an earlier bronchoscopy has the following vital signs: heart rate 132 beats/min, respiratory rate 26 breaths/min, and blood pressure 98/50 mm Hg. The client is anxious and his skin is cyanotic. What is the nurse's first action? a. call the rapid response team b. give methylene blue 1% 1 to 2 mg/kg by IV injection c. administer oxygen d. notify the health care provider immediately

c. administer oxygen Administering oxygen and reassessing vital signs to observe for improvement is the first action. Administration of oxygen by itself may help relieve the client's anxiety. The Rapid Response Team should be called if the client has any symptoms of methemoglobinemia; calling a rapid response will not be the nurse's first action because abnormal vital signs can result from many causes. Methylene blue is given for treatment of methemoglobinemia; information is insufficient for the nurse to determine whether the client has this condition. The health care provider will receive an update of the client's condition; however, this is not the highest priority at this time.

The nurse is caring for a client who is on a ventilator. An alarm goes off on the ventilator. What is the first thing the nurse should do? a. shut off the ventilator and restart it to reset the alarm b. empty the ventilator tubing of excess moisture c. assess the client for abnormalities d. check the ventilator settings

c. assess the client for abnormalities

While percussing a patient's chest and lung fields, the nurse notes a high, loud, musical, drumlike sound similar to tapping a cheek that is puffed out with air. What is the nurse's priority action? a. document this expected finding using words like, "high," "loud," and "hollow" b. immediately notify the provider because the patient has an airway obstruction c. assess the patient for air hunger or pain at the end of inhalation and exhalation d. palpate for crackling sensation underneath the skin or for localized tenderness

c. assess the patient for air hunger or pain at the end of inhalation and exhalation

A patient's pulse oximetry reading is 89%. What is the nurse's first priority action? a. recheck the reading with a different oximeter b. apply supplemental oxygen and recheck the oximeter reading in 15 minutes c. assess the patient for respiratory distress and recheck the oximeter reading d. place the patient in the recovery position and monitor frequently

c. assess the patient for respiratory distress and recheck the oximeter reading

A patient with left-sided heart failure is having difficulty breathing. Which of the following is the most appropriate nursing intervention? a. encourage the patient to cough and deep breathe b. place the patient in Semi-Fowler's position c. assist the patient into High Fowler's position d. perform chest percussion therapy

c. assist the patient into High Fowler's position Due to the patient being in fluid overload (especially with left-sided heart failure...remember the lungs are majorly affected in this type of heart failure), it is most appropriate to place the patient in High Fowler's position to help make breathing easier.

Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? a. serum potassium level of 3.2 mEq/L b. ejection fraction of 60% c. b-type natriuretic peptide (BNP) of 760 ng/dL d. chest x-ray report showing right middle lobe consolidation

c. b-type natriuretic peptide (BNP) of 760 ng/dL BNP is produced and released by the ventricles when the client has fluid overload as a result of HF; a normal value is less than 100 pg/mL. Hypokalemia may occur in response to diuretic therapy for HF, but may also occur with other conditions; it is not specific to HF. Ejection fraction of 60% represents a normal value of 50% to 70%. Consolidation on chest x-ray may indicate pneumonia.

A client with a history of Congestive Heart Failure (CHF) is reviewing their medications with the nurse. The client states, "I take so many medications I don't know which one I take for my CHF. The nurse knows that which of the following medication is used to treat CHF? a. cimetidine b. cephalexin c. captopril d. clopidogrel

c. captopril Cephalexin (Kephlex) is an anti-infective medication used for skin infections, Pneumonia, UTI's and Otitis Media. Captopril (Capoten) is an ACE inhibitor that treats hypertension and CHF. Cimetidine (Tagamet) is an antiulcer H2 antagonist that treats GERD, Ulcers and can be used to prevent GI bleeding. Clopidogrel (Plavix) is an antiplatelet agent used to manage CVA, MI, PVD, etc.

A patient who received a bronchoscopy was NPO (nothing by mouth) for several hours before the test. Now a few hours after the test, the patient is hungry and would like to eat a meal. What does the nurse do before allowing the patient to eat? a. order a meal because the patient is now alert and oriented b. check pulse oximetry to be sure oxygen saturation has returned to normal c. check for a gag reflex before allowing the patient to eat d. assess for nausea from the medications given for the test

c. check for a gag reflex before allowing the patient to eat

The night shift nurse is listening to report and hears that a patient has paroxysmal nocturnal dyspnea. What does the nurse plan to do next? a. instruct the patient to sleep in a side-lying position and then check on the patient every 2 hours to help with switching sides b. make the patient comfortable in a bedside recliner with several pillows to keep the patient more upright throughout the night c. check on the patient several hours after bedtime and assist the patient to sit upright and dangle the feet when dyspnea occurs d. check the patient frequently because the patient has insomnia due to a fear of suffocation

c. check on the patient several hours after bedtime and assist the patient to sit upright and dangle the feet when dyspnea occurs

An older adult patient is taking digoxin for treatment of heart failure. What is the priority nursing action for this patient related to the medication therapy? a. give the medication in conjunction with an antacid b. keep the patient on the cardiac monitor and observe for ventricular dysrhythmias c. check that the dose is in the lowest possible range for therapeutic effect d. advise the patient that there is increased mortality related to toxicity

c. check that the dose is in the lowest possible range for therapeutic effect

You are giving a bed bath to your intubated patient. The ventilator begins alarming loudly. After identifying your patient is not in distress, what should your next action be? a. immediately administer O2 breaths b. quickly finish the bed bath c. check the display to see why the ventilator is alarming d. suction immediately

c. check the display to see why the ventilator is alarming

A patient with acute decompensated heart failure has been prescribed intravenous diuretic medications to control fluid and congestion. Which nursing intervention would the nurse need to perform in order to best monitor fluid and electrolyte balance in this patient? a. insert a Foley catheter b. administer pain medications as ordered c. check the patient's weight daily d. monitor for signs of pancreatic dysfunction

c. check the patient's weight daily Decompensated heart failure can cause a patient to experience fluid overload, leading to difficulties with breathing and increased amounts of fluid in peripheral tissues (edema). In this case the nurse should weigh the patient daily and record it. If the patient is retaining fluid, he will gain weight.

A 56-year-old client admitted with a diagnosis of acute myelogenous leukemia (AML) is prescribed IV cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. An infection develops. What knowledge does the nurse use to determine that the appropriate antibiotic has been prescribed for this client? a. evaluating the client's liver function tests (LFTs) and serum creatinine levels b. evaluating the client's white blood cell (WBC) count level c. checking the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection d. recognizing that vancomycin (Vancocin) is the drug of choice used to treat all infections in clients with AML

c. checking the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection Checking the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection is the best action to take. Drug therapy is the main defense against infections that develop in clients undergoing therapy for AML. Agents used depend on the client's sensitivity to various antibiotics for the organism causing the infection. Although LFTs and kidney function tests may be influenced by antibiotics, these tests do not determine the effectiveness of the antibiotic. Although the WBC count is elevated in infection, this test does not influence which antibiotic will be effective in fighting the infection. Vancomycin may not be effective in all infections; culturing of the infection site and determining the organism's sensitivity to a cohort of drugs are needed, which will provide data on drugs that are capable of eradicating the infection in this client.

The nurse is completing documentation for a client with acute kidney injury who is being discharged today. The nurse notices that the client has a serum potassium level of 5.8 mEq/L. Which is the priority nursing action? a. asking the client to drink an extra 500 mL of water to dilute the electrolyte concentration and then re-checking the serum potassium level b. encouraging the client to eat potassium-binding foods and to contact his or her primary care provider within 24 hours c. checking the remaining values on the electrolyte panel and informing the provider of all results before the client is discharged d. applying a cardiac monitor and evaluating the client's muscle strength and muscle irritability

c. checking the remaining values on the electrolyte panel and informing the provider of all results before the client is discharged Repeating the laboratory test is a reasonable option, but the provider must make this decision after being informed about the context, including the results of the entire electrolyte panel, which will also have information about renal function (creatinine and blood urea nitrogen). Although the potassium level is slightly elevated, it is not a value commonly associated with cardiac dysrhythmias or skeletal muscle changes. Although additional fluid intake may dilute some electrolytes, potassium is not generally altered by plasma volume. There are no foods that specifically bind potassium and, depending on the rapidity of the rise in serum potassium, waiting a day may result in harm to the patient.

The client is 3 weeks post-transplant from an allogeneic stem cell transplantation for acute lymphocytic leukemia. There is now some peeling of the client's skin on the palms of the hands and the soles of the feet. Which additional assessment data supports the nurse's suspicion of possible graft-versus-host disease (GVHD)? a. client's temperature is slightly below normal b. today's platelet count is 5,000/mm3 and the WBCs are low c. client has had 6 to 10 watery stools daily for 3 days d. client's urine output is less than 800 mL in 24 hours

c. client has had 6 to 10 watery stools daily for 3 days GVHD occurs when the immunocompetent cells of the donated marrow recognize the patient's (recipient) cells, tissues, and organs as foreign and start an immunologic attack against them. The tissues most susceptible are the skin, intestinal tract, and liver. The earliest manifestation of gastrointestinal involvement for GVHD is large-volume watery diarrhea. The temperature is unaffected. The fact that the urine output is low is related to dehydration from diarrhea, not kidney damage by GVHD.

Which critically ill client has the greatest risk for developing acute respiratory distress syndrome (ARDS)? a. client with diabetic ketoacidosis (DKA) b. client with atrial fibrillation c. client with aspiration pneumonia d. client with acute kidney failure

c. client with aspiration pneumonia Aspiration of acidic gastric contents is a risk for ARDS. Clients with DKA may develop metabolic acidosis, but not ARDS, which develops in lung injury. Atrial fibrillation does not cause lung injury unless embolization occurs. Acute kidney failure results in metabolic acidosis, not in acute lung injury.

The nurse is teaching a patient with heart failure about signs and symptoms that suggest a return or worsening of heart failure. What does the nurse include in the teaching? Select all that apply. a. rapid weight loss of 3 lbs in a week b. increase in exercise tolerance lasting 2 to 3 days c. cold symptoms (cough) lasting more than 3 to 5 days d. excessive awakening at night to urinate e. development of dyspnea or angina at rest or worsening angina f. increased swelling in the feet, ankles, or hands

c. cold symptoms (cough) lasting more than 3 to 5 days d. excessive awakening at night to urinate e. development of dyspnea or angina at rest or worsening angina f. increased swelling in the feet, ankles, or hands

Mr. B., a 67-year-old, is admitted with a diagnosis of COPD and left upper lobe pneumonia, which has been confirmed with a chest x-ray. He has the following arterial blood gas results pH 7.35 O2 62 mmHg CO2 59 mmHg HCO3 32 mEq/L The nurse interprets the above arterial blood gas to be: a. uncompensated respiratory acidosis b. compensated metabolic acidosis c. compensated respiratory acidosis d. uncompensated respiratory alkalosis

c. compensated respiratory acidosis

A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What diagnostic test does the nurse expect to help confirm the diagnosis? a. bronchoscopy b. chest x-ray c. computed tomography (CT) scan d. thoracoscopy

c. computed tomography (CT) scan CT scans, especially spiral or helical CT scans, with injected contrast can detect pulmonary emboli. The client has a pulmonary embolism; bronchoscopy will not help to confirm this diagnosis. A chest x-ray will rule out other causes of the symptoms but is not specific for pulmonary embolism. Thoracoscopy is not used to detect pulmonary emboli.

For a patient with AKI, the nurse would consider questioning the order for which diagnostic test? a. kidney biopsy b. ultrasonography c. computed tomography with contrast dye d. kidney, ureter, bladder (KUB) x-ray

c. computed tomography with contrast dye

A patient is hospitalized with chronic pericarditis. On assessment, you note the patient has pitting edema in lower extremities, crackles in lungs, and dyspnea on excretion. The patient's echocardiogram shows thickening of the pericardium. This is known as what type of pericarditis? a. pericardial effusion b. acute pericarditis c. constrictive pericarditis d. effusion-constrictive pericarditis

c. constrictive pericarditis This describes constrictive pericarditis. The key words in this question are: the patient's signs and symptoms which indicate heart failure (a common finding with patients who have constrictive pericarditis) and that the echo showed "thickening" of the pericardium.

The nurse is teaching a group of teens about prevention of heart disease. Which point should the nurse emphasize? a. reduce abdominal fat b. avoid stress c. do not smoke or chew tobacco d. avoid alcoholic beverages

c. do not smoke or chew tobacco Tobacco exposure, including secondhand smoke, reduces coronary blood flow; causes vasoconstriction, endothelial dysfunction, and thickening of the vessel walls; increases carbon monoxide; and decreases oxygen. Because it is highly addicting, beginning smoking in the teen years may lead to decades of exposure. Teens are not likely to experience metabolic syndrome from obesity, but are very likely to use tobacco. Avoiding stress is a less modifiable risk factor, which is less likely to cause heart disease in teens. The risk of smoking outweighs the risk of alcohol use.

A client with end-stage kidney disease has been put on fluid restrictions. Which assessment finding indicates that the client has not adhered to this restriction? a. blood pressure of 118/78 mm Hg b. weight loss of 3 pounds during hospitalization c. dyspnea and anxiety at rest d. central venous pressure (CVP) of 6 mm Hg

c. dyspnea and anxiety at rest Dyspnea is a sign of fluid overload and possible pulmonary edema; the nurse should assist the client in correlating symptoms of fluid overload with nonadherence to fluid restriction. Nonadherence to fluid restriction results in fluid volume excess and higher blood pressures; 118/78 mm Hg is a normal blood pressure. Excess fluid intake and fluid retention are manifested by an elevated CVP (>8 mm Hg) and weight gain, not weight loss.

You are providing diet teaching to a patient with low iron levels. Which foods would you encourage the patient to eat regularly? a. herbal tea, apples, and watermelon b. sweet potatoes, artichokes, and packaged meat c. egg yolks, beef, and legumes d. chocolate, cornbread, and cabbage

c. egg yolks, beef, and legumes

The nurse notes an abnormal laboratory test finding for a patient with CKD and alerts the health care provider. The nurse also consults with the registered dietitian because an excessive dietary protein intake is directly related to which factor? a. elevated serum creatinine level b. protein presence in the urine c. elevated BUN level d. elevated serum potassium level

c. elevated BUN level

Which nursing intervention is the priority in preparing a client for pulmonary function testing (PFT)? a. administer bronchodilator medication on call b. encourage clear fluid intake 12 hours before the procedure c. ensure no smoking 6 hours before the test d. provide supplemental oxygen as testing begins

c. ensure no smoking 6 hours before the test If the client has been smoking, this may alter parts of the PFT (diffusing capacity [DLCO]), yielding inaccurate results. Administering bronchodilators is not indicated for PFT, but they may be withheld for 4 to 6 hours before the test. Fluid intake does not have an effect on PFT testing. Unless the client develops distress during testing, supplemental oxygen is not required and will alter the results of PFT.

Upon assessing the lungs, the nurse hears short, discrete popping sounds "like hair being rolled between fingers near the ear" in the bilateral lower lobes. How is this assessment documented? a. rhonchi b. wheezes c. fine crackles d. coarse crackles

c. fine crackles

A patient is trying to make dietary modifications to reduce lipid levels. The patient would like information about omega-3 fatty acid food sources. What best source does the nurse recommend? a. flaxseed b. flaxseed oil c. fish d. walnuts

c. fish

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. The nurse reviews the medical record, which contains the following information: Crackles in all fields S3 present Oliguria Ejection fraction 30% BNP 560 Sodium 130 mEq/L Diagnosis: heart failure Enalapril 10 mg orally daily, Heparin 5000 units subcutaneously every 12 hours, & Furosemide 40 mg IV daily Strict I & O Which prescription does the nurse implement first? a. enalapril b. heparin c. furosemide d. intake and output (I & O)

c. furosemide The client is displaying typical signs of acute pulmonary edema secondary to fluid-filled alveoli and pulmonary congestion; a diuretic will promote fluid loss. Although enalapril will promote vasodilation and decrease cardiac workload, the client is demonstrating signs of acute pulmonary edema secondary to intra-alveolar fluid. Heparin will prevent deep vein thrombosis secondary to immobility, but will not reduce fluid excess. Although all clients with congestive heart failure should have daily weights and I & O monitored, this is not a priority; removing fluid volume and treating dyspnea are matters of priority.

What is the term for the opening between the vocal cords? a. arytenoid cartilage b. epiglottis c. glottis d. palatine tonsils

c. glottis The glottis is the opening of the vocal cords into which the endotracheal tube is passed during intubation for surgery. The arytenoid cartilages work with the thyroid cartilage to control the movement of the vocal cords. The epiglottis is a structure that prevents aspiration during swallowing. The palatine tonsils are part of the immune system and are located in the oropharynx.

A patient is diagnosed with renal osteodystrophy. What does the nurse instruct the unlicensed assistive personnel (UAP) to do in relation to this patient's diagnosis? a. assist the patient with toileting every 2 hours b. gently wash the patient's skin with a mild soap and rinse well c. handle the patient gently because of risk for fractures d. assist the patient with eating because of loss of coordination

c. handle the patient gently because of risk for fractures

A patient reports fatigue and shortness of breath when getting up to walk to the bathroom; however, the pulse oximetry reading is 99%. The nurse identifies a diagnosis of Activity intolerance. Which laboratory value is consistent with the patient's subjective symptoms? a. BUN of 15 mg/dL b. white blood cell count (WBC) of 8000/mm3 c. hemoglobin of 9 g/dL d. glucose 160 mg/dL

c. hemoglobin of 9 g/dL

A patient is taking Digoxin. Prior to administration you check the patient's apical pulse and find it to be 61 bpm. Morning lab values are the following: K+ 3.3 and Digoxin level of 5 ng/mL. Which of the following is the correct nursing action? a. hold this dose and administer the second dose at 1800 b. administer the dose as ordered c. hold the dose and notify the physician of the digoxin level d. hold this dose until the patient's potassium level is normal

c. hold the dose and notify the physician of the digoxin level The patient is Digoxin toxic. A normal Digoxin level is <2 ng/mL. Therefore, the nurse should not administer the dose but hold it and notify the doctor for further orders.

The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority? a. inadequate nutrition related to food-drug interactions and anticoagulant therapy b. potential for infection related to leukocytosis c. hypoxemia related to ventilation-perfusion mismatch d. insufficient knowledge related to the cause of PE

c. hypoxemia related to ventilation-perfusion mismatch Restoring adequate oxygenation and tissue perfusion takes priority when a client presents with a PE. Although nutrition must be addressed, priorities include airway, breathing, and circulation. The client has a leukocytosis related to lung inflammation; leukopenia places clients at risk for infection, but this is not the priority at this time. Education as to the cause of PE must be postponed until oxygenation and hemodynamic stability occur.

A patient with a history of angina is admitted for surgery. The patient reports nausea, pressure in the chest radiating to the left arm, appears anxious, skin is cool and clammy, blood pressure is 150/90 mm Hg, pulse is 100, and respiratory rate is 32. What are the priorities of nursing care for this patient? Select all that apply. a. relieve nausea b. maintain NPO status c. improve coronary perfusion d. improve coronary oxygenation e. relieve chest pain

c. improve coronary perfusion d. improve coronary oxygenation e. relieve chest pain

The nurse is inspecting a patient's chest and observes an increase in anteroposterior diameter of the chest. When is this an expected finding? a. with a pulmonary mass b. upon deep inhalation c. in older adult patients d. with chest trauma

c. in older adult patients

The nurse understands the goal of treatment for ARDS is to: a. increase PCO2 elimination b. decrease respiratory rate c. increase functional residual capacity d. increase tidal volume

c. increase functional residual capacity

In the neurologic control of the heart, norepinephrine has two effects, alpha and beta-adrenergic; both causes stimulation of the heart. Beta-adrenergic stimulation would cause: a. decreased force of myocardial contractility b. deceleration of AV conduction time c. increased SA node discharge d. peripheral arteriolar vasoconstriction

c. increased SA node discharge

A patient who is in the cardiac unit and who suffers from heart failure has been given a dose of enalapril IV. What effect should most likely occur after administration of this drug? a. decreased clotting time and improved blood flow b. decreased orthostatic hypotension with movement c. increased cardiac output and decreased blood pressure d. decreased urinary output and increased peripheral edema

c. increased cardiac output and decreased blood pressure Enalapril (Vasotec) is a drug typically used to treat high blood pressure and heart failure in adults. Enalapril works to increase cardiac output and decrease blood pressure among patients with hypertension. It is considered an ACE inhibitor, or angiotensin converting enzyme inhibitor.

The health care provider has ordered intraperitoneal heparin for a patient with a new PD catheter to prevent clotting of the catheter by blood and fibrin formation. How does the nurse advise the patient? a. watch for bruising or bleeding from the gums b. make a follow-up appointment for coagulation studies c. intraperitoneal heparin does not affect clotting times d. heparin will be given with a small subcutaneous needle

c. intraperitoneal heparin does not affect clotting times

Which of the following is a symptom of right ventricular heart failure? a. dyspnea on exertion b. elevated pulmonary capillary wedge pressure c. jugular vein distention d. paroxysmal nocturnal dyspnea

c. jugular vein distention

Physical assessment findings indicative of a significant right ventricular (RV) infarction would include: a. bibasilar crackles b. flat neck veins with the patient in a semi-fowler's position c. jugular venous distention d. tachypnea and frothy sputum

c. jugular venous distention

A patient, with a history of gastric bypass surgery 6 months ago, reports feeling very fatigued and is having food cravings for clay and dirt. On assessment, you note the patient has nail changes that look "spoon-shaped". This spoon-shaped appearance of the nails is called? a. terry's nails b. onychoschizia c. koilonychias d. leukonychia

c. koilonychias Koilonychias is the medial term for a spoon-shaped appearance of nails found in iron-deficiency anemia.

A doctor suspects pernicious anemia in a patient presenting with a beefy red tongue. The patient reports feeling extremely fatigued and numbness and tingling in the hands. The doctor orders a peripheral blood smear. From your nursing knowledge, how will the red blood cells appear in the peripheral blood smear if pernicious anemia is present? a. round-shaped and hypochromic b. oval-shaped and hyperchromic c. large and oval-shaped d. small and hyperchromic

c. large and oval-shaped In pernicious anemia, the RBCs will appear very large (rather than normal size) and oval-shaped (rather than round).

Which coronary artery provides blood to the left atrium and left ventricle? a. right marginal artery b. posterior descending artery c. left circumflex artery d. right coronary artery

c. left circumflex artery

Why does the nurse document the precise location of crackles auscultated in the lungs of a patient with heart failure? a. crackles will eventually change to wheezes as the pulmonary edema worsens. b. level of the fluid spreads laterally as the pulmonary edema worsens c. level of the fluid ascends as the pulmonary edema worsens d. crackles will eventually diminish as the pulmonary edema worsens

c. level of the fluid ascends as the pulmonary edema worsens

The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action should the nurse take first? a. check the ventilator alarm settings b. assess the set tidal volume c. listen to the client's breath sounds d. call the respiratory therapist

c. listen to the client's breath sounds A typical reason for the high-pressure alarm to sound is the need for suctioning or tension pneumothorax. The nurse should begin the assessment with the client, not with the ventilator. Although an excessively high tidal volume could contribute to sounding of the high-pressure alarm, assessment always begins with the client. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention.

The nurse is caring for a hospitalized patient being treated initially with IV nitroglycerin. What intervention must the nurse include in this patient's care? a. increase the dose rapidly to achieve pain relief b. restrict the patient to bedrest with bedpan use c. monitor blood pressure continuously d. elevate the head of the bed to 90 degrees

c. monitor blood pressure continuously

The visiting nurse is seeing a client postoperative for coronary artery bypass graft. Which nursing action should be performed first? a. assess coping skills b. assess for postoperative pain at the client's incision site c. monitor for dysrhythmias d. monitor mental status

c. monitor for dysrhythmias Dysrhythmias are the leading cause of prehospital death; the nurse should monitor the client's heart rhythm. Assessing mental status, coping skills, or postoperative pain is not the priority for this client.

Which treatments below would decrease cardiac preload? Select all that apply. a. IV fluid bolus b. norepinephrine c. nitroglycerin d. furosemide

c. nitroglycerin d. furosemide Nitroglycerin is a vasodilator that will dilate vessels, which will decrease venous return to the heart and this will decrease preload. Furosemide is a diuretic which will remove extra fluid from the body via the kidneys. This will decrease venous return to the heart and decrease preload. An IV fluid bolus and Norepinephrine (a vasoconstrictor) will increase venous return to the heart and increase preload.

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. nurse monitors the client's pulse and blood pressure frequently c. nurse obtains a bedside commode before administering furosemide d. nurse returns the client to bed when he becomes tachycardic

c. nurse obtains a bedside commode before administering furosemide Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand. Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand; the nurse should prevent this situation.

The nurse is palpating a patient's chest and identifies an increased tactile fremitus or vibration of the chest wall produced when the patient speaks. What does the nurse do next? a. observe for other findings associated with subcutaneous emphysema b. document the observation as an expected normal finding c. observe the patient for other findings associated with a pneumothorax d. document the observation as a pleural friction rub

c. observe the patient for other findings associated with a pneumothorax

Which nursing action may be delegated to a nursing assistant working on the medical unit? a. determine the usual alcohol intake for a client with cardiomyopathy b. monitor the pain level for a client with acute pericarditis c. obtain daily weights for several clients with class IV heart failure d. check for peripheral edema in a client with endocarditis

c. obtain daily weights for several clients with class IV heart failure Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN. The role of the professional nurse is to perform assessments; determining alcohol intake, monitoring pain level, and assessing for peripheral edema should not be delegated.

The nurse is caring for a client with neutropenia who has a suspected infection. Which intervention does the nurse implement first? a. hydrate the client with 1000 mL of IV normal saline b. initiate the administration of prescribed antibiotics c. obtain requested cultures d. place the client on bleeding precautions

c. obtain requested cultures Obtaining cultures to identify the infectious agent correctly is the priority for this client. Hydrating the client is not the priority. Administering antibiotics is important, but antibiotics should always be started after cultures are obtained. Placing the client on Bleeding Precautions is unnecessary.

A patient is receiving treatment for infective endocarditis. The patient has a history of intravenous drug use and underwent mitral valve replacement a year ago. The patient is scheduled for a transesophageal echocardiogram tomorrow. On assessment, you find tender, red lesions on the patient's hands and feet. You know that this is a common finding in patients with infective endocarditis and is known as? a. janeway lesions b. roth spots c. osler's nodes d. trousseau's sign

c. osler's nodes They are TENDER, red lesions on the hands and feet. Don't get this confused with Janeway Lesions which are NON-TENDER, red lesions on the PALMS of the hands and SOLES of the feet. Roth spots are retinal hemorrhages with white centers and Trousseau's Sign is found in hypocalcemia.

A nurse is caring for a client with ARDS. Which of the following clinical indicators would signify that this client is in respiratory failure? Select all that apply. a. respiratory rate greater than 16 breaths per minute b. pulse oximetry of 94% on room air c. pCO2 level over 50 mmHg d. ABG pH level of 7.35 e. PaO2 level below 60 mmHg

c. pCO2 level over 50 mmHg e. PaO2 level below 60 mmHg

Four clients arrive in the emergency department simultaneously with chest pain. The client with which type of chest pain requires immediate attention by the nurse? a. pain on deep inspiration b. pain on palpation c. pain radiating to the shoulder d. pain that is rubbing in nature

c. pain radiating to the shoulder Chest pain radiating to the shoulder should be assumed to be cardiac in origin until proven otherwise; this requires the immediate attention of the nurse. Pain on inspiration and chest pain that is rubbing in nature are usually pulmonary in origin but do not require immediate attention. Pain on palpation is not usually pulmonary in nature; it may be due to trauma or may be referred from another source, such as the gastrointestinal tract.

In pernicious anemia, intrinsic factor is not being secreted by the _______ cells which are found in the gastric mucosa. a. visceral b. langerhan c. parietal d. chief

c. parietal Parietal cells in the GI system secrete intrinsic factor.

Which patient is the most likely candidate for CVVH? a. patient with fluid volume overload b. patient who needs long-term management c. patient who is critically ill d. patient who is ready for discharge to home

c. patient who is critically ill

Pulmonary function tests are scheduled for a patient with a history of smoking who reports dyspnea and chronic cough. What will patient teaching information about this procedure include? a. do not smoke for at least 2 weeks before the test b. bronchodilator drugs may be withheld 2 days before the test c. patient will breathe through the mouth and wear a nose clip during the test d. patient will be expected to walk on a treadmill during the test

c. patient will breathe through the mouth and wear a nose clip during the test

A 32-year-old client recovering from a sickle cell crisis is to be discharged. The nurse says, "You and all clients with sickle cell disease are at risk for infection because of your decreased spleen function. For this reason, you will most likely be prescribed an antibiotic before discharge." Which drug does the nurse anticipate the health care provider will request? a. cefaclor (Ceclor) b. gentamicin (Garamycin) c. penicillin V (Pen-V K) d. vancomycin (Vancocin)

c. penicillin V (Pen-V K) Prophylactic therapy with twice-daily oral penicillin reduces the incidence of pneumonia and other streptococcal infections and is the correct drug to use. It is a standard protocol for long-term prophylactic use in clients with sickle cell disease. Cefaclor (Ceclor) and vancomycin (Vancocin) are antibiotics more specific for short-term use and would be inappropriate for this client. Gentamicin (Garamycin) is a drug that can cause liver and kidney damage with long-term use.

A client comes to the emergency department with a productive cough. Which symptom does the nurse look for that will require immediate attention? a. blood in the sputum b. mucoid sputum c. pink, frothy sputum d. yellow sputum

c. pink, frothy sputum Pink, frothy sputum is common with pulmonary edema and requires immediate attention and intervention to prevent the client's condition from getting worse. Blood in the sputum may occur with chronic bronchitis or lung cancer; because this condition is chronic, the situation does not require immediate attention. Mucoid sputum may be related to smoking and does not require immediate attention. Although yellow sputum may indicate an infection that requires treatment, the condition is not emergent.

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? a. monitor pulse oximetry and cardiac rate and rhythm b. reassure the client that his distress can be relieved with proper intervention c. place the client in high-Fowler's position with the legs down d. ask a family member to remain with the client

c. place the client in high-Fowler's position with the legs down High-Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion. Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member's presence may help to alleviate anxiety, but dyspnea and anxiety result from hypoxemia secondary to intra-alveolar edema, which must be relieved.

You are providing care to a patient with pericarditis. Which of the following is NOT a proper nursing intervention for this patient? a. monitor the patient for complications of cardiac tamponade b. administer ibuprofen as scheduled c. place the patient in supine position to relieve pain d. monitor the patient for pulsus paradoxus & muffled heart sounds

c. place the patient in supine position to relieve pain Placing the patient in supine position is not a proper nursing intervention for a patient experiencing pericarditis because this increases pain. The high Fowler's position or leaning forward is the best position for a patient with pericarditis.

The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity does the nurse suggest? a. need to increase activities slowly at home b. planning and participating in a walking program c. placing a chair in the shower for independent hygiene d. consultation with social worker for disability planning

c. placing a chair in the shower for independent hygiene Phase 1 begins with the acute illness and ends with discharge from the hospital; it focuses on promoting rest and allowing clients to improve their activities of daily living based on their abilities. Phase 2 begins after discharge and continues through convalescence at home, including consultation with a social worker for long-term planning; it consists of achieving and maintaining a vital and productive life while remaining within the limits of the heart's ability to respond to increases in activity and stress. Phase 3 refers to long-term conditioning, such as a walking program.

A complication of PEEP may be: a. atelectasis b. liver infarction c. pneumothorax d. hypertension

c. pneumothorax

A client had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse? a. abscess b. pneumonia c. pneumothorax d. pulmonary embolism

c. pneumothorax A pneumothorax would be the complication of thoracentesis that causes the greatest concern, along with these symptoms. Although it is possible that an abscess has formed, this is not the most likely diagnosis because it would not cause a great deal of shortness of breath. It is not likely that pneumonia would develop this rapidly, causing this level of symptoms. Thoracentesis is not a cause of pulmonary emboli.

A 59-year-old male is admitted complaining of chest pain and dyspnea. ST elevation and T-wave inversion were seen on the ECG in V2, V3, and V4. IV thrombolytic therapy was started in the ED. Which of the following medication orders should the nurse question for the patient? a. metoprolol (Lopressor) b. aspirin c. propranolol (Inderal) d. heparin

c. propranolol (Inderal)

A patient has recently started PD therapy and reports some mild pain when the dialysate is flowing in. What does the nurse do next? a. immediately report the pain to the health care provider b. try warming the dialysate in the microwave oven c. reassure that pain should subside after the first week or two d. assess the connection tubing for kinking or twisting

c. reassure that pain should subside after the first week or two

A patient is admitted with iron- deficiency anemia and has been receiving iron supplementation. The patient voices concern about how their stool is dark black. As the nurse, you would? a. notify the doctor b. hold the next dose of iron c. reassure the patient this is a normal side effect of iron supplementation d. none of the options are correct

c. reassure the patient this is a normal side effect of iron supplementation This is a normal side effect of iron supplementation and demonstrates the body is absorbing the iron.

The nurse is monitoring a patient's PD treatment. The total outflow is slightly less than the inflow. What does the nurse do next? a. instruct the patient to ambulate b. notify the health care provider c. record the difference as intake d. put the patient on fluid restriction

c. record the difference as intake

What is the effect of age-related decreased skeletal strength on the effectiveness of gas exchange? a. reduced gas exchange as a result of decreased alveolar surface b. reduced gas exchange as a result of longer relaxation of bronchiolar smooth muscles c. reduced gas exchange as a result of decreased changes in pressures of the chest cavity d. reduced gas exchange as a result of failure pulmonary circulation to fully perfuse lung tissue

c. reduced gas exchange as a result of decreased changes in pressures of the chest cavity Breathing occurs through changes in the size of and pressure within the chest cavity. Contraction and relaxation of chest muscles (and the diaphragm) cause changes in the size and pressure of the chest cavity. When skeletal muscle strength is decreased in these muscles, pressure changes are decreased, and less air moves in and out of the lungs. This reduced airflow limits gas exchange at the alveolar-capillary membrane. The alveolar surface itself is not decreased by weaker skeletal muscles, nor does this cause any relaxation of bronchiolar smooth muscle. Weaker skeletal muscles do not directly affect pulmonary circulation.

A nurse is working with a patient who has a central catheter in place that is measuring central venous pressure (CVP). When looking at the waveform, the nurse understands that descending portion of the wave indicates: a. closing of the Tricuspid valve b. contraction of the atria c. relaxation of the atria d. contraction of the ventricles

c. relaxation of the atria

Which behavior is the strongest indicator that a patient with ESKD is not coping well with the illness and may need a referral for psychological counseling? a. displays irritability when the meal tray arrives b. refuses to take one of the drugs because it causes nausea c. repeatedly misses dialysis appointments d. seems distracted when the health care provider talks about the prognosis

c. repeatedly misses dialysis appointments

A patient with heart failure has excessive aldosterone secretion and is therefore experiencing thirst and continuously asking for water. What instruction does the nurse give the unlicensed assistive personnel (UAP)? a. severely restrict fluid to 500 mL plus output from the previous 24 hours b. give the patient as much water as desired to prevent dehydration c. restrict fluid to a normal 2 L daily, with accurate intake and output d. frequently offer the patient ice chips and moistened toothettes

c. restrict fluid to a normal 2 L daily, with accurate intake and output

A patient with endocarditis has listed in their medical history "Roth Spots". You know that this is a complication of infective endocarditis and presents as? a. non-tender spots found on the feet and hands b. red and tender lesions found in the eyes c. retinal hemorrhages with white centers d. purplish spots found on the forearms and groin

c. retinal hemorrhages with white centers Roth spots are found in the eyes as retinal hemorrhages with white centers.

The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper client identification? a. asks the client's name b. checks the client's armband c. reviews all information with another registered nurse d. verifies the client's room number

c. reviews all information with another registered nurse With another registered nurse, verify the client by name and number, check blood compatibility, and note expiration time. Human error is the most common cause of ABO incompatibility reactions, even for experienced nurses. Asking the client's name and checking the client's armband are not adequate for identifying the client before transfusion therapy. Using the room number to verify client identification is never appropriate.

Which laboratory test does the nurse monitor for potential cardiac problems and digoxin toxicity? a. complete blood count b. bun and creatinine level c. serum potassium level d. pt and international normalized ratio (INR)

c. serum potassium level

Which statement about silent MI is correct? a. in a silent MI, the patient does not have any pain, so there is less myocardial damage. b. diabetic patients are prone to silent MI that goes undiagnosed without complications c. silent MI increases the incidence of new coronary events d. in silent MI, the myocardium is oxygenated by increased collateral circulation

c. silent MI increases the incidence of new coronary events

What type of breath odor is most likely to be noted in a patient with CKD? a. fruity smell b. fecal smell c. smells like urine d. smells like blood

c. smells like urine

Which sounds in the smaller bronchioles and the alveoli indicate normal lung sounds? a. harsh, hollow, and tubular blowing b. nothing; normally no sounds are heard c. soft, low rustling; like wind in the trees d. flat, dull tones with a moderate pitch

c. soft, low rustling; like wind in the trees

The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? a. friction rub auscultated at the left lower sternal border b. pain aggravated by breathing, coughing, and swallowing c. splinter hemorrhages d. thickening of the endocardium

c. splinter hemorrhages Splinter hemorrhages are indicative of infective endocarditis. Friction rub in the left lower sternal border and pain aggravated by breathing, coughing, and swallowing are signs and symptoms indicative of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.

A patient reports during a routine check-up that he is experiencing chest pain and shortness of breath while performing activities. He states the pain goes away when he rests. This is known as: a. unstable angina b. variant angina c. stable angina d. prinzmetal angina

c. stable angina Stable angina occurs during activities but goes away when the patient rests. Variant and Prinzmetal angina are the same and occur at rest during cycles. Unstable angina is chest pain felt during rest and is more severe.

A patient reports chest pain that is unrelieved with a sublingual nitroglycerin tablet. What does the nurse administer next to this patient? a. valium intramuscularly b. morphine sulfate IV c. supplemental oxygen d. chewable aspirin

c. supplemental oxygen

You are looking through your patients history and note that the patient has aortic stenosis. When you go to assess the patient, what heart sound do you expect to hear? a. clicking b. rubbing c. swooshing d. gallop

c. swooshing When listening to heart sounds, if you hear a rubbing noise, it means there is inflammation in the pericardium (pericarditis). Clicks are often heard with mitral valve prolapse or someone with a prosthetic valve. Aortic stenosis causes a murmur, which makes a swooshing sound. If you hear a gallop sound (S3) you are hearing the blood prematurely rushing into the ventricle which can be from either pulmonary hypertension, heart failure or coronary artery disease.

The nurse has just given a patient two doses of sublingual nitroglycerin for anginal pain. The patient's blood pressure is typically 130/80 mm Hg. which finding warrants immediate notification of the health care provider? a. patient reports a headache b. systolic pressure is 140 mm Hg c. systolic pressure is 90 mm Hg d. anginal pain continues but is somewhat relieved

c. systolic pressure is 90 mm Hg

A patient's bilateral radial pulses are occasionally weak and irregular. Which assessment technique does the nurse use first to investigate this finding? a. check the color and the capillary refill in the upper extremities b. check the peripheral pulses in the lower extremities c. take the apical pulse for 1 minute, noting any irregularity in heart rhythm d. check the cardiac monitor for irregularities in rhythm

c. take the apical pulse for 1 minute, noting any irregularity in heart rhythm

A 38-year-old female is admitted with respiratory failure secondary to viral pneumonitis. She is receiving mechanical ventilation and suddenly becomes restless, tachypneic, tachycardic, and hypotensive. The high-pressure ventilator alarm is continuous, and pulse oximetry (SpO2) decreases to 0.83. Breathe sounds are diminished on the right with tracheal deviation to the left. What condition is likely developing? a. ARDS b. hemothorax c. tension pneumothorax d. pulmonary embolism

c. tension pneumothorax

A patient has heart failure related to MI. What interventions does the nurse plan for this patient's care? a. administering digoxin (Lanoxin) 1.0 mg as a loading dose and then daily b. infusing IV fluids to maintain a urinary output of 60 mL/hr c. titrating vasoactive drugs to maintain a sufficient cardiac output d. observing for such complications as hypertension and flushed, hot skin

c. titrating vasoactive drugs to maintain a sufficient cardiac output

A client has a fever of 104° F (40° C). In which direction, if any, does this shift the oxygen-hemoglobin dissociation curve? a. down b. to the left c. to the right d. will not shift

c. to the right A client with fever has a higher demand for oxygen, so the curve will shift to the right for easier dissociation. The curve does not move up or down on the vertical axis. Moving to the left would cause hemoglobin to dissociate oxygen less easily.

A patient is admitted with sepsis. The patient has a temperature of 104.2 'F and is experiencing chills. On assessment, you note a mitral murmur which the patient states they've never had before, and dark, small lines on the patient's fingernails. The patient has a history of IV drug use in the past. However, the patient states they are no longer using drugs. The physician suspects possible infective endocarditis. What diagnostic test do you expect the physician to order in order to confirm the presence of infective endocarditis? a. abdominal ultrasound b. heart catheterization c. transesophageal echocardiogram d. WBC

c. transesophageal echocardiogram Transesophageal echocardiogram (TEE) is an ultrasound performed to look at the back side of the heart and assesses the valve structure. It is a test used to diagnose vegetations found on the valves. All the other options do not confirm endocarditis.

When auscultating a heart murmur, the nurse understands that the sound produced by a heart murmur can be caused by: a. opening and shutting of diseased valves b. vibrations caused by the diseased valves c. turbulence of abnormal blood flow d. rapid blood flow through the valves

c. turbulence of abnormal blood flow

While assisting a client during peritoneal dialysis, the nurse observes the drainage stop after 200 mL of peritoneal effluent drains into the bag. What action should the nurse implement first? a. instruct the client to deep-breathe and cough b. document the effluent as output c. turn the client to the opposite side d. re-position the catheter

c. turn the client to the opposite side With peritoneal dialysis, usually 1 to 2 L of dialysate is infused by gravity into the peritoneal space. The fluid dwells in the peritoneal cavity for a specified time, then drains by gravity into a drainage bag. The dialyzing fluid is called peritoneal effluent on outflow. The outflow should be a continuous stream after the clamp is completely open. Potential causes of flow difficulty include constipation, kinked or clamped connection tubing, the client's position, fibrin clot formation, and catheter displacement. If inflow or outflow drainage is inadequate, re-position the client to stimulate inflow or outflow. Turning the client to the other side or ensuring that he or she is in good body alignment may help. Instructing the client to deep-breathe and cough will not promote dialysate drainage. Increased abdominal pressure from coughing contributes to leakage at the catheter site. The nurse needs to measure and record the total amount of outflow after each exchange. However, the nurse should re-position the client first to assist with complete dialysate drainage. An x-ray is needed to identify peritoneal dialysis catheter placement. Only the physician re-positions a displaced catheter.

Which factor represents a sign or symptom of digoxin toxicity? a. serum digoxin level of 1.2 ng/mL b. polyphagia c. visual changes d. serum potassium of 5.0 mEq/L

c. visual changes Visual changes, anorexia, nausea, and vomiting are symptoms of digoxin toxicity. A digoxin level of 1.2 ng/mL is normal (0.5 to 2.0 ng/mL). Polyphagia is a symptom of diabetes. Although hypokalemia may predispose to digoxin toxicity, this represents a normal, not low, potassium value.

When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? a. auscultation of crackles b. pedal edema c. weight loss of 6 pounds since the last visit d. reports sucking on ice chips all day for dry mouth

c. weight loss of 6 pounds since the last visit Weight loss in this client indicates effective fluid restriction and diuretic drug therapy. Lung crackles indicate intra-alveolar edema and fluid excess. Pedal edema indicates fluid excess. Sucking on ice chips indicates noncompliance with fluid restrictions; alternative methods of treating dry mouth should be explored.

You are providing care to a patient experiencing chest pain when coughing or breathing in. The patient has pericarditis. The physician has ordered the patient to take Ibuprofen for treatment. How will you administer this medication? a. strictly without food b. with a full glass of juice c. with a full glass of water d. with or without food

c. with a full glass of water Ibuprofen should be taken with a full glass of water to prevent GI problems, such as ulcers or bleeding.

A patient is being discharged home after hospitalization of left ventricular systolic dysfunction. As the nurse providing discharge teaching to the patient, which statement is NOT a correct statement about this condition? a. "Signs and symptoms of this type of heart failure can include: dyspnea, persistent cough, difficulty breathing while lying down, and weight gain." b. "It is important to monitor your daily weights, fluid and salt intake." c. "Left-sided heart failure can lead to right-sided heart failure, if left untreated." d. "This type of heart failure can build up pressure in the hepatic veins and cause them to become congested with fluid which leads to peripheral edema."

d. "This type of heart failure can build up pressure in the hepatic veins and cause them to become congested with fluid which leads to peripheral edema." Left-sided systolic dysfunction is where the left side of the heart is unable to CONTRACT efficiently which causes blood to back-up into the lungs...leading to pulmonary edema.

A client with thrombocytopenia is being discharged. What information does the nurse incorporate into the teaching plan for this client? a. "Avoid large crowds." b. "Drink at least 2 liters of fluid per day." c. "Elevate your lower extremities when sitting." d. "Use a soft-bristled toothbrush."

d. "Use a soft-bristled toothbrush." Using a soft-bristled toothbrush reduces the risk for bleeding in the client with thrombocytopenia. Avoiding large crowds reduces the risk for infection, but is not specific to the client with thrombocytopenia. Increased fluid intake reduces the risk for dehydration, but is not specific to the client with thrombocytopenia. Elevating extremities reduces the risk for dependent edema, but is not specific to the client with thrombocytopenia.

A client is being treated for kidney failure. Which statement by the nurse encourages the client to express his or her feelings and concerns about the risk for death and the disruption of lifestyle? a. "All of this is new. What can't you do?" b. "Are you afraid of dying?" c. "How are you doing this morning?" d. "What concerns do you have about your kidney disease?"

d. "What concerns do you have about your kidney disease?" Asking the client about any concerns is open-ended and specific to the client's concerns. Asking the client to explain what he or she can't do implies inadequacy on the client's part. Asking the client if he or she is afraid of dying is too direct and would likely cause the client to be anxious. Asking the client how he or she is doing is too general and does not encourage the client to share thoughts on a specific topic.

During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." What is the nurse's best response? a. "You are right. Work on your diet then." b. "You must find someplace to walk." c. "Walk around the edge of your apartment complex." d. "Where might you be able to walk?"

d. "Where might you be able to walk?" Asking the client where he or she might be able to walk calls for cooperation and participation from the client; increased activity is imperative for this client. Telling the client to work on diet is an inappropriate response. Telling the client to find someplace to walk is too demanding to be therapeutic. Telling the client to walk around the apartment complex is domineering and will not likely achieve cooperation from the client.

The nurse is talking to a patient with angina about resuming sexual activity. which statement by the patient indicates a correct understanding about the effects of angina on sexual activity? a. "I won't be able to resume the same level of physical exertion as I did before I had chest pain." b. "I will discuss alternative methods with my partner since I will no longer be able to have sexual intercourse." c. "If I cannot walk a mile, I am not strong enough to resume intercourse." d. "With approval from my health care provider, I should resume sexual activity in the mornings or after a rest period."

d. "With approval from my health care provider, I should resume sexual activity in the mornings or after a rest period."

A client with multiple myeloma reports bone pain that is unrelieved by analgesics. How does the nurse respond to this client's problem? a. "Ask your doctor to prescribe more medication." b. "It is too soon for additional medication to be given." c. "I'll turn on some soothing classical music for you." d. "Would you like to try some relaxation techniques?"

d. "Would you like to try some relaxation techniques?" Because most clients with multiple myeloma have local or generalized bone pain, analgesics and alternative approaches for pain management, such as relaxation techniques, are used for pain relief. This also offers the client a choice. Before prescribing additional medication, other avenues should be explored to relieve this client's pain. Even if it is too soon to give additional medication, telling that to the client is not helpful because it dismisses the client's pain concerns. Although music therapy can be helpful, this response does not give the client a choice.

A client was intubated 30 minutes ago for acute respiratory distress syndrome and possible sepsis. The following orders have been given for the client. In what sequence would the nurse perform these orders for this client? 1. Infuse levofloxacin (Levaquin) 500 mg IV. 2. Obtain baseline aerobic and anaerobic sputum cultures. 3. Teach the client and family methods of communicating. 4. Analyze postintubation arterial blood gases (ABGs). a. 2, 1, 3, 4 b. 4, 3, 1, 2 c. 3, 4, 2, 1 d. 4, 2, 1, 3

d. 4, 2, 1, 3 ABGs should be analyzed first before the other assessments/actions are carried out. A baseline of sputum cultures should then be obtained before medications are administered. Then levofloxacin can be given. Client and family education on communication methods is important, but is the lowest priority here.

When the mitral and tricuspid valves open, there is a rapid filling of blood passively from the atria into the ventricles. What percentage of blood fills the ventricles during this phase of the diastole? a. 50% b. 60% c. 70% d. 80%

d. 80%

The nurse assesses the client with which hematologic problem first? a. 32-year-old with pernicious anemia who needs a vitamin B12 injection b. 40-year-old with iron deficiency anemia who needs a Z-track iron injection c. 67-year-old with acute myelocytic leukemia with petechiae on both legs d. 81-year-old with thrombocytopenia and an increase in abdominal girth

d. 81-year-old with thrombocytopenia and an increase in abdominal girth An increase in abdominal girth in a client with thrombocytopenia indicates possible hemorrhage; this warrants further assessment immediately. The 32-year-old with pernicious anemia, the 40-year-old with iron deficiency anemia, and the 67-year-old with acute myelocytic leukemia do not indicate any acute complications, so the nurse can assess them after assessing the client with thrombocytopenia.

These drugs are used as first-line treatment of heart failure. They work by allowing more blood to flow to the heart which decreases the work load of the heart and allows the kidneys to secrete sodium. However, some patients can develop a nagging cough with these types of drugs. This description describes? a. beta blockers b. vasodilators c. angiotensin II receptor blockers d. ACE inhibitors

d. ACE inhibitors

Your patient was admitted with shortness of breath and has a new diagnosis of heart failure. Which of the following labs indicate the patient is suffering from severe heart failure? a. HDL 192 mg/dL b. CVP 8 mmHg c. BNP 8.5 pg/mL d. BNP 850 pg/mL

d. BNP 850 pg/mL BNP can help quantify the severity of heart failure. A BNP from 600-900 pg/mL indicates severe heart failure. HDL is a measurement of the high densitiy lipoporteins, which would not provide any further information abotu heart failure. CVP (central venous pressure) is reflective of the blood pressure in the vena cava and within normal range.

Increased BUN and creatinine, hyperkalemia, and hypernatremia are all characteristics of which stage of kidney disease? a. stage I CKD b. mild CKD c. moderate CKD d. ESKD

d. ESKD

A nurse is caring for a client with ARDS and views the ABG results seen in the diagram. Based on the ABG results, which of the following findings would the nurse be most likely find in this client? pH = 7.35 PaCO2 = 26 mmHg HCO3 = 22 mEq/L PaO2 = 95 mmHg a. SpO2 82% b. BP 124/68 mmHg c. HR 94 bpm d. RR 32 bpm

d. RR 32 bpm

A patient reports having crushing chest pain that radiates to the jaw. You administer sublingual nitroglycerin and obtain a 12 lead EKG. Which of the following EKG findings confirms your suspicion of a possible myocardial infraction? a. absent Q wave b. QRS widening c. absent P wave d. ST segment elevation

d. ST segment elevation

A 56-year-old male patient has been admitted to the cardiac unit with exacerbation of heart failure symptoms. The nurse has given him a nursing diagnosis of decreased cardiac output related to heart failure, as evidenced by a poor ejection fraction, weakness, edema, and decreased urinary output. Which of the following nursing interventions are most appropriate in this situation? a. increase activity by encouraging ambulation b. administer IV fluid boluses to increase urinary output c. maintain the patient in the Trendelenburg position while in bed d. administer stool softeners as ordered

d. administer stool softeners as ordered When a patient has a nursing diagnosis of decreased cardiac output, the nurse should avoid any activities that would put undue stress on the patients heart. In this situation, the nurse can administer stool softeners so that the patient does not have to strain to have a bowel movement, which would place less stress on his heart.

The nurse just recieved report on her client who is on the ventilator for volume. The nurse should be concerned if which of the following setting on the ventilator changes? a. airway pressure decreases b. any change on the vent settings is alarming c. no changes on settings, the nurse doesn't adjust the settings. d. airway pressure increases

d. airway pressure increases

A patient is at risk for heart failure, but currently has no official medical diagnosis. While assessing the patient's lungs, the nurse hears profuse fine crackles. What does the nurse do next? a. report the finding to the health care provider b. document the finding as a baseline for later comparison c. give the patient low-flow supplemental oxygen d. ask the patient to cough and reausculate the lungs

d. ask the patient to cough and reausculate the lungs

The health care provider has ordered an ARB for a patient with heart failure. The parameters are to maintain a systolic blood pressure ranging from 90 to 110 mm Hg. Today the patient has a blood pressure of 110/80 mm Hg, but shows acute confusion. What is the nurse's first priority action? a. give the medication because blood pressure is within the parameters b. call the health care provider about the new onset of confusion c. hold the medication and document the new findings d. assess the patient for other symptoms of decreased tissue perfusion

d. assess the patient for other symptoms of decreased tissue perfusion

The health care provider has prescribed varenicline (Chantix) for the patient who wishes to quit smoking. What specific priority teaching must the nurse provide for the patient and his family? a. avoid spending time in enclosed spaces with active smokers b. make a list of all the reasons that you wish to quit smoking cigarettes c. plan to reward yourself with the money you save from not smoking cigarettes d. be sure to report any changes in behavior or thought processes to your health care provider

d. be sure to report any changes in behavior or thought processes to your health care provider

Which of the following is consistent with the diagnosis of acute-left sided systolic heart failure? a. brain-natriuretic peptide level <80 pg/mL b. ejection fraction >65% c. pericardial friction rub d. bilateral pleural effusions

d. bilateral pleural effusions

A patient has AKI related to nephrotoxins. In order to maintain cell integrity, improve GFR, and improve blood flow to the kidneys, which type of medication does the nurse anticipate the health care provider will prescribe? a. loop diuretics b. alpha-adrenergic blockers c. beta blockers d. calcium channel blockers

d. calcium channel blockers

A patient has recently been diagnosed with acute heart failure. Which medication order does the nurse question? a. dobutamine (Dobutrex), a beta-adrenergic agonist b. milrinone (Primacor), a phosphodiesterase inhibitor c. levosimendan (Simdax), a positive inotropic d. carvedilol (Coreg), a beta blocker

d. carvedilol (Coreg), a beta blocker

A client has been taking furosemide (Lasix) and valsartan (Diovan) for the past year. The hospital laboratory notifies the nurse that the client's serum potassium level is 6.2 mEq/L. What is the nurse's best action at this time? a. assess the client's oxygen saturation level b. ask the laboratory to retest the potassium level c. give potassium as an IV infusion d. check the client's serum creatinine

d. check the client's serum creatinine Clients who are hyperkalemic (those with an elevated serum potassium level) may also be in renal failure. The client's serum creatinine should be reviewed to determine if it is greater than 1.8 mg/dL, at which time the health care provider should be notified before administering any supplemental potassium.

You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding? a. reposition the patient because the tubing is kinked b. continue to monitor the drainage system c. increase the suction to the drainage system until the bubbling stops d. check the drainage system for an air leak

d. check the drainage system for an air leak Continuous bubbling in the water seal chamber is NOT normal and indicates there is an air leak. However, oscillation of the water in the water seal chamber is normal.

A patient who has diabetes will be started on Metoprolol for medical management of coronary artery disease. Which of the following will you include in your discharge teaching about this medication? a. check your heart rate regularly because Metoprolol can cause an irregular heart rate b. check your glucose regularly because this medication can cause hyperglycemia c. check your blood pressure regularly because this medication can cause hypertension d. check your glucose regularly because this medication can mask the typical signs and symptoms of hypoglycemia

d. check your glucose regularly because this medication can mask the typical signs and symptoms of hypoglycemia This patient needs to be educated to check their glucose levels regularly because this medication can mask the typical signs and symptoms of hypoglycemia. This is very important since the patient is diabetic.

A 38-year-old female is admitted with respiratory failure secondary to viral pneumonitis. She is receiving mechanical ventilation and suddenly becomes restless, tachypneic, tachycardic, and hypotensive. The high-pressure ventilator alarm is continuous, and pulse oximetry (SpO2) decreases to 0.83. Breathe sounds are diminished on the right with tracheal deviation to the left. Treatment for the patient would likely include which of the following? a. morphine and furosemide b. addition of PEEP c. vasopressors d. chest tube

d. chest tube

To validate that a client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests? a. creatine kinase-mb fraction (ck-mb) and alkaline phosphatase b. homocysteine and c-reactive protein c. total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol d. ck-mb and troponin

d. ck-mb and troponin CK-MB and troponin are the cardiac markers used to determine whether MI has occurred. Alkaline phosphatase is often elevated in liver disease. Homocysteine and C-reactive protein are markers of inflammation, which may represent risk for MI, but they are not diagnostic for MI. Elevated cholesterol levels are risks for MI, but they do not validate that an MI has occurred.

Which diagnostic tests are used to assess myocardial damage caused by an MI? Select all that apply. a. positive chest x-ray b. creatine kinase (CK) elevation c. ecg: st depression d. ck-mb isoenzymes elevation e. troponin I isoenzyme elevation

d. ck-mb isoenzymes elevation e. troponin I isoenzyme elevation

The nurse is working in an urgent care clinic. Which client needs to be evaluated first by the nurse? a. client who is short of breath after walking up two flights of stairs b. client with soreness of the arm after receiving purified protein derivative (Mantoux) skin test c. client with sore throat and fever of 102.2° F (39° C) oral d. client who is speaking in three-word sentences and has an SpO2 of 90% by pulse oximetry

d. client who is speaking in three-word sentences and has an SpO2 of 90% by pulse oximetry A client should be able to speak in sentences of more than three words, and an SpO2 of 90% indicates hypoxemia that requires intervention on the part of the nurse. Shortness of breath after walking up two flights of stairs may not be an emergency. Although not a usual finding, the arm may be sore after a skin test is performed. Sore throat and fever are symptoms of infection that require further evaluation but not emergently.

Which client does the charge nurse on the medical unit assign to an RN who has floated from the postanesthesia care unit (PACU)? a. client with allergic rhinitis scheduled for skin testing b. client with emphysema who needs teaching about pulmonary function testing c. client with pancreatitis who needs a preoperative chest x-ray d. client with pleural effusion who has had 1200 mL removed by thoracentesis

d. client with pleural effusion who has had 1200 mL removed by thoracentesis A nurse working in the PACU would be familiar with assessing vital signs and respiratory status after procedures such as thoracentesis. Skin testing is performed in the outpatient setting. Pulmonary function testing is not a procedure that requires PACU care. Although a client with pancreatitis is seriously ill and would require a chest x-ray before undergoing operative procedures, a nurse with a PACU monitoring skill set would not be required.

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective? a. client has diuresis of 400 mL in 24 hours b. client's blood pressure is 122/84 mm Hg c. client has an apical pulse of 82 beats/min d. client's weight decreases by 2.5 kg

d. client's weight decreases by 2.5 kg The best indicator of fluid volume gain or loss is daily weight; because each kilogram represents approximately 1 liter, this client has lost approximately 2500 mL of fluid. Diuresis of 400 mL in 24 hours represents oliguria. Although a blood pressure of 122/84 mm Hg is a normal finding, alone it is not significant for relief of hypervolemia. Although an apical pulse of 82 beats/min is a normal finding, alone it is not significant to determine whether hypervolemia is relieved.

Which assessment finding is an objective sign of chronic oxygen deprivation? a. continuous cough productive of clear sputum b. audible inspiratory and expiratory wheeze c. chest pain that increases with deep inspiration d. clubbing of fingernails and a barrel-shaped chest

d. clubbing of fingernails and a barrel-shaped chest

Which early reaction is most common in patients with the chest discomfort associated with unstable angina or MI? a. depression b. anger c. fear d. denial

d. denial

During your morning assessment of a patient with heart failure, the patient complains of sudden vision changes that include seeing yellowish-green halos around the lights. Which of the following medications do you suspect is causing this issue? a. lisinopril b. losartan c. lasix d. digoxin

d. digoxin Yellowish-green halos/vision changes are classic signs of Digoxin toxicity.

The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY? a. place the patient in supine position and clamp the tubing b. notify the physician immediately c. disconnect the drainage system and get a new one d. disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system

d. disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system A new system needs to be obtained, however, in order to maintain a water seal until the new system arrives you will need to place the tubing 1 inch in sterile water or sterile saline to regain a water seal.

The nurse is caring for a patient with an arteriovenous fistula. What instructions are given to the UAP regarding the care of this patient? a. palpate for thrills and auscultate for bruits every 4 hours b. check for bleeding at needle insertion site c. assess the patient's distal pulses and circulation d. do not take blood pressure readings in the arm with the fistula

d. do not take blood pressure readings in the arm with the fistula

Which new assessment finding in a client with sickle cell disease who currently is in crises does the nurse report immediately to the health care provider? a. pain in the right hip with limited range of motion b. slow capillary refill in the toes of the right foot c. yellow appearance of the roof of the mouth d. facial drooping on the right side

d. facial drooping on the right side All current assessment findings are important. However, the pain in the hip, the slow capillary refill, and the yellow appearance of the roof of the mouth are related to the crises and are expected. The facial drooping as a new finding indicates the possibility of reduced brain perfusion and stroke. This dew development requires immediate attention and intervention.

The nurse is caring for the kidney transplant patient in the immediate postoperative period. During this initial period, the nurse will assess the urine output at least every hour for how many hours? a. first 8 hours b. first 12 hours c. first 24 hours d. first 48 hours

d. first 48 hours

Which of the following is a late sign of heart failure? a. shortness of breath b. orthopnea c. edema d. frothy-blood tinged sputum

d. frothy-blood tinged sputum Shortness of breath, orthopnea, and edema are EARLY signs and symptoms. Frothy-blood tinged sputum is a late sign.

A nurse is preparing to administer furosemide to a patient who is in the hospital with heart failure. Which of the following should the nurse consider when administering this medication? a. do not administer the medication with meals b. decrease fluid intake to avoid excess urine secretion c. monitor the patient's temperature every 4 hours d. give the dose early in the day

d. give the dose early in the day Furosemide is a diuretic medication that reduces excess fluid through urination. When giving this medication, the nurse should give it early in the day, as it will cause the patient to need to use the bathroom frequently. The nurse should avoid giving it in the evening, because it will disrupt sleep if the patient has to get up multiple times during the night to urinate.

What is the most important determinant of coronary arteyr blood flow to the myocardial tissue? a. afterload b. systemic vascular resistance c. preload d. heart rate

d. heart rate

The physician's order says to administered Lasix 40 mg IV twice a day. The patient has the following morning labs: Na+ 148, BNP 900, K+ 2.0, and BUN 10. Which of the following is a nursing priority? a. administer the Lasix as ordered b. notify the physician of the BNP level c. assess the patient for edema d. hold the dose and notify the physician about the potassium level

d. hold the dose and notify the physician about the potassium level Lasix is a diuretic that wastes potassium. A normal potassium level is 3.5-5.1. The nurse should hold the dose and notify the physician who will order a potassium supplement to replace the potassium deficient.

An 82-year-old client with anemia is requested to receive 2 units of whole blood. Which assessment findings cause the nurse to discontinue the transfusion because it is unsafe for the client? Select all that apply. a. capillary refill less than 3 seconds b. decreased pallor c. flattened superficial veins d. hypertension e. hypotension f. rapid, bounding pulse

d. hypertension e. hypotension f. rapid, bounding pulse In an older adult receiving a transfusion, hypertension is a sign of overload, low blood pressure is a sign of a transfusion reaction, and a rapid and bounding pulse is a sign of fluid overload. In this scenario, 2 units, or about a liter of fluid, could be problematic. Capillary refill time that is less than 3 seconds is considered to be normal and would not pose a problem. Increased (not decreased) pallor and cyanosis are signs of a transfusion reaction, while swollen (not flattened) superficial veins are present in fluid overload in older adult clients receiving transfusions.

The nurse is taking a history on a patient with diabetes and hypertension. Because of the patient's high risk for developing kidney problems, which early sign of chronic kidney disease (CKD) does the nurse assess for? a. decreased output with subjective thirst b. urinary frequency of very small amounts c. pink or blood-tinged urine d. increased output of very dilute urine

d. increased output of very dilute urine

Appropriate drug therapy for dilated cardiomyopathy is aimed toward: a. decreasing contractility and decreasing preload and afterload b. decreasing contractility and increasing preload and afterload c. increasing contractility and increasing both preload and afterload d. increasing contractility and decreasing both preload and afterload

d. increasing contractility and decreasing both preload and afterload

A nurse is caring for a client who is in respiratory distress because of ARDS. Which of the following nursing diagnoses would most likely be associated with this condition? a. disturbed personal identity b. impaired urinary elimination c. ineffective thermoregulation d. ineffective tissue perfusion

d. ineffective tissue perfusion

A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which potential problem takes priority in the client's nursing care plan? a. fluid overload (overhydration) b. hemorrhage c. hypoxia d. infection

d. infection The main objective in caring for a newly diagnosed client with leukemia is protection from infection. Fluid overload, hemorrhage, and hypoxia are not priority problems for the client with leukemia.

A patient with pernicious anemia is ordered to receive supplementary Vitamin B12. What is the best route to administer this medication for patients with this disorder? a. IV b. orally c. through a central line d. intramuscular

d. intramuscular Patients with Vitamin B12 do NOT absorb vitamin B12 through the GI system due to lacking intrinsic factor (which helps with the absorption of vitamin B12)....therefore, you would not give it orally. The best route for administering vitamin B12 is via the muscle (intramuscular).

ARDS is characterized by the destruction of surfactant. Which of the following statements accurately describes surfactant? a. it increases surface tension as alveolar volume decreases b. reduced surfactant increases compliance c. it allows alveoli to collapse and re-expand during respiration d. it is produced by alveolar epithelial cells

d. it is produced by alveolar epithelial cells

Select the statement below that best describes cardiac afterload: a. it's the volume amount that fills the ventricles at the end of diastole b. it's the volume the ventricles must work against to pump blood out of the bod c. it's the amount of blood the left ventricle pumps per beat d. it's the pressure the ventricles must work against to open the semilunar valves so blood can be pumped out of the heart

d. it's the pressure the ventricles must work against to open the semilunar valves so blood can be pumped out of the heart Cardiac afterload is the pressure the ventricles must work against to pump blood out of the heart by opening up through the semilunar valves. So, it's the pressure the ventricles must overcome to open the semilunar valves to push blood out of the heart.

A patient has been diagnosed with AKI, but the cause is uncertain. The nurse prepares patient educational material about which diagnostic test? a. flat plate of the abdomen b. renal ultrasonography c. computed tomography d. kidney biopsy

d. kidney biopsy

The nurse is giving a community presentation about heart disease. Because many sudden cardiac arrest victims die of ventricular fibrillation before reaching the hospital, which teaching point does the nurse emphasize? a. controlling alcohol consumption and quitting cigarette smoking b. modifying risk factors such as diet and weight, and blood pressure medication compliance c. recognizing the difference between chronic stable angina and unstable angina d. learning to operate the automatic external defibrillators (AEDs) in the workplace

d. learning to operate the automatic external defibrillators (AEDs) in the workplace

What type of heart failure does this statement describe? The ventricle is unable to properly fill with blood because it is too stiff. Therefore, blood backs up into the lungs causing the patient to experience shortness of breath. a. left ventricular systolic dysfunction b. left ventricular ride-sided dysfunction c. right ventricular diastolic dysfunction d. left ventricular diastolic dysfunction

d. left ventricular diastolic dysfunction

Which assessment finding represents a positive response to erythropoietin (Epogen, Procrit) therapy? a. hematocrit of 26.7% b. potassium within normal range c. absence of spontaneous fractures d. less fatigue

d. less fatigue Treatment of anemia with erythropoietin will result in increased hemoglobin and hematocrit (H&H) and decreased shortness of breath and fatigue. A hematocrit value of 26.7% is low; erythropoietin should restore the hematocrit to at least 36% to be effective. Erythropoietin causes more red blood cells to be produced, increasing H&H, not potassium. Calcium supplements and phosphate binders prevent renal osteodystrophy; erythropoietin treats anemia.

Lipitor is prescribed for a patient with a high cholesterol level. As the nurse, how do you educate the patient on how this drugs works on the body? a. lipitor increases LDL levels and decreases HDL levels, total cholesterol, and triglyceride levels b. lipitor decreases LDL, HDL levels, total cholesterol, and triglyceride levels c. lipitor increases HDL levels, total cholesterol, and triglyceride levels d. lipitor increases HDL levels and decreases LDL, total cholesterol, and triglyceride levels

d. lipitor increases HDL levels and decreases LDL, total cholesterol, and triglyceride levels Lipitor is a common "statin" medication used to lower cholesterol in CAD. It works by increasing HDL levels (the "good" cholesterol") and decreases LDL (the "bad" cholesterol"), total cholesterol, and triglyceride levels.

The nurse is reviewing the ECG of a patient on digoxin therapy. What early sign of digitalis toxicity does the nurse look for? a. tachycardia b. peaked T wave c. atrial fibrillation d. loss of p wave

d. loss of p wave

All patient with hypertension or diabetes should have yearly screenings for which factor? a. creatinine b. BUN c. glycosuria d. microalbuminuria

d. microalbuminuria

A client has returned to the postanesthesia care unit (PACU) after a bronchoscopy. Which nursing task is best for the charge nurse to delegate to the experienced nursing assistant working in the PACU? a. assess breath sounds b. check gag reflex c. determine level of consciousness d. monitor blood pressure and pulse

d. monitor blood pressure and pulse A nursing assistant working in the PACU would have experience in taking client vital signs after the client has had conscious sedation or anesthesia. Evaluating breath sounds and gag reflex and determining level of consciousness require the skill and knowledge of a higher-level provider.

Which of the following statement regarding coronary blood flow is true? a. coronary blood flow is about 150 mL per minute b. coronary blood flow is increased by tachycardia d. most of the coronary blood flow is in diastole d. heart uses 50% of the oxygen available in the coronary circulation

d. most of the coronary blood flow is in diastole

What is an early sign of left ventricular failure that a patient is most likely to report? a. nocturia b. weight gain c. swollen legs d. nocturnal coughing

d. nocturnal coughing

Which would be an appropriate task to delegate to unlicensed assistive personnel (UAP) working on a medical-surgical unit? a. administering erythropoietin to a client with myelodysplastic syndrome b. assessing skin integrity on an anemic client who fell during ambulation c. assisting a client with folic acid deficiency in making diet choices d. obtaining vital signs on a client receiving a blood transfusion

d. obtaining vital signs on a client receiving a blood transfusion Obtaining vital signs on a client is within the scope of practice for UAP. Administering medication, assessing clients, and assisting with prescribed diet choices are complex actions that should be done by licensed nurses.

A 70-year-old client with heart failure is being treated in the hospital for complications of the disease. The nurse notes that the client has swelling in the lower extremities and assesses for pitting edema. In which location should the nurse most likely test for pitting edema? a. by squeezing the great toe b. on the back of the lower leg c. behind the knee d. on the dorsum of the foot

d. on the dorsum of the foot Pitting edema is the accumulation of fluid in the lower extremities. It is termed pitting if the nurse can press a fingertip into the swelling area and leave a mark or pit as an indentation. Pitting edema is graded based on its severity and is typically checked by pressing a finger onto the dorsum of the foot, next to the ankle, or on the front of the shin. "By squeezing the great toe", "On the back of the lower leg", and "Behind the knee" are incorrect, because these are not places where assessment for pitting edema is done.

A patient is diagnosed with left-sided systolic dysfunction heart failure. Which of the following are expected findings with this condition? a. echocardiogram shows an ejection fraction of 38% b. heart catheterization shows an ejection fraction of 65% c. [atient has frequent episodes of nocturnal paroxysmal dyspnea d. options a and c are both expected findings with left-sided systolic dysfunction heart failure

d. options a and c are both expected findings with left-sided systolic dysfunction heart failure

A patient with AKI is ill and has a poor appetite. What would the health care team try first? a. iv normal saline to prevent dehydration b. familiar foods brought by the family c. nasogastric tube for enteral feedings d. oral supplements designed for kidney patients

d. oral supplements designed for kidney patients

Which patient with kidney problems is the best candidate for peritoneal dialysis (PD)? a. patient with peritoneal adhesion b. patient with a history or extensive abdominal surgery c. patient with peritoneal membrane fibrosis d. patient with a history of difficulty with anticoagulants

d. patient with a history of difficulty with anticoagulants

Based on the etiology and the main cause of heart failure, which patient has the greatest need for health promotion measures to prevent heart failure? a. alzheimer's patient b. patient with cystitis c. patient with asthma d. patient with hypertension

d. patient with hypertension

On physical assessment of a patient with pericarditis, you may hear what type of heart sound? a. S3 or S4 b. mitral murmur c. pleural friction rub d. pericardial friction rub

d. pericardial friction rub A common sign of pericarditis is being able to auscultate a pericardial friction rub.

A patient with severe pericarditis has developed a large pericardial effusion. The patient is symptomatic. The physician orders what type of procedure to help treat this condition? a. pericardiectomy b. heart catherization c. thoractomy d. pericardiocentesis

d. pericardiocentesis The physician will probably order a pericardiocentesis. This is a procedure to remove excessive fluid from the pericardial sac.

The client is experiencing heart failure, the nurse knows that the client is experiencing right sided heart failure based on which of the following assessment? a. shortness of breath upon exertion b.fixed pupils c. course crackles in the lungs d. pitting edema in the bilateral legs

d. pitting edema in the bilateral legs Left sided heart failure effects the lungs and causes the auditory sounds over the lung fields to be crackles. Right sided heart failure has edema in the rest of the body.

The RN and the LPN/LVN are working together to provide care for a client hospitalized with dyspnea who requires all of these nursing actions. Which action is best accomplished by the RN? a. administer the purified protein derivative for tuberculosis testing b. assess vital signs and the puncture site after thoracentesis c. monitor oxygen saturation using pulse oximetry every 4 hours d. plan client and family teaching regarding upcoming pulmonary function testing

d. plan client and family teaching regarding upcoming pulmonary function testing Developing the teaching plan is the most complex of the skills listed and requires RN education and licensure. Medication administration and monitoring of vital signs and client status after procedures can be accomplished by the LPN/LVN. Monitoring of oxygen saturation by pulse oximetry can be included in the vital signs assessment.

The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? a. determines the client's physical limitations b. encourages alternate rest and activity periods c. monitors and documents heart rate, rhythm, and pulses d. positions the client to alleviate dyspnea

d. positions the client to alleviate dyspnea Positioning the client to alleviate dyspnea will help ease air hunger and anxiety. Administering oxygen therapy is also an important priority action. Determining the client's physical limitations is not a priority in this situation. Encouraging alternate rest and activity periods is not the immediate priority. Monitoring of heart rate, rhythm, and pulses is important, but is not the priority.

A nurse is discussing dietary intake for a patient with symptomatic heart failure. Which of the following foods should the nurse tell the patient to avoid? a. canned peaches b. salad with balsamic vinegar dressing c. fresh fish d. pre-packaged macaroni salad

d. pre-packaged macaroni salad Macaroni salad, when purchased already packaged, often contains large amounts of sodium. The nurse should assess whether the patient with heart failure is eating foods with too much sodium, as this can increase intravascular volume and contribute to worsening of symptoms. The nurse should tell the patient to avoid foods high in sodium, such as processed meats and pre-packaged soups and pasta.

The nurse is reviewing diagnostic test results for a patient who is hypertensive. Which laboratory result is an early warning sign of decreased heart compliance, and prompts the nurse to immediately notify the health care provider? a. normal B-type natriuretic peptide b. decreased hemoglobin and hematocrit c. elevated thyroxine (T4) d. presence of microalbuminuria

d. presence of microalbuminuria

Which problem excludes a client hoping to receive a kidney transplant from undergoing the procedure? a. history of hiatal hernia b. presence of diabetes and glycosylated hemoglobin of 6.8% c. history of basal cell carcinoma on the nose 5 years ago d. presence of tuberculosis

d. presence of tuberculosis Long-standing pulmonary disease and chronic infection typically exclude clients from transplantation; these conditions worsen with the immune suppressants that are required to prevent rejection. A client with a history of hiatal hernia is not exempt from undergoing a kidney transplant. Good control of diabetes is a positive point, and would not exclude the client from transplantation. Basal cell carcinoma is considered curable and occurred 5 years ago, consistent with appropriate candidates for transplantation.

The nurse is caring for a client who is in sickle cell crisis. What action does the nurse perform first? a. apply cool compresses to the client's forehead b. encourage the client's use of two methods of birth control c. increase food sources of iron in the client's diet d. provide pain medications as needed

d. provide pain medications as needed Analgesics are needed to treat sickle cell pain. Warm soaks or compresses can help reduce pain perception. Cool compresses do not help the client in sickle cell crisis. Birth control is not the priority for this client. Increasing iron in the diet is not pertinent for the client in sickle cell crisis.

Which of the following best describes the purpose of a ventricular assist device? a. assisting in gas exchange between oxygen and carbon dioxide at the alveolar level b. pumping deoxygenated blood to the pulmonary system to acquire oxygen c. opening the coronary vessels to provide more room for blood flow d. pumping blood from the lower chamber of the heart to perfuse the organs and tissues

d. pumping blood from the lower chamber of the heart to perfuse the organs and tissues A ventricular assist device (VAD) is used for clients with a weakened heart. This pumps blood from the ventricles to perfuse the organs and tissues in the same way that the heart normally would. This device may be used to support a client's heart following surgery or while waiting for a heart transplant.

Which of the following may be an effect of mechanical ventilation and PEEP (positive end-expiratory pressure)? a. atelectasis b. oxygen toxicity c. ARDS d. reduced cardiac output

d. reduced cardiac output

The nurse is caring for a client 36 hours after coronary artery bypass grafting, with a priority problem of intolerance for activity related to imbalance of myocardial oxygen supply and demand. Which finding causes the nurse to terminate an activity and return the client to bed? a. pulse 60 beats/min and regular b. urinary frequency c. incisional discomfort d. respiratory rate 28 breaths/min

d. respiratory rate 28 breaths/min Tachypnea and tachycardia reflect activity intolerance; activity should be terminated. Pulse 60 beats/min and regular is a normal finding. Urinary frequency may indicate infection or diuretic use, but not activity intolerance. Pain with activity after surgery is anticipated; pain medication should be available.

Your patient is experiencing chest pain and the patients inflammatory markers are elevated. You are worried about the patient having pericarditis. What heart sound would you expect to hear if your patient had pericarditis? a. swooshing b. gallop c. clicking d. rubbing

d. rubbing When listening to heart sounds, if you hear a rubbing noise, it means there is inflammation in the pericardium (pericarditis). Clicks are often heard with mitral valve prolapse or aortic stenosis (and also someone with a prosthetic valve). Murmurs make a swooshing sound. If you hear a gallop sound (S3) you are hearing the blood prematurely rushing into the ventrical which can be from either pulmonary hypertension, heart failure or coronary artery disease.

What is the most important environmental risk for developing leukemia? a. direct contact with others with leukemia b. family history c. living near high-voltage power lines d. smoking cigarettes

d. smoking cigarettes According to the American Cancer Society (ACS), the only proven lifestyle-related risk factor for leukemia is cigarette smoking. Leukemia is not contagious. Genetics is a strong indicator, but it is not an environmental risk factor. According to the ACS, living near high-voltage power lines is not a proven risk factor for leukemia.

A patient being treated for infective endocarditis is complaining of very sharp radiating abdominal pain that goes to the left shoulder and back. As the nurse familiar with complications of infective endocarditis, what do you suspect is the cause of this patient finding? a. renal embolic event b. pulmonary embolic event c. central nurse system embolic event d. splenic embolic event

d. splenic embolic event These are classic signs and symptoms of a splenic embolic event. The patient with endocarditis is at risk for renal, pulmonary, central nervous system, or spleen emboli. Renal emboli would present with flank pain with pus or blood in the urine. Pulmonary emboli would present with dyspnea, chest pain, or shortness of breath, and CNS emboli would present with confusion or difficulty speaking.

A client who is receiving a blood transfusion suddenly exclaims to the nurse, "I don't feel right!" What does the nurse do next? a. call the Rapid Response Team b. obtain vital signs and continue to monitor c. slow the infusion rate of the transfusion d. stop the transfusion

d. stop the transfusion The client may be experiencing a transfusion reaction; the nurse should stop the transfusion immediately. Calling the Rapid Response Team or obtaining vital signs is not the first thing that should be done. The nurse should not slow the infusion rate, but should stop it altogether.

The nurse is assessing a client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI? a. chest pain brought on by exertion or stress b. substernal chest discomfort occurring at rest c. substernal chest discomfort relieved by nitroglycerin or rest d. substernal chest pressure relieved only by opioids

d. substernal chest pressure relieved only by opioids Substernal chest pressure relieved only by opioids is typically indicative of MI. Substernal chest discomfort that occurs at rest is not necessarily indicative of MI; it could be a sign of unstable angina. Both chest pain brought on by exertion or stress and substernal chest discomfort relieved by nitroglycerin or rest are indicative of angina.

When caring for a client who receives peritoneal dialysis (PD), which finding does the nurse report to the provider immediately? a. pulse oximetry reading of 95% b. sinus bradycardia, rate of 58 beats/min c. blood pressure of 148/90 mm Hg d. temperature of 101.2° F (38.4° C)

d. temperature of 101.2° F (38.4° C) Peritonitis is the major complication of PD, caused by intra-abdominal catheter site contamination; meticulous aseptic technique must be used when caring for PD equipment. A pulse oximetry reading of 95% is a normal saturation. Although a heart rate of 58 beats/min is slightly bradycardic, the provider can be informed upon visiting the client. Clients with kidney failure tend to have slightly higher blood pressures due to fluid retention; this is not as serious as a fever.

A patient with heart failure has been ordered to reduce her sodium intake in order to better control her condition. Which best explains why reduction in sodium intake will affect symptoms of heart failure? a. increased sodium intake damages the heart valves and affects circulation b. increased dietary sodium leads to greater risk of atherosclerosis c. too much sodium intake is associated with fluid retention d. too much sodium has been shown to cause cardiac dysrhythmias

d. too much sodium has been shown to cause cardiac dysrhythmias Fluid retention is a risk for patients with fluid retention which causes volume overload associated with heart failure. Most patients with heart failure are counseled to avoid excess sodium and they often need to take medications to eliminate excess fluid from the body.

A middle-aged patient with no known medical problems has acute-onset chest pain and dyspnea. In order to rule out acute MI, the nurse obtains orders for which diagnostic tests? Select all that apply. a. triglyceride levels and C-reactive protein b. chest x-ray c. total serum cholesterol, low-density lipoprotein, high-density lipoprotein d. troponin T and I e. creatine kinase-MB f. arterial blood gases

d. troponin T and I e. creatine kinase-MB

A student nurse is working with a client in the ICU who is intubated and being mechanically ventilated. What action by the student causes the registered nurse to intervene? a. repositioning the client every 2 hours b. providing oral care with chlorhexidine rinse c. checking tube placement at the client's incisor d. turning off ventilator alarms while working in the room

d. turning off ventilator alarms while working in the room Ventilator alarms are critical to safety and indicating a need for early intervention when the client's gas exchange needs are not being met. Even when a nurse or other health care professional is present at the bedside, the alarms should never be turned off or set so inappropriately that they do not sound when parameters indicate a problem.

The nurse is assessing the skin of a patient with ESKD. Which clinical manifestation is considered a sign of very late, premorbid, advanced uremic syndrome? a. ecchymoses b. sallowness c. pallor d. uremic frost

d. uremic frost

The nurse is mentoring a recent graduate RN about administering blood and blood products. What does the nurse include in the data? a. obtain the client's initial set of vital signs (VS) within the first 10 minutes of the infusion b. remain with the client who is receiving the blood for the first 5 minutes of the infusion c. use a 22-gauge needle to obtain venous access when starting the infusion d. verify with another RN all of the data on blood products

d. verify with another RN all of the data on blood products All data are checked by two RNs. Human error is the most common cause of ABO incompatibilities in administering blood and blood products. Initial VS should be recorded before the start of infusion of blood, not after it has begun. The nurse remains with the client for the first 15 to 30 minutes (not 5) of the infusion. This is the period when any transfusion reactions are likely to happen. A 20-gauge needle (or a central line catheter) is used; the 22-gauge needle is too small.

Which description best defines preload? a. pressure the ventricles must press against to pump blood into the aorta b. closing of the mitral and tricuspid valves at the end of systole c. ability of the heart's muscle fibers to stretch enough to force blood into pulmonary circulation d. volume of blood returning to the heart and filling the ventricles at the end of diastole

d. volume of blood returning to the heart and filling the ventricles at the end of diastole The heart follows a specific cycle of filling and contracting that is effective in pumping blood to the organs and tissues. Preload is measured at the end of diastole of the previous heartbeat, and represents the volume of blood in the ventricles at their fullest point. The muscle fibers in the ventricles stretch in preparation for the next contraction in order to pump the 'load' of blood in contraction, or systole

The nurse is transfusing a unit of whole blood to a client when the health care provider requests the following: "Furosemide (Lasix) 20 mg IV push." What does the nurse do? a. add furosemide to the normal saline that is infusing with the blood b. administer furosemide to the client intramuscularly (IM) c. piggyback furosemide into the infusing blood d. wait until the transfusion has been completed to administer furosemide

d. wait until the transfusion has been completed to administer furosemide Completing the transfusion before administering furosemide is the best course of action in this scenario. Drugs are not to be administered with infusing blood products; they can interact with the blood, causing risks for the client. Stopping the infusing blood to administer the drug and then restarting it is also not the best decision. Changing the admission route is not a nursing decision.

Place the sequence of steps of continous ambulatory peritoneal dialysis (CAPD) in the correct order using the numbers 1 through 4. a. fluid stays in the cavity for a specified time prescribed by the health care provider b. 1 to 2 L of dialysate is infused by gravity over a 10- to 20-minute period c. fluid flows out of the body by gravity into a drainage bag d. warm the dialysate bags before installation by using a heating pad to wrap the bag

d. warm the dialysate bags before installation by using a heating pad to wrap the bag b. 1 to 2 L of dialysate is infused by gravity over a 10- to 20-minute period a. fluid stays in the cavity for a specified time prescribed by the health care provider c. fluid flows out of the body by gravity into a drainage bag

A patient is admitted for heart failure and has edema, neck vein distention, and ascites. What is the most reliable way to monitor fluid gain or loss in this patient? a. check for pitting edema in the dependent body parts b. auscultate the lungs for crackles or wheezing c. assess skin turgor and the condition of mucous membranes d. weight the patient daily at the same time with the same scale

d. weight the patient daily at the same time with the same scale

The nurse is caring for a client with neutropenia. Which clinical manifestation indicates that an infection is present or should be ruled out? a. coughing and deep breathing b. evidence of pus c. fever of 102° F or higher d. wheezes or crackles

d. wheezes or crackles Wheezes or crackles in the neutropenic client may be the first symptom of infection in the lungs. Coughing and deep breathing are not indications of infection, but can help prevent it. The client with leukopenia, not neutropenia, may have a severe infection without pus or with only a low-grade fever.

A patient has a history of heart failure. Which of the following statements by the patient indicates the patient may be experiencing heart failure exacerbation? a. "I've noticed that I've gain 6 lbs in one week." b. "While I sleep I have to prop myself up with a pillow so I can breathe." c. "I haven't noticed any swelling in my feet or hands lately." d. options b and c are correct e. options a and b are correct f. options a, b, and c are all correct

e. options a and b are correct

A client with acute kidney injury is receiving a fluid challenge of 500 mL of normal saline over 1 hour. With a drop factor of 20 drops/mL, how many drops per minute does the nurse infuse?__

167 drops/min

The nurse and the idetitian are planning dietary intake for a patient with AKI who is currently not on dialysis therapy. The dietitian informs the nurse that 0.6 g/kg of body weight of protein are needed. The patient weighs 130 pounds. How many grams of protein should the patient receive? Round grams to the nearest whole number.

55

ACE inhibitors work to decrease the workload on the heart by blocking the conversion of Angiotensin II to Angiotensin I which causes vasodilation. T or F

F ACE inhibitors work to decrease the workload on the heart by blocking the conversion of Angiotensin I to Angiotensin II (not Angiotensin II to Angiotensin I) which causes vasoconstriction (NOT vasodilation).

Endocarditis only affects the atrioventricular and semi-lunar valves in the heart. T or F

F Endocarditis can affect not only the heart valves but the interventricular septum and chordae tendineae as well.

Early signs and symptoms of iron-deficiency anemia are vague. T or F

T

Intrinsic factor is a protein that plays a role in how the body absorbs Vitamin B12. T or F

T

Patients with left-sided diastolic dysfunction heart failure usually have a normal ejection fraction. T or F

T

The left anterior descending coronary artery provides blood supply to the left ventricle, front of the septum and part of the right ventricle. T or F

T

The nurse administers sublingual nitroglycerine to a patient experiencing an angina episode. How soon does the nurse expect the pain to begin to subside? a. 1-2 minutes b. 5-6 minutes c. 10-12 minutes d. 15-20 minutes

a. 1-2 minutes

While monitoring a patient post-thoractomy, the nurse suspects hypoventilation. Which characteristics best define hypoventilation? a. PaCO2 >45 mmHg b. respiratory rate <12 c. pH <7.35 d. PaO2 <60 mmHg

a. PaCO2 >45 mmHg

A patient is scheduled to have a pulmonary function test (PFT). Which type of information does the nurse include in the nursing history so that PFT results can be appropriately determined? a. age, gender, race, height, weight, and smoking status b. occupational status, activity tolerance for activities of daily living c. medication history and history of allergies to contrast media d. history of chronic medical conditions and surgical procedures

a. age, gender, race, height, weight, and smoking status

The right coronary artery supplies blood to all of the following structures except: a. anterior wall b. right atrium and right ventricle c. AV node in 90% of hearts d. inferior-posterior wall of the left ventricle

a. anterior wall

In the older adult, there are a decreased number of functional alveoli. To assist the patient to compensate for this change related to aging, what does the nurse do? a. encourage the patient to ambulate and change positions b. allow the patient to rest and sleep frequently c. have face-to-face conversations when possible d. obtain an order for supplemental oxygen

a. encourage the patient to ambulate and change positions

The nurse would define anatomic dead space (VD) as: a. entire area from nose to the terminal bronchioles b. area from pharynx to the posterior nares c. tracheal tree and its branches d. bad lung areas of the chest

a. entire area from nose to the terminal bronchioles

A patient who was admitted for newly diagnosed heart failure is now being discharged. The nurse instructs the patient and family on how to manage heart failure at home. What major self-management categories should the nurse include? Select all that apply. a. medications b. weight c. heart transplants d. activity e. diet

a. medications b. weight d. activity e. diet

During auscultation of the chest, which of the following heart murmurs would not occur during systole? a. mitral stenosis b. tricuspid insufficiency c. aortic stenosis d. mitral insufficiency

a. mitral stenosis

The nurse is assessing a newly admitted client with thrombocytopenia. Which factor needs immediate intervention? a. nosebleed b. reports of pain c. decreased urine output d. increased temperature

a. nosebleed The client with thrombocytopenia has a high risk for bleeding. The nosebleed should be attended to immediately. The client's report of pain, decreased urine output, and increased temperature are not the highest priority.

The nurse assists a client with acute kidney injury (AKI) to modify the diet in which ways? Select all that apply. a. restricted protein b. liberal sodium c. restricted fluids d. low potassium e. low fat

a. restricted protein c. restricted fluids d. low potassium Breakdown of protein leads to azotemia and increased blood urea nitrogen. Fluid is restricted during the oliguric stage. Potassium intoxication may occur, so dietary potassium is also restricted. Sodium is restricted during AKI because oliguria causes fluid retention. Fats may be used for needed calories when proteins are restricted.

According to the RIFLE classification (Risk, Injury, Failure, Loss, End-stage kidney failure). How would the nurse interpret the following data? Serum creatinine increased x 1.5 or glomerular filtration rate (GFR) decrease > 25 % Urine output is <0.5 mL/kg/hr for ≥6 hours. a. risk stage b. injury stage c. failure stage d. end-stage kidney disease (ESKD)

a. risk stage

Metabolic syndrome increases the risk for coronary heart disease. Which are indicators of this syndrome? Select all that apply. a. triglyceride level of 170 mg/dL b. hdl cholesterol level of 45 mg/dL in a male c. hdl cholesterol level of 45 mg/dL in a female d. blood pressure of 130/86 mm Hg while taking a beta blocker e. fasting blood sugar level of 120 mg/dL

a. triglyceride level of 170 mg/dL c. hdl cholesterol level of 45 mg/dL in a female d. blood pressure of 130/86 mm Hg while taking a beta blocker e. fasting blood sugar level of 120 mg/dL

A patient and family are trying to plan a schedule that coordinates with the patient's dialysis regimen. The patient asks, "How often will I have to go and how long does it take?" What is the nurse's best response? a. "If you are compliant with the diet and fluid restrictions, you spend less time in dialysis; about 12 hours a week." b. "Most patients require about 12 hours per week; this is usually divided into three 4-hour treatments." c. "It varies from patient to patient. You will have to call your health care provider for specific instructions." d. "If you gain a large amount of fluid weight, a longer treatment time may be needed to prevent severe side effects."

b. "Most patients require about 12 hours per week; this is usually divided into three 4-hour treatments."

The nurse is auscultating the heart of a patient who had an MI. Which finding most strongly indicates heart failure? a. murmur b. S3 gallop c. split S1 and S2 d. pericardial friction rub

b. S3 gallop

The health care provider is considering treating a 125-pound 76-year-old MI patient with thrombolytic therapy. What action does the nurse expect regarding this therapy for this patient? a. Due to her age, the patient will not receive this therapy b. The thrombolytic therapy dosage may be decreased to decrease risk of bleeding. c. Heparin by continuous IV is the best choice after antiplatelet therapy with an aspirin d. Because the MI is recent, the patient will receive the usual dosage of thrombolytic drug

b. The thrombolytic therapy dosage may be decreased to decrease risk of bleeding.

The nurse is caring for a patient admitted with unstable angina and elevated lipid levels. What does the nurse include in teaching this patient about his or her elevated lipid levels? Select all that apply. a. begin a vigorous exercise program b. avoid trans-fatty acids c. reduce intake of saturated fats d. monitor the amount of cholesterol ingested, staying below 200 mg/day e. consider a weight loss program

b. avoid trans-fatty acids c. reduce intake of saturated fats d. monitor the amount of cholesterol ingested, staying below 200 mg/day e. consider a weight loss program

Which instruction by the nurse will help a client with chronic kidney disease prevent renal osteodystrophy? a. consuming a low-calcium diet b. avoiding peas, nuts, and legumes c. drinking cola beverages only once daily d. increasing dairy products enriched with vitamin D

b. avoiding peas, nuts, and legumes Kidney failure causes hyperphosphatemia; this client must restrict phosphorus-containing foods such as beans, peas, nuts (peanut butter), and legumes. Calcium should not be restricted; hyperphosphatemia results in a decrease in serum calcium and demineralization of the bone. Cola beverages and dairy products are high in phosphorus, contributing to hypocalcemia and bone breakdown.

The nurse is reviewing the laboratory results for a patient whose chief complaint is dyspnea. Which diagnostic test best differentiates between heart failure and lung dysfunction? a. arterial blood gas b. b-type natriuretic peptide c. hemoglobin and hematocrit d. serum electrolytes

b. b-type natriuretic peptide

Which drug is given within 1 to 2 hours of an MI when the patient is hemodynamically stable, to help the heart to perform more work without ischemia? a. vasodilators, such as sublingual or spray nitroglycerin (NGT) b. beta-adrenergic blocking agents, such as metoprolol (Lopressor) c. antiplatelet agents, such as clopidogrel (Plavix) d. calcium channel blockers, such as diltiazem (Cardizem)

b. beta-adrenergic blocking agents, such as metoprolol (Lopressor)

A patient calls the cardiac clinic you are working at and reports that they have taken 3 sublingual doses of Nitroglycerin as prescribed for chest pain, but the chest pain is not relieved. What do you educate the patient to do next? a. take another dose of Nitroglycerin in 5 minutes. b. call 911 immediately c. lie down and rest to see if that helps with relieving the pain d. take two doses of Nitroglycerin in 5 minutes

b. call 911 immediately If a patient's chest pain is not relieved with 3 doses of Nitroglycerin, taken 5 minutes apart, they should call 911 immediately. The patient should never exceed more than 3 doses of Nitroglycerin or take 2 doses at one time.

A 59-year-old male is admitted complaining of chest pain and dyspnea. ST elevation and T-wave inversion were seen on the ECG in V2, V3, and V4. IV thrombolytic therapy was started in the ED. Indications of successful reperfusion would include all of the following except: a. pain cessation b. decrease in CK or troponin c. reversal of ST segment elevation with return to baseline d. short runs of ventricular tachycardia

b. decrease in CK or troponin

Which of the following is a common side effect of Spironolactone? a. renal failure b. hyperkalemia c. hypokalemia d. dry cough

b. hyperkalemia Spironolactone is potassium-sparing. Therefore, it can increase the potassium level (hyperkalemia).

Which characteristics place women at high risk for myocardial infarction (MI)? Select all that apply. a. premenopausal b. increasing age c. family history d. abdominal obesity e. breast cancer

b. increasing age c. family history d. abdominal obesity Increasing age is a risk factor, especially after 70 years. Family history is a significant risk factor in both men and women. A large waist size and/or abdominal obesity are risk factors for both metabolic syndrome and MI. Premenopausal women are not at higher risk for MI, and breast cancer is not a risk factor for MI.

What are serious side effects of antiviral agents prescribed for a client with acute myelogenous leukemia? Select all that apply. a. cardiomyopathy b. nephrotoxicity c. ototoxicity d. stroke e. diarrhea

b. nephrotoxicity c. ototoxicity Antiviral agents, although helpful in combating severe infection, have serious side effects, especially nephrotoxicity and ototoxicity. Cardiomyopathy and stroke are not serious side effects of antiviral agents. Diarrhea is a mild side effect associated with antibiotic therapy.

Which substances from cigarette smoke have been implicated in the development of serious lung diseases? Select all that apply. a. carbon dioxide b. nicotine c. tar d. carbon monoxide e. dust particles

b. nicotine c. tar d. carbon monoxide

Stroke volume plays an important part in cardiac output. Select all the factors below that influence stroke volume. a. heart rate b. preload c. contractility d. afterload e. blood pressure

b. preload c. contractility d. afterload

A daughter is considering donating a kidney to her mother for organ transplant. What information does the nurse give to the daughter about the criteria for donation? Select all that apply. a. age limit is at least 21 years old b. systemic disease and infection must be absent c. there must be no history of cancer d. hypertension or kidney disease must be absent e. there must be adequate kidney function as determined by diagnostic studies f. donor must understand the surgery and be willing to give up the organ

b. systemic disease and infection must be absent c. there must be no history of cancer d. hypertension or kidney disease must be absent e. there must be adequate kidney function as determined by diagnostic studies f. donor must understand the surgery and be willing to give up the organ

The nurse is caring for the kidney transplant patient who is 3 days postsurgery. The nurse notes a sudden and abrupt decrease in urine. The nurse alerts the health care provider because this is a sign of which anomaly? a. rejection b. thrombosis c. stenosis d. infection

b. thrombosis

A nurse is performing an assessment on a client with heart failure. The nurse checks the client's peripheral pulses in the feet and documents the pulses as 1+. Which best describes this type of pulse? a. bounding and strong b. weak and barely palpable c. absent d. normal and easily palpable

b. weak and barely palpable During the nursing head-to-toe assessment, peripheral pulses can be checked and then graded according to their intensity. A nurse who feels a peripheral pulse as described as a 1+ would most likely feel a weak and thready, or barely palpable pulse. "Absent" is incorrect. A 0 indicates an absent pulse. "Bounding and strong" is incorrect. A 3+ indicates a bounding pulse. "Normal and easily palpable" is incorrect. A 2+ indicates a normal pulse.

When is B-type natriuretic peptide (BNP) produced and released for a patient with heart failure? a. when a patient has an enlarged liver b. when a patient has fluid overload c. when a patient's ejection fraction is lower than normal d. when a patient has ventricular hypertrophy

b. when a patient has fluid overload

A patient with heart failure is taking Losartan and Spironolactone. The patient is having EKG changes that presents with tall peaked T-waves and flat p-waves. Which of the following lab results confirms these findings? a.. Na+ 135 b. BNP 560 c. K+ 8.0 d. K+ 1.5

c. K+ 8.0

The nurse is talking to a group of healthy young college students about maintaining good kidney health and preventing AKI. Which health promotion point is the nurse most likely to emphasize with this group? a. "Have your blood pressure checked regularly." b. "Find out if you have a family history of diabetes." c. "Avoid dehydration by drinking at least 2 to 3 L of water daily." d. "Have annual testing for microalbuminuria and urine protein."

c. "Avoid dehydration by drinking at least 2 to 3 L of water daily."

Which drug category is not indicated for primary management of acute heart failure? a. nitrates b. ACE inhibitors c. calcium channel blockers d. beta blockers

c. calcium channel blockers

The nurse is caring for a group of clients. Which person does the nurse identify as having the highest risk for pulmonary embolism (PE)? a. client with diabetes and cellulitis of the leg b. client receiving IV fluids through a peripheral line c. client returning from an open reduction and internal fixation of the tibia d. client with hypokalemia receiving potassium supplements

c. client returning from an open reduction and internal fixation of the tibia Surgery and immobility are risks for deep vein thrombosis and PE. No evidence suggests that the client with diabetes has been immobile, which is a risk factor for PE; the client will be treated with antibiotics. For the client with a peripheral line, no evidence indicates a problem with the IV or with breakage of the catheter, which could lead to an air embolism. For the client with hypokalemia, no evidence reveals risk for PE; no immobility or hyper-coagulability is present.

Pulmonary capillary leakage occurs in ARDS because of a decrease in: a. cardiac output b. blood pressure c. colloid osmotic pressure d. pulmonary capillary wedge pressure

c. colloid osmotic pressure

Which ARDS statement is true? a. it can be caused by hyper-albuminemia b. on autopsy, the diseased lung looks like the intestine c. it causes an increase in shunting d. it results in an increase in lung compliance

c. it causes an increase in shunting

A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find? a. water in the chamber will increase during inspiration and decrease during expiration b. there will be continuous bubbling noted in the chamber c. water in the chamber will decrease during inspiration and increase during expiration d. water in the chamber will not move

c. water in the chamber will decrease during inspiration and increase during expiration When a patient is receiving mechanical ventilation the water in the water seal chamber will oscillate oppositely than if the patient were breathing on their own. Therefore, the water in the chamber will decrease during inspiration and increase during expiration.

The nurse is assessing a patient who has just returned from hemodialysis. Which assessment finding is cause for greatest concern? a. feeling of malaise b. headache c. muscle cramps in the legs d. bleeding at the access site

d. bleeding at the access site

High levels of iron lead to the body producing fewer red blood cells. T or F

F LOW (not high) levels of iron lead to the body producing fewer red blood cells.

The least common type of anemia is iron-deficiency anemia. T or F

F The MOST common type of anemia is iron-deficiency anemia.

The body uses hemoglobin to make iron. T or F

F The body uses IRON to make hemoglobin.

The pericardium layer consists of a fibrous layer that is made up of two layers called the parietal and visceral layers. T or F

F The pericardium layer consists of a fibrous layer and SEROUS layer that is made up of two layers called that parietal and visceral layers.

Pulmonary and systemic vascular resistance both play a role with influencing cardiac. T or F

T If pulmonary vascular resistance or systemic vascular resistance is high, it will create an increased cardiac afterload. If pulmonary vascular resistance or systemic vascular resistance is low, it will create a decreased cardiac afterload.

The nurse is teaching a client about induction therapy for acute leukemia. Which client statement indicates a need for additional education? a. "After this therapy, I will not need to have any more." b. "I will need to avoid people with a cold or flu." c. "I will probably lose my hair during this therapy." d. "The goal of this therapy is to put me in remission."

a. "After this therapy, I will not need to have any more." Induction therapy is not a cure for leukemia, it is a treatment; therefore, the client needs more education to understand this. Because of infection risk, clients with leukemia should avoid people with a cold or flu. Induction therapy will most likely cause the client with leukemia to lose his or her hair. The goal of induction therapy is to force leukemia into remission.

The nurse is talking to a patient with ESKD. The patient frequently displays weight gain and increased blood pressure beyond the baseline measurements. Which question is the nurse most likely to ask to determine if the patient is doing something that is contributing to these assessment findings? a. "Are you controlling your salt intake?" b. "Are you following the protein restrictions?" c. "Have you been eating a lot of sweets?" d. "Have you been exercising regularly?"

a. "Are you controlling your salt intake?"

A distant family member arrives to visit a female client recently diagnosed with leukemia. The family member asks the nurse, "What should I say to her?" Which responses does the nurse suggest? Select all that apply. a. "Ask her how she is feeling." b. "Ask her if she needs anything." c. "Tell her to be brave and to not cry." d. "Talk to her as you normally would when you haven't seen her for a long time." e. "Tell her what you know about leukemia."

a. "Ask her how she is feeling." b. "Ask her if she needs anything." d. "Talk to her as you normally would when you haven't seen her for a long time." Asking the client how she is feeling is a broad general opening and would be nonthreatening to the client. Asking if she needs anything is a therapeutic communication of offering self and would be considered to be therapeutic and helpful to the client. The family member should talk to her as she normally would when she hasn't seen her in a long time. There is no need to act differently with the client. If she wants to offer her feelings, keeping a normal atmosphere facilitates that option. Acting as if things are "different" because she has cancer takes the control of the situation from the client. Telling her to be brave and not to cry is callous and unfeeling; if the client is feeling vulnerable and depressed, telling her to "be brave" shuts off any opportunity for her to express her feelings. There is no need to inform the client about her disease, unless she asks about it. Opening the conversation with discussion about leukemia should be the client's prerogative.

The home health nurse is visiting a patient who independently performs PD. Which question does the nurse ask the patient to assess for the major complication associated with PD? a. "Have you noticed any signs or symptoms of infection?" b. "Are you having any pain during the dialysis treatment?" c. "Is the dialysate fluid slow or sluggish?" d. "Have you noticed any leakage around the catheter?"

a. "Have you noticed any signs or symptoms of infection?"

A patient has been receiving erythropoietin (Epogen). Which statement by the patient indicates that the therapy is producing the desired effect? a. "I can do my housework with less fatigue." b. "I have been passing more urine than I was before." c. "I have less pain and discomfort now." d. "I can swallow and eat much better than before."

a. "I can do my housework with less fatigue."

The nurse is teaching a patient about the treatment regimen for heart failure. Which statement by the patient indicates a need for further instruction? a. "I must weigh myself once a month and watch for fluid retention." b. "If my heart feels like it is racing, I should call the doctor." c. "I'll need to consider my activities for the day and rest as needed." d. "I'll need periods of rest and activity, and I should avoid activity after meals."

a. "I must weigh myself once a month and watch for fluid retention."

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching? a. "I will call the provider if I have a cough lasting 3 or more days." b. "I will report to the provider weight loss of 2 to 3 pounds in a day." c. "I will try walking for 1 hour each day." d. "I should expect occasional chest pain."

a. "I will call the provider if I have a cough lasting 3 or more days." Cough, a symptom of heart failure, is indicative of intra-alveolar edema; the provider should be notified. The client should call the provider for weight gain of 3 pounds in a week. The client should begin by walking 200 to 400 feet per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure; the provider should be notified.

You're providing education to a patient who will be undergoing a heart catheterization. Which statement by the patient requires you to re-educate the patient about this procedure? a. "The brachial artery is most commonly used for this procedure." b. "A dye is injected into the coronary arteries to assess for blockages." c. "Not all patients who have a heart catheterization will need a stent placement." d. "I will not be completely asleep and will be able to breathe on my own during the procedure."

a. "The brachial artery is most commonly used for this procedure." The femoral or radial artery is used during a heart cath...not the brachial.

The nurse is caring for several patients on a medical-surgical unit. None of the patient currently has any acute or chronic kidney problems. Which patient has the greatest risk to develop AKI? a. 73-year-old male who has hypertension and peripheral vascular disease b. 32-year-old female who is pregnant and has gestational diabetes c. 49-year-old male who is obese and has a history of skin cancer d. 23-year-old female who has been treated for a urinary tract infection

a. 73-year-old male who has hypertension and peripheral vascular disease

While assessing a client who has been receiving heparin intravenously for the past 3 days, the nurse notes the IV pump is set at twice the required setting. What orders does the nurse anticipate from the prescriber? Select all that apply. a. activated partial thromboplastin time b. international normalized ratio c. prothrombin time d. vitamine k e. protamine sulfate

a. activated partial thromboplastin time e. protamine sulfate The client has been receiving an excessive dose of heparin. The activated partial thromboplastin time will help assess this client's degree of bleeding risk. Depending on the results of this test, the client may need a heparin antidote, which is protamine sulfate.

A patient had an IWMI. The nurse closely monitors the patient for which dysrhythmia associated with IWMI? a. bradycardia and second-degree heart block b. premature ventricular contractions c. supraventricular tachycardia d. atrial fibrillation

a. bradycardia and second-degree heart block

The RN has just received change-of-shift report. Which of the assigned clients should be assessed first? a. client with chronic kidney failure who was just admitted with shortness of breath b. client with kidney insufficiency who is scheduled to have an arteriovenous fistula inserted c. client with azotemia whose blood urea nitrogen and creatinine are increasing d. client receiving peritoneal dialysis who needs help changing the dialysate bag

a. client with chronic kidney failure who was just admitted with shortness of breath The dyspnea of the client with chronic kidney failure may indicate pulmonary edema and should be assessed immediately. The client with kidney insufficiency is stable and assessment can be performed later. The client with azotemia requires assessment and possible interventions, but is not at immediate risk for life-threatening problems. The client receiving peritoneal dialysis can be seen last because it is a slow process and the client has no urgent needs.

When shock or other problems cause an acute reduction in blood flow to the kidneys, how do the kidneys compensate? Select all that apply. a. constrict blood vessels in the kidneys b. activate the renin-angiotensin-aldosterone pathway c. release beta blockers. d. dilate blood vessels throughout the body. e. release antidiuretic hormones

a. constrict blood vessels in the kidneys b. activate the renin-angiotensin-aldosterone pathway e. release antidiuretic hormones

To prevent pre-renal acute kidney injury, which person is encouraged to increase fluid consumption? a. construction worker b. office secretary c. schoolteacher d. taxicab driver

a. construction worker Physical labor and working outdoors, especially in warm weather, cause diaphoresis and place the construction worker at risk for dehydration and pre-renal azotemia. The office secretary and schoolteacher work indoors and, even without air conditioning, will not lose as much fluid to diaphoresis as someone performing physical labor. The taxicab driver, even without air conditioning, will not experience diaphoresis and fluid loss like the construction worker.

In collaboration with the registered dietitian, the nurse teaches the patient about which diet recommendations for management of CKD? (Select all that apply.) a. controlling protein intake b. limiting fluid intake c. restricting potassium d. increasing sodium e. restricting phosphorus f. reducing calories

a. controlling protein intake b. limiting fluid intake c. restricting potassium e. restricting phosphorus

What is the best description of CAPD? a. daily infusion of four 2 L exchanges of dialysate every 4 to 6 hours while awake b. form of automated dialysis that uses an automated cycling machine c. functions of the cycling machine are programmed to the patient's needs d. decreases the risk of peritonitis and poor dialysate flow

a. daily infusion of four 2 L exchanges of dialysate every 4 to 6 hours while awake

A client is admitted to the medical floor with a new diagnosis of lung cancer. How does the nurse assist the client initially with the anxiety associated with the new diagnosis? a. encourage the client to ask questions and verbalize concerns b. leave the client alone to deal with his or her own feelings c. medicate the client with diazepam (Valium) for anxiety every 8 hours d. provide journals about cancer treatment

a. encourage the client to ask questions and verbalize concerns Anxiety causes increased oxygen consumption, and oxygen availability is limited in lung cancer; the availability of the nurse to answer questions and listen to the client's concerns will decrease anxiety. The client may choose to be alone, although this may be a maladaptive coping behavior. Scheduled medication does not solve the anxiety associated with the new diagnosis, although administering Valium (diazepam) every 8 hours will assist with reducing the anxiety; it is more important to work with the client to determine the cause of the anxiety and assist him or her in dealing with those issues first. Knowledge about cancer may help relieve anxiety but is not the best initial step in a newly diagnosed client. The nurse must first assess how the client learns best and what the client's needs are. The nurse also must be aware of the plan of care for the client.

A nurse is caring for a client in the ICU who requires a mechanical ventilator. The client has been sedated while the endotracheal tube is in place. During the nurse's shift, the client's ventilator repeatedly alarms to indicate high pressure. Which of the following situations would most likely indicate a high pressure alarm? a. excess secretions b. cuff leak c. excess FiO2 d. client apnea

a. excess secretions

The nurse is reviewing urinalysis results for a patient who is in the early stages of CKD, what results might the nurse expect to see? a. excessive protein, glucose, red blood cells, and white blood cells b. increased specific gravity with a dark amber discoloration c. dramatically increased urine osmolarity d. pink-tinged urine with obvious small blood clots

a. excessive protein, glucose, red blood cells, and white blood cells

The nurse is assessing a patient with uremia. Which gastrointestinal changes does the nurse expect to find? Select all that apply. a. halitosis b. hiccups c. anorexia d. nausea e. vomiting f. salivation

a. halitosis b. hiccups c. anorexia d. nausea e. vomiting

Which disorder could be a complication from AKI? a. heart failure b. diabetes mellitus c. kidney cancer d. compartment syndrome

a. heart failure

What two factors are used to calculate cardiac output? Select all that apply. a. heart rate b. blood pressure c. stroke volume d. mean arterial pressure

a. heart rate c. stroke volume Cardiac output is calculated by taking the heart rate and multiplying it by stroke volume. CO = HR x SV

What might the nurse notice if the patient is experiencing reduced perfusion and altered urinary elimination related to AKI? Select all that apply. a. hemodynamic instability, especially persistent hypotension and tachycardia. b. urine output of less than 0.5 mL/kg/hour for 6 or more hours c. serum creatinine below baseline or admission values d. urine may be clear or have a pale yellow color e. abnormal serum and urine potassium and sodium values

a. hemodynamic instability, especially persistent hypotension and tachycardia. b. urine output of less than 0.5 mL/kg/hour for 6 or more hours e. abnormal serum and urine potassium and sodium values

A patient with heart failure has a new prescription for furosemide. Which information would the nurse include as part of teaching this patient about Lasix? Select all that apply. a. high doses of Lasix can cause hearing loss b. medication is given to prevent fluid retention c. patient should not take blood pressure medications with furosemide d. furosemide should only be used if the client cannot urinate e. patient may need to monitor his sodium and potassium intake with this medicine

a. high doses of Lasix can cause hearing loss b. medication is given to prevent fluid retention e. patient may need to monitor his sodium and potassium intake with this medicine

A 63-year-old male is admitted with acute respiratory distress. Symptoms include marked shortness of breath and circumoral cyanosis. He is awake and complains of shortness of breath. He has a history of COPD (chronic obstructive pulmonary disease). Blood gases reveal the following information: pH 7.22 PaCO2 62 PaO2 54 SaO2 81% HCO3 25 FiO2 30% What would be the priority treatment indicated at this time? a. increase the FiO2 b. intubate and initiate mechanical ventilation c. postural drainage treatment d. administer a bronchodilator

a. increase the FiO2

In the older adult client, which respiratory change requires no further assessment by the nurse? a. increased anteroposterior (AP) diameter b. increased respiratory rate c. shortness of breath d. sputum production

a. increased anteroposterior (AP) diameter Increased AP diameter is normal with aging. Increased respiratory rate is not a normal finding with aging and may be an indication of pain or infection; it needs to be evaluated further by the nurse. Shortness of breath is not associated with aging and needs to be evaluated further, because it may be related to infection, tumor, or cardiac issues, for example. Sputum production is not related to the aging process; although it may be chronic in nature, it should be assessed further. It is important to note the character and quantity of the sputum, as well as the duration of sputum production.

Which clinical manifestation indicates the need for increased fluids in a client with kidney failure? a. increased blood urea nitrogen (BUN) b. increased creatinine level c. pale-colored urine d. decreased sodium level

a. increased blood urea nitrogen (BUN) An increase in BUN can be an indication of dehydration, and an increase in fluids is needed. Increased creatinine indicates kidney impairment. Urine that is pale in color is diluted; an increase in fluids is not necessary. Sodium is increased, not decreased, with dehydration.

What conditions shift the curve to the right, meaning hemoglobin will dissociate oxygen? Select all that apply. a. increased carbon dioxide concentration b. decreased tissue concentration of glucose breakdown products c. increased tissue pH (alkalosis) d. decreased tissue temperature e. decreased tissue pH (acidosis)

a. increased carbon dioxide concentration b. decreased tissue concentration of glucose breakdown products e. decreased tissue pH (acidosis)

A patient with AKI has a high rate of catabolism. What is this related to? a. increased levels of catecholamines, corticosol, and glucagon b. inability to excrete excess electrolytes c. conversion of body fat into glucose d. presence of retained nitrogenous wastes

a. increased levels of catecholamines, corticosol, and glucagon

Which are the most accurate ways to monitor kidney function in the patient with CKD? Select all that apply. a. monitoring intake and output b. checking urine specific gravity c. reviewing BUN and serum creatinine levels d. reviewing x-ray reports e. consulting the dietitian's notes

a. monitoring intake and output b. checking urine specific gravity c. reviewing BUN and serum creatinine levels

Which signs/symptoms does the nurse expect to see in the patient with AKI that has progressed in severity? Select all that apply. a. oliguria b. hypotension c. shortness of breath d. pulmonary crackles e. weight loss

a. oliguria c. shortness of breath d. pulmonary crackles

The nurse is taking a history on a patient who reports sleeping in a recliner chair at night because lying on the bed causes shortness of breath. How is this documented? a. orthopnea b. paroxysmal nocturnal dyspnea c. orthostatic nocturnal dyspnea d. tachypnea

a. orthopnea

A patient is admitted for acute MI, but the nurse notes that the traditional manifestation of ST-elevation myocardial infarction (STEMI) is not occurring. What other evidence for acute MI does the nurse expect to find in the patient? Select all that apply. a. positive troponin markers b. chronic stable angina c. non-st elevation im (non-STEMI) on ecg d. cardiac dysrhythmia e. heart failure

a. positive troponin markers c. non-st elevation im (non-STEMI) on ecg

A patient with AKI is receiving total parenteral nutriton (TPN). What is the therapeutic goal of using TPN? a. preserve lean body mass b. promote tubular reabsorption c. create a negative nitrogen balance d. prevent infection

a. preserve lean body mass

Hemodynamically, PEEP causes an increase in: a. pulmonary vascular resistance b. blood pressure c. cardiac output d. preload

a. pulmonary vascular resistance

An 18-year-old is admitted with a history of a syncopal episode at the mall and has a history of an eating disorder. The nurse notes a prolonged QT on the 12-lead ECG and anticipates a reduction in an electrolyte to be the cause. Which of the following is least likely to cause this patient's problem? a. sodium b. magnesium c. potassium d. calcium

a. sodium

Which interventions are effective for a patient with a potential for pulmonary edema caused by heart failure? Select all that apply. a. sodium and fluid restriction b. slow infusion of hypotonic saline c. administration of potassium d. administration of loop diuretics e. position in semi-Fowler's position f. weekly weight monitoring

a. sodium and fluid restriction d. administration of loop diuretics e. position in semi-Fowler's position

The home health nurse is evaluating the home setting for a patient who wishes to have inhome hemodialysis. What is important to have in the home setting to support this therapy? a. specialized water treatment system to provide a safe, purified water supply b. large dust-free space to accommodate and store the dialysis equipment c. modified electrical system to provide high voltage to power the equipment d. specialized cooling system to maintain strict temperature control

a. specialized water treatment system to provide a safe, purified water supply

When heart failure develops, what is the initial compensatory mechanism of the heart that maintains cardiac output? a. sympathetic stimulation b. parasympathetic stimulation c. renin-angiotensin activation system (RAAS) d. myocardial hypertrophy

a. sympathetic stimulation

Which of the following best describes systolic heart failure? a. systolic heart failure occurs when left ventricle does not contract with enough force b. systolic heart failure occurs when the heart contracts normally, but the ventricle does not relax properly c. systolic heart failure is caused by the ventricles' inability to accept blood d. systolic heart failure is caused by decreased ventricular compliance

a. systolic heart failure occurs when left ventricle does not contract with enough force

The nurse monitors a CKD patient's daily weights because of the risk for fluid retention. What instructions does the nurse give to the UAP? a. weigh the patient daily at the same time each day, same scale, with the same amount of clothing b. weigh the patient daily and add 1 kilogram of weight for the intake of each liter of fluid c. weigh the patient in the morning before breakfast and weigh the patient at night just before bedtime d. ask the patient what his or her normal weight is and them weigh the patient before and after each voiding

a. weigh the patient daily at the same time each day, same scale, with the same amount of clothing

The nurse wishes to reduce the incidence of hospital-acquired acute kidney injury. Which question by the nurse to the interdisciplinary health care team will result in reducing client exposure? a. "Should we filter air circulation?" b. "Can we use less radiographic contrast dye?" c. "Should we add low-dose dobutamine?" d. "Should we decrease IV rates?"

b. "Can we use less radiographic contrast dye?" Contrast dye is severely nephrotoxic, and other options can be used in its place. Air circulation and low-dose dopamine are not associated with nephrotoxicity. Pre-renal status results from decreased blood flow to the kidney, such as fluid loss or dehydration; IV fluids can correct this.

The nurse is interviewing a patient with a history of high blood pressure and heart problems. Which statement by the patient causes the nurse to suspect the patient may have heart failure? a. "I noticed a very fine red rash on my chest." b. "I had to take off my wedding ring last week." c. "I've had fever quite frequently." d. "I have pain in my shoulder when I cough."

b. "I had to take off my wedding ring last week."

Which client statement indicates that stem cell transplantation that is scheduled to take place in his home is not a viable option? a. "I don't feel strong enough, but my wife said she would help." b. "I was a nurse, so I can take care of myself." c. "I will have lots of medicine to take." d. "We live 5 miles from the hospital."

b. "I was a nurse, so I can take care of myself." Stem cell transplantation in the home setting requires support, assistance, and coordination from others. The client cannot manage this type of care on his own. The client must be emotionally stable to be a candidate for this type of care. It is acceptable for the client's spouse to support the client undergoing this procedure. It is not unexpected for the client to be taking several prescriptions. Five miles is an acceptable distance from the hospital, in case of emergency.

The home health nurse is evaluating a patient being treated for heart failure. Which statement by the patient is the best indicator of hope and well-being as a desired psychological outcome? a. "I'm taking the medication and following the doctor's orders." b. "I'm looking forward to dancing with my wife on our wedding anniversary." c. "I'm planning to go on a long trip; I'll never go back to the hospital again." d. "I want to thank you for all that you have done. I know you did your best."

b. "I'm looking forward to dancing with my wife on our wedding anniversary."

A patient with severe pernicious anemia is being discharged home and requires routine injections of Vitamin B12. Which statement by the patient demonstrates they understood your instructions about their treatment regime? a. "I will require one injection every 6 months until my Vitamin B12 levels are therapeutic and then I'm done." b. "Initially, I will need weekly injections of Vitamin B12 and then monthly injections for maintenance, which will be a lifelong regime." c. "I will only need vitamin B12 injections for a month and then I can take a low dose of oral vitamin B12." d. "When I start to feel weak and short of breath I need to call the doctor so I can schedule an appointment for a Vitamin B12 injection."

b. "Initially, I will need weekly injections of Vitamin B12 and then monthly injections for maintenance, which will be a lifelong regime." A patient with pernicious anemia cannot absorb vitamin B12 through the GI system. So, eating foods or taking supplements of vitamin B12 are pointless because the patient lacks intrinsic factor to absorb vitamin B12. Therefore, the typical regime for a patient with pernicious anemia is to receive vitamin B12 through intramuscular injections. Normally, the physician will order weekly injections and then monthly as maintenance, which is usually a lifelong treatment.

A patient had severe chest pain several hours ago but is currently pain-free and has a normal ECG. Which statement by the patient indicates a correct understanding of the significance of the ECG results? a. "I'll go home and make an appointment to see my family doctor next week." b. "The ECG could be normal since I am currently pain-free." c. "A normal ECG means I am okay." d. "I have always had a strong heart, low blood pressure, and a normal ECG."

b. "The ECG could be normal since I am currently pain-free."

The nurse is reinforcing information about genetic counseling to a client with sickle cell disease who has a healthy spouse. What information does the nurse include? a. "Sickle cell disease will be inherited by your children." b. "The sickle cell trait will be inherited by your children." c. "Your children will have the disease, but your grandchildren will not." d. "Your children will not have the disease, but your grandchildren could."

b. "The sickle cell trait will be inherited by your children." The children of the client with sickle cell disease will inherit the sickle cell trait, but may not inherit the disease. If both parents have the sickle cell trait, their children could get the disease.

The nurse is performing a respiratory assessment including pulse oximetry on several patients. Which conditions or situations may cause an artificially low reading? Select all that apply. a. fever b. anemia c. receiving narcotic pain medications d. peripheral artery disease e. history of respiratory disease such as cystic fibrosis or tuberculosis

b. anemia d. peripheral artery disease

The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which method provides an alternative to mechanical ventilation? a. oropharyngeal airway b. bi-level positive airway pressure (BiPAP) c. non-rebreather mask with 100% oxygen d. positive end-expiratory pressure (PEEP)

b. bi-level positive airway pressure (BiPAP) BiPAP ventilation is a noninvasive method that may provide short-term ventilation without intubation. An oropharyngeal airway is used to prevent the tongue from occluding the airway or the client from biting the endotracheal tube. A non-rebreather mask will assist with oxygenation; however, muscle fatigue and hypoventilation may occur as causes of respiratory failure. The need for PEEP indicates a severe gas-exchange problem; this modality is "dialed in" on the mechanical ventilator.

Which assessment finding is of greatest concern in a client with emphysema? a. barrel-shaped chest b. bronchial breath sounds heard at the bases c. hyperresonance to percussion of the chest d. ribs lying horizontal

b. bronchial breath sounds heard at the bases Bronchial breath sounds are not normally heard in the periphery and may indicate increased lung density, as in a tumor or an infective process such as pneumonia. The anteroposterior diameter is the same as the lateral-to-lateral or side-to-side diameter in a client with emphysema, so he will generally have a barrel-shaped chest. Air-filled cavities, such as the lung, are hyperresonant to percussion. Air trapping causes the lungs in a client with emphysema to lie in a horizontal direction.

A patient has been admitted for acute angina. which diagnostic test identifies if the patient will benefit from further invasive management after acute angina or an MI? a. exercise tolerance test b. cardiac catheterization c. thallium scan d. multigated angiogram (MUGA) scan

b. cardiac catheterization

A patient with mitral regurgitation develops atrial fibrillation with a rate of 88, BP of 118/75. Which of the following may be indicated? a. beta blockers and vasopressors b. cardiac glycosides and calcium channel blockers c. beta blockers and calcium channel blockers d. antiarrhythmics and angiotensin-converting enzyme inhibitors

b. cardiac glycosides and calcium channel blockers

The nurse is teaching a patient about performing PD at home. In order to identify the earliest manifestation of peritonitis, what does the nurse instruct the patient to do? a. monitor temperature before starting PD b. check the effluent for cloudiness c. be aware of feelings of malaise d. monitor for abdominal pain

b. check the effluent for cloudiness

A client has just returned from coronary artery bypass graft surgery. For which finding does the nurse contact the surgeon? a. temperature 98.2° F b. chest tube drainage 175 mL last hour c. serum potassium 3.9 mEq/L d. incisional pain 6 on a scale of 0 to 10

b. chest tube drainage 175 mL last hour Some bleeding is expected after surgery; however, the nurse should report chest drainage over 150 mL/hr to the surgeon. Although hypothermia is a common problem after surgery, a temperature of 98.2° F is a normal finding. Serum potassium of 3.9 mEq/L is a normal finding. Incisional pain of 6 on a scale of 0 to 10 is expected immediately after major surgery; the nurse should administer prescribed analgesics.

The nurse is performing a client assessment for the client's potential employer. The client reports dyspnea when climbing stairs but is not dyspneic at rest. Which dyspnea classification does the nurse assign to this client in the report to the employer? a. class I, can perform manual labor b. class II, can perform desk job c. class III, minimally employable d. class IV, must remain at home

b. class II, can perform desk job This client is dyspneic when climbing stairs or walking on an incline, but not on level walking; therefore, this client is considered class II and employable only for a sedentary job or under special circumstances. If the client had class I dyspnea, the dyspnea would only occur on more-than-normal or strenuous exertion; this client's dyspnea occurs beyond normal or strenuous exertion, so he or she would not be able to perform manual labor. The client's dyspnea does not occur on minimal exertion (class III), and does not prevent him or her from performing essential activities of daily living (class IV), so the client is still employable in some capacity.

What is the expected outcome for the collaborative problem potential for pulmonary edema? a. no dysrhythmias b. clear lung sounds c. less fatigue d. no disorientation

b. clear lung sounds

A nurse is caring for a client who is on a ventilator. The nurse checks the vent settings at the beginning of her shift and notes that the FiO2 is set at 40. Based on the nurse's knowledge of ventilation parameters, which of the following statements is correct? a. client is breathing 40 mL of air with each breath b. client is using 40% oxygen c. client is breathing at a rate of 40 breaths per minute d. oxygen flow rate for this client is 4 LPM

b. client is using 40% oxygen

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

b. client states that she is able to sleep on one pillow Improvement in activity tolerance, less orthopnea, and improved symptoms represent a positive response to beta blockers. An ejection fraction of 25% is well below the normal of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest; this is not a positive outcome.

Which client is best to assign to an LPN/LVN working on the telemetry unit? a. client with heart failure who is receiving dobutamine (Dobutrex) b. client with dilated cardiomyopathy who uses oxygen for exertional dyspnea c. client with pericarditis who has a paradoxical pulse and distended jugular veins d. client with rheumatic fever who has a new systolic murmur

b. client with dilated cardiomyopathy who uses oxygen for exertional dyspnea The client with dilated cardiomyopathy who needs oxygen only with exertion is the most stable; administration of oxygen to a stable client is within the scope of LPN/LVN practice. The client with heart failure is receiving an intravenous inotropic agent, which requires monitoring by the RN. The client with pericarditis is displaying signs of cardiac tamponade and requires immediate lifesaving intervention. The client with a new-onset murmur requires assessment and notification of the provider, which is within the scope of practice of the RN.

The patient admitted with a carboxyhemoglobin level of 45% is lethargic, complains of headache, is receiving 100% O2 per face mask, and is noted to have an SpO2 of 100%. Which of the following is indicated a. administer hydrocodone with acetaminophen b. continue the FiO2 of 1.00 c. decrease the FiO2 d. intubate and initiate mechanical ventilation

b. continue the FiO2 of 1.00

Which respiratory changes occur as a result of aging? Select all that apply. a. increased elastic recoil b. dilation of alveolar ducts c. decreased ability to cough d. alveolar surface tension increases e. diffusion capacity decreases

b. dilation of alveolar ducts c. decreased ability to cough e. diffusion capacity decreases

The nurse is caring for a patient with ESKD and dialysis has been initiated. Which drug order does the nurse question? a. erythropoietin b. diuretic c. ACE inhibitor d. calcium channel blocker

b. diuretic

An older adult taking digoxin and hydrochlorothiazide (HCTZ) for chronic heart failure is admitted to the emergency department (ED) with an apical pulse of 48. A family member states that the client has reported blurred vision and loss of appetite for 2 weeks. What is the nurse's first action? a. call the ED physician immediately b. draw a serum digoxin level c. assess for signs of hypokalemia d. establish the client's airway

b. draw a serum digoxin level Rationale: The clinical manifestations of digoxin toxicity are often vague and nonspecific and include anorexia, fatigue, blurred vision, and changes in mental status, especially in older adults. Older adults are more likely than other patients to become toxic because of decreased renal excretion.

A client is receiving immune-suppressive therapy after kidney transplantation. Which measure for infection control is most important for the nurse to implement? a. adherence to therapy b. handwashing c. monitoring for low-grade fever d. strict clean technique

b. handwashing The most important infection control measure for the client receiving immune-suppressive therapy is handwashing. Adherence to therapy and monitoring for low-grade fever are important, but are not infection control measures. The nurse should practice aseptic technique for this client, not simply clean technique.

The following is not a clinical finding seen in pneumonia: a. chest x-ray with an area of consolidation b. hypoxemia refractory to O2 administration with a need for PEEP c. normal WBCs with increased immature neutrophils (bands) d. bronchial breath sounds, diminished breath sounds, or crackles on auscultation

b. hypoxemia refractory to O2 administration with a need for PEEP

A patient receives dialysis therapy and the health care provider has ordered sodium restriction to 3 g daily. What does the nurse teach the patient? a. add smaller amounts of salt at the table or during cooking b. identify foods that are high in sodium (e.g., bacon, potato chips, fast foods) c. avoid foods that have a metallic, salty, or bitter taste d. eat larger amounts of bland foods with very minimal amounts of spicing

b. identify foods that are high in sodium (e.g., bacon, potato chips, fast foods)

Which of the following are NOT typical signs and symptoms of pericarditis? Select all that apply. a. fever b. increased pain when leaning forward c. ST segment depression d. pericardial friction rub e. radiating substernal pain felt in the left shoulder f. breathing in relieves the pain

b. increased pain when leaning forward c. ST segment depression f. breathing in relieves the pain These are findings NOT found in pericarditis. :eaning forward actually helps relieve pain felt in pericarditis (supine position makes it worst). ST segment ELEVATION is seen, not depression. Inspiration (breathing in) increases the pain felt with pericarditis.

The health care provider is considering use of thrombolytic therapy for a patient. What is the criterion for this therapy? a. chest pain of greater than 15 minutes duration that is unrelieved by nitroglycerin b. indications of transmural ischemia and injury as shown by the ecg c. ventricular dysrhythmias shown on the cardiac monitor d. history of chronic, severe, poorly controlled hypertension

b. indications of transmural ischemia and injury as shown by the ecg

A patient is prescribed bumetanide (Bumex). What is an important teaching point for the nurse to include about this medication? a. caution to move slowly when changing positions, especially from lying to sitting b. information about potassium-rich foods to include in the diet c. written instructions on how to count the radial pulse rate d. information about low-sodium diets and reading food labels for sodium content

b. information about potassium-rich foods to include in the diet

During PD, the nurse notes slowed dialysate outflow. What does the nurse do to troubleshoot the system? Select all that apply. a. ensure that the drainage bag is elevated b. inspect the tubing for kinking or twisting c. ensure that clamps are open d. turn the patient to the other side e. make sure the patient is in good body alignment f. instruct the patient to stand or cough

b. inspect the tubing for kinking or twisting c. ensure that clamps are open d. turn the patient to the other side e. make sure the patient is in good body alignment

A recently admitted client who is in sickle cell crisis requests "something for pain." What does the nurse administer? a. intramuscular (IM) morphine sulfate b. intravenous (IV) hydromorphone (Dilaudid) c. oral ibuprofen (Motrin) d. oral morphine sulfate (MS-Contin)

b. intravenous (IV) hydromorphone (Dilaudid) The client needs IV pain relief, and it should be administered on a routine schedule (i.e., before the client has to request it). Morphine is not administered intramuscularly (IM) to clients with sickle cell disease (SCD). In fact, all IM injections are avoided because absorption is impaired by poor perfusion and sclerosed skin. Nonsteroidal anti-inflammatory drugs may be used for clients with SCD for pain relief once their pain is under control; however, in a crisis, this choice of analgesic is not strong enough. Moderate pain may be treated with oral opioids, but this client is in a sickle cell crisis; IV analgesics should be used until his or her condition stabilizes.

Which medication is most effective in slowing the progression of kidney failure in a client with chronic kidney disease? a. diltiazem (Cardizem) b. lisinopril (Zestril) c. clonidine (Catapres) d. doxazosin (Cardura)

b. lisinopril (Zestril) Angiotensin-converting enzyme inhibitors such as lisinopril appear to be the most effective drugs to slow the progression of kidney failure. Calcium channel blockers such as diltiazem may indirectly prevent kidney disease by controlling hypertension, but are not specific to slowing progression of kidney disease. Vasodilators such as clonidine and doxazosin control blood pressure, but do not specifically protect from kidney disease.

Before positive end-expiratory pressure (PEEP) is instituted for Mr. Z, he must be assessed for hypovolemia because PEEP can directly result in: a. dysrhythmias b. low cardiac output c. hypoxia d. high pulmonary capillary wedge pressure

b. low cardiac output

A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? a. this is an expected finding b. lung may have re-expanded or there is a kink in the system c. system is broken and needs to be replaced d. there is an air leak in the tubing

b. lung may have re-expanded or there is a kink in the system

The nurse is reviewing the medication list and appropriate dose a adjustments made for a patient with CKD. The nurse would question the use and/or dosage adjustment of which type of medication? a. antibiotics b. magnesium antacids c. oral antidiabetics d. opioids

b. magnesium antacids

The nurse is caring for a patient with AKI that developed after a severe anaphylactic reaction. What is a primary treatment goal of the initial phase that will help to prevent permanent kidney damage for this patient? a. correct fluid volume by administering IV normal saline b. maintain a mean arterial pressure (MAP) of 65 mm Hg c. prevent kidney infections by administering antibiotics d. give antihistamines to prevent allergic response

b. maintain a mean arterial pressure (MAP) of 65 mm Hg

A patient is in the diuretic phase of AKI. During this phase, what is the nurse mainly concerned about? a. assessing for hypertension and fluid overload b. monitoring for hypovolemia and electrolyte loss c. adjusting the dosage of diuretic medications d. balancing diuretic therapy with intake

b. monitoring for hypovolemia and electrolyte loss

A 50 year-old male with a history of endocarditis reports he is having a hard time breathing and it feels like an elephant is sitting on his chest. As the nurse, what is your first priority? a. assess oxygen saturation b. obtain an ECG c. auscultate the lungs a. assess for recent IV drug use

b. obtain an ECG The main concern for anyone with pain in the chest area is myocardial infarction. The most important thing to do is to get an ECG. The quicker the better. All other options will happen but not as the very first thing.

Upon performing a lung sound assessment of the anterior chest, the nurse hears moderately loud sounds on inspiration that are equal in length with expiration. In what area is this lung sound considered normal? a. trachea b. primary bronchi c. lung fields d. larynx

b. primary bronchi

What pulse change might the nurse expect associated with cardiac tamponade? a. pulsus alternans b. pulsus paradoxus c. pulsus magnus d. pulsus bisferiens

b. pulsus paradoxus

A patient's laboratory results show an elevated creatinine level. The patient's history reveals no risk factors for kidney disease. Which question does the nurse ask the patient to shed further light on the laboratory result? a. "How many hours of sleep did you get the night before the test?" b. "How much fluid did you drink before the test?" c. "Did you take any type of antibiotics before taking the test?" d. "When and how much did you last urinate before having the test?"

c. "Did you take any type of antibiotics before taking the test?"

You are providing discharge teaching to a patient being discharged home after hospitalization with pericarditis. The physician has ordered the patient to take Colchicine. Which of the following statements indicates the patient did NOT understand the education you provided? a. "I can take this medication with or without food." b. "I will notify the doctor immediately if I start experiencing nausea, vomiting, or stomach pain while taking this medication." c. "I like to take all my medications in the morning with grapefruit juice." d. "This medication is also used to treat patients with gout."

c. "I like to take all my medications in the morning with grapefruit juice." Patients should not take Colchicine with grapefruit juice because it increases the amount of Colchicine the body absorbs (causing an increased chance of Colchicine toxicity). This medication can be taken WITH or WITHOUT food.

You're providing discharge teaching to a patient being treated for endocarditis. Which statement by the patient demonstrated they understood your teaching about this condition? a. "I will stop taking the antibiotics once my fever is gone in order to prevent antibiotic resistance." b. "I will only wash my hands with soap and water." c. "I will inform my dentist about my history of endocarditis prior to any invasive procedures." d. "I will avoid eating fish and organ meats."

c. "I will inform my dentist about my history of endocarditis prior to any invasive procedures." Patients should finish all antibiotics doses and never stop taking them in the middle of treatment because this increases antibiotic resistances. Also, the patient should maintain good oral hygiene and should go to the dentist regularly for cleanings. However, it is very important the patient inform all other healthcare practitioners about their history of endocarditis because they will need prophylactic antibiotics therapy prior to any invasive procedures to prevent acquiring endocarditis again.

A client is scheduled to undergo kidney transplant surgery. Which teaching point does the nurse include in the preoperative teaching session? a. "Your diseased kidneys will be removed at the same time the transplant is performed." b. "The new kidney will be placed directly below one of your old kidneys." c. "It is essential for you to wash your hands and avoid people who are ill." d. "You will receive dialysis the day before surgery and for about a week after."

c. "It is essential for you to wash your hands and avoid people who are ill." Anti-rejection medications increase the risks for infection, sepsis, and death. Strict aseptic technique and handwashing are essential. Unless severely infected, the client's kidneys are left in place and the graft is placed in the iliac fossa. Dialysis is performed the day before surgery; after the surgery, the new kidney should begin to make urine.

The nurse is teaching the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate? a. "Sedation is needed so your loved one does not rip the breathing tube out." b. "Suctioning is important to remove organisms from the lower airway." c. "Paralysis and sedatives help decrease the demand for oxygen." d. "We are encouraging oral and IV fluids to keep your loved one hydrated."

c. "Paralysis and sedatives help decrease the demand for oxygen." Paralytics and sedation decrease oxygen demand. Sedation is needed more for its effects on oxygenation than to prevent the client from ripping out the endotracheal tube. Suctioning is performed to maintain airway patency. Minimizing fluids while administering diuretics leads to better outcomes.

Discharge teaching has been provided for a client recovering from kidney transplantation. Which information indicates that the client understands the instructions? a. "I can stop my medications when my kidney function returns to normal." b. "If my urine output is decreased, I should increase my fluids." c. "The anti-rejection medications will be taken for life." d. "I will drink 8 ounces of water with my medications."

c. "The anti-rejection medications will be taken for life." Immune-suppressant therapy must be taken for life to prevent organ rejection. Adherence to immunosuppressive drugs is crucial to survival for clients with transplanted kidneys. Lack of adherence can lead to complications such as rejection, graft loss, return to dialysis, and death. Oliguria is a symptom of transplant rejection; the transplant team should be contacted immediately if this occurs. It is not necessary to take anti-rejection medication with 8 ounces of water.

A client undergoing coronary artery bypass grafting asks why the surgeon has chosen to use the internal mammary artery for the surgery. Which response by the nurse is correct? a. "This way you will not need to have a leg incision." b. "The surgeon prefers this approach because it is easier." c. "These arteries remain open longer." d. "The surgeon has chosen this approach because of your age."

c. "These arteries remain open longer." Mammary arteries remain patent much longer than other grafts. Although no leg incision will be made with this approach, veins from the legs do not remain patent as long as the mammary artery graft does. Long-term patency, not ease of the procedure, is the primary concern. Age is not a determining factor in selection of these grafts.

The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? a. "How does this make you feel?" b. "This can be caused by taking performance-enhancing drugs." c. "This may be caused by a genetic trait." d. "Just imagine how bad it would be if you weren't in good shape."

c. "This may be caused by a genetic trait." Hypertrophic cardiomyopathy is often transmitted as a single gene autosomal dominant trait. Exploring the client's feelings is important, but does not address the client's question. Hypertrophic cardiomyopathy is not caused by performance-enhancing drugs. Reminding the client that he or she is in good shape is not at all therapeutic and does not address the client's question.

The right coronary artery supplies the SA node in: a. 100% of all hearts b. 90% of all hearts c. 55% of all hearts d. 10% of all hearts

c. 55% of all hearts

An LPN/LVN is scheduled to work on the inpatient "stepdown" cardiac unit. Which client does the charge nurse assign to the LPN/LVN? a. 60-year-old who was admitted today for pacemaker insertion because of third-degree heart block and who is now reporting chest pain b. 62-year-old who underwent open heart surgery 4 days ago for mitral valve replacement and who has a temperature of 38.2° C c. 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is scheduled for discharge to a group home later today d. 69-year-old who had a stent placed 2 hours ago in the left anterior descending artery and who has bursts of ventricular tachycardia

c. 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is scheduled for discharge to a group home later today The LPN/LVN scope of practice includes administration of medications to stable clients. Third-degree heart block is characterized by a very low heart rate and usually by required pacemaker insertion; the skills of the RN are needed to care for this client. Fever after surgery requires collaboration with the health care provider, which is more consistent with the role of the RN. The client with a recent stent placement and having bursts of ventricular tachycardia is unstable and is showing ventricular irritability; he will need medications and monitoring beyond the scope of practice of the LPN/LVN.

A patient taking Digoxin is experiencing severe bradycardia, nausea, and vomiting. A lab draw shows that their Digoxin level is 4 ng/mL. What medication do you anticipate the physician to order for this patient? a. Narcan b. Aminophylline c. Digibind d. no medication because this is a normal digoxin level

c. Digibind

The intensive care nurse is caring for the kidney transplant patient who was just transferred from the recovery unit. Which finding is the most serious within the first 12 hours after surgery and warrants immediate notification of the transplant surgeon? a. diuresis with increased output b. pink and bloody urine c. abrupt decrease in urine d. small clots in bladder irrigation fluid

c. abrupt decrease in urine

A 63-year-old male is admitted with acute respiratory distress. Symptoms include marked shortness of breath and circumoral cyanosis. He is awake and complains of shortness of breath. He has a history of COPD (chronic obstructive pulmonary disease). Blood gases reveal the following information: pH 7.22 PaCO2 62 PaO2 54 SaO2 81% HCO3 25 FiO2 30% Based on the information above, what condition is likely developing? a. congestive heart failure b. ARDS c. acute respiratory failure d. pulmonary emboli

c. acute respiratory failure

Which combination of drugs is the most nephrotoxic? a. angiotensin-converting enzyme (ACE) inhibitors and aspirin b. antiotensin II receptor blockers and antiacids c. aminoglycoside antibiotics and nonsteroidal antiinflammatory drugs (NSAIDs) d. calcium channel blockers and antihistamines

c. aminoglycoside antibiotics and nonsteroidal antiinflammatory drugs (NSAIDs)

Quality measures for the management of heart failure identified by JCAHO include all of the following except: a. ejection fraction evaluated before or during admission b. appropriate use of angiotensin converting enzyme inhibitor/angiotensin receptor blocker at discharge c. appropriate use of nitrates during admission d. education regarding smoking cessation

c. appropriate use of nitrates during admission

A 50 year-old male with a history of endocarditis reports he is having a hard time breathing and it feels like an elephant is sitting on his chest. Which interventions are an emergent priority? Select all that apply. a. ask the patient to cough b. auscultate the lungs c. assess oxygen saturation d. assess for recent IV drug use e. obtain an ECG

c. assess oxygen saturation e. obtain an ECG The main concerns for anyone with pain in the chest area is a heart issue (myocardial infarction) or lung issue (Pulmonary Embolism). The first thing to do is to get an ECG, followed by checking the oxygen saturation. Listening to lung sounds is important and you will do this eventually, but lungs sounds at this time will not give you emergent life-saving information. Asking the patient about drug use and to cough can be helpful but it is not going to diagnose any life threatnening issues, and therefore is not the priority.

An older adult client, 4 hours after coronary artery bypass graft (CABG), has a blood pressure of 80/50 mm Hg. What action does the nurse take? a. no action is required; low blood pressure is normal for older adults b. no action is required for postsurgical CABG clients c. assess pulmonary artery wedge pressure (PAWP) d. give ordered loop diuretics

c. assess pulmonary artery wedge pressure (PAWP) Decreased preload as exhibited by decreased PAWP could indicate hypovolemia secondary to hemorrhage or vasodilation; hypotension could cause the graft to collapse. Low blood pressure is not normal in older adults or postoperative clients. The cause of hypotension must be found and treated; further action is needed to determine additional interventions. Hypotension could be caused by hypovolemia; giving loop diuretics increases hypovolemia.

Which of the following would be the earliest sign of hypoventilation? a. respiratory rate of 20/minute b. anxiety c. decreased level of consciousness d. SpO2 of 85%

c. decreased level of consciousness

The nurse assesses a client who had a coronary artery bypass graft yesterday. Which assessment finding will the nurse report to the surgeon immediately? a. incisional pain b. blood pressure of 136/76 c. decreased level of consciousness d. apical pulse of 88

c. decreased level of consciousness A change in level of consciousness should be reported to the surgeon immediately. Incisional pain is to be expected. The blood pressure is only slightly elevated, which can indicate a response to pain; the apical pulse is normal.

Which definition best describes left-sided heart failure? a. increased volume and pressure develop and result in peripheral edema b. can occur when cardiac output remains normal or above normal c. decreased tissue perfusion from poor cardiac output and pulmonary congestion from increased pressure in the pulmonary vessels d. percentage of blood ejected from the heart during systole

c. decreased tissue perfusion from poor cardiac output and pulmonary congestion from increased pressure in the pulmonary vessels

When auscultating the client's breath sounds, the nurse hears soft rustling sounds at the lung edges. What is the nurse's best action? a. listen again with the bell of the stethoscope rather than the diaphragm b. ask the client to cough and spit out any collected mucus c. document the finding as the only action d. notify the health care provider

c. document the finding as the only action The sounds described are vesicular sounds, which are normally heard at the peripheral lung fields where air flows through smaller bronchioles and alveoli. Thus, this is a normal finding that does not require any action other than documentation.

The nurse is infusing platelets to a client who is scheduled for a hematopoietic stem cell transplant. What procedure does the nurse follow? a. administer intravenous corticosteroids before starting the transfusion b. allow the platelets to stabilize at the client's bedside for 30 minutes c. infuse the transfusion over a 15- to 30-minute period d. set up the infusion with the standard transfusion Y tubing

c. infuse the transfusion over a 15- to 30-minute period The volume of platelets—200 or 300 mL (standard amount)—needs to be infused rapidly over a 15- to 30-minute period. Administering steroids is not standard practice in administering platelets. Platelets must be administered immediately after they are received; they are considered to be quite fragile. A special transfusion set with a smaller filter and shorter tubing is used to get the platelets into the client quickly and efficiently.

A systolic murmur is auscultated when regurgitant blood flows across which of the following heart valves? a. mitral and aortic b. tricuspid and pulmonic c. mitral and tricuspid d. pulmonic and aortic

c. mitral and tricuspid

The nursing student is explaining principles of hemodialysis to the nursing instructor. Which statement by the student indicates a need for additional study and research on the topic? a. "Dialysis works as molecules from an area of higher concentration move to an area of lower concentration." b. "Blood and dialyzing solution flow in opposite directions across an enclosed semipermeable membrane." c. "Excess water, waste products, and excess electrolytes are removed from the blood." d. "Bacteria and other organisms can also pass through the membrane, so the dialysate must be kept sterile."

d. "Bacteria and other organisms can also pass through the membrane, so the dialysate must be kept sterile."

You're providing diet discharge teaching to a patient with a history of heart failure. Which of the following statements made by the patient represents they understood the diet teaching? a.. "I will limit my sodium intake to 5-6 grams a day." b. "I will be sure to incorporate canned vegetables and fish into my diet." c. "I'm glad I can still eat sandwiches because I love bologna and cheese sandwiches." d. "I will limit my consumption of frozen meals."

d. "I will limit my consumption of frozen meals." Patients with heart failure should limit sodium intake to 2 to 3 grams per day (not 5-6 grams), avoid canned vegetable/fish, and avoid sandwich meats and cheeses because of their high sodium content. Frozen meals are high in sodium, therefore the patient is correct in saying they should limit their consumption of them.

Which statement by a client scheduled for a percutaneous transluminal coronary angioplasty (PTCA) indicates a need for further preoperative teaching? a. "I will be awake during this procedure." b. "I will have a balloon in my artery to widen it." c. "I must lie still after the procedure." d. "My angina will be gone for good."

d. "My angina will be gone for good." Reocclusion is possible after PTCA. The client is typically awake, but drowsy, during this procedure. PTCA uses a balloon to widen the artery, and the client will have to lie still after the procedure because of the large-bore venous access. Time is necessary to allow the hole to heal and prevent hemorrhage.

A 69-year-old client has been diagnosed with cardiomyopathy. The nurse gives the client a nursing diagnosis of powerlessness because the client has said that she feels sad and angry about what she will miss out on with her diagnosis. Which nursing intervention is most appropriate for this nursing diagnosis? a. talk about the client's feelings before she is dismissed to go home b. have the client talk to another client who also has the diagnosis of powerlessness c. have the client write down all of the things she likes about herself d. help the client identify factors that she can control

d. help the client identify factors that she can control Powerlessness is a nursing diagnosis that can be given when a client feels a lack of control over his or her situation. The client may demonstrate this powerlessness by avoiding self-care measures or grieving heavily over the situation. With a nursing diagnosis of powerlessness, the nurse can help the client to identify those factors that she can control, which may help her to feel as if she has power in some areas of her life, even if she cannot control her medical condition.

What is a pulse oximeter used to measure? a. oxygen perfusion in the extremities b. pulse and perfusion in the extremities c. generalized tissue perfusion d. hemoglobin saturation

d. hemoglobin saturation

The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8° F Pulse: 48 beats/min and irregular Respirations: 20 breaths/min Potassium level: 3.2 mEq/L What action does the nurse take? a. give the digoxin; reassess the heart rate in 30 minutes b. give the digoxin; document assessment findings in the medical record c. hold the digoxin, and obtain a prescription for an additional dose of furosemide d. hold the digoxin, and obtain a prescription for a potassium supplement

d. hold the digoxin, and obtain a prescription for a potassium supplement Digoxin causes bradycardia; hypokalemia potentiates digoxin. Because digoxin causes bradycardia, the medication should be held. Furosemide decreases circulating blood volume and depletes potassium; no indication suggests that the client has fluid volume excess at this time.

Which of the following tests/procedures are NOT used to diagnose heart failure? a. echocardiogram b. brain natriuretic peptide blood test c. nuclear stress test d. holter monitoring

d. holter monitoring A holter monitor is used to monitor a patient's heart rate and rhythm.

During assessment of a patient with heart failure, the nurse notes that the patient's pulses alternate in strength. What does this assessment indicate to the nurse? a. pulsus paradoxus b. orthostatic hypotension c. hypotension d. pulsus alternans

d. pulsus alternans

___________ is the amount of blood pumped by the left ventricle with each beat. a. cardiac output b. preload c. afterload d. stroke volume

d. stroke volume Stroke volume is the amount of blood pumped by the left ventricle with each beat.

The nurse is caring for a client who was discharged 3 weeks ago after a diagnosis of pulmonary embolism (PE). He is currently admitted with gastrointestinal (GI) bleeding and an international normalized ratio (INR) of 6.9. For which factors should the nurse assess this client? a. consumption of green leafy vegetables b. prolonged exhalation c. client has massaged his calves d. use of aspirin or salicylates

d. use of aspirin or salicylates Use of aspirin and salicylates will prolong the INR and cause gastric irritation. Green leafy vegetables are high in vitamin K and would antagonize warfarin, resulting in a low(er) INR. A prolonged expiratory phase is typical in chronic obstructive pulmonary disease, not GI bleeding or a prolonged INR. Massaging the calves may present a risk for PE if deep vein thrombosis is present, but does not relate to GI bleeding and prolonged INR.