N372 Exam 2- Book ?s

CH33: The nurse is admitting a client with an ulcer on the right foot. Which client statement indicates venous insufficiency to the nurse? Select all that apply. A. "My ankles swell up all the time." B. "My leg hurts after I walk about a block." C. "My feet are always really cold." D. "My veins really stick out in my legs." E. "My ankles have been discolored for years."

A. "My ankles swell up all the time." D. "My veins really stick out in my legs." E. "My ankles have been discolored for years."

CH35: The nurse is preparing to discharge a client who recently experienced a STEMI. Which client statement indicates understanding of nitroglycerin use? A. "The nitroglycerin should tingle when I put it in my mouth." B. "I will keep nitroglycerin in the glove compartment of my car." C. "Since the pills are small, they won't be hard to swallow." D. "The nitroglycerin should relieve the pain immediately."

A. "The nitroglycerin should tingle when I put it in my mouth."

CH32: The nurse is teaching a client with heart failure about a newly prescribed medication, ivabradine. What teaching will the nurse include? Select all that apply. A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your health care provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the health care provider if elevated."

A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your health care provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the health care provider if elevated."

CH33: Which assessment finding will the nurse anticipate in a client with severe atherosclerotic disease? A. Carotid artery bruit B. HDL 60 mg/dL C. Palpable peripheral pulses D. BP 120/58 mm Hg

A. Carotid artery bruit

CH35: The nurse is providing community education regarding myocardial infarction. What teaching will the nurse include? Select all that apply. A. Denial is common reaction to chest pain. B. A myocardial infarction can occur in minutes. C. Exercise at least 20 minutes three to four times per week. D. Age is a significant risk factor in the development of CAD. E. Women are more likely to experience atypical chest pain. F. Atherosclerosis is a primary factor in the development of CAD.

A. Denial is common reaction to chest pain. D. Age is a significant risk factor in the development of CAD. E. Women are more likely to experience atypical chest pain. F. Atherosclerosis is a primary factor in the development of CAD

CH32: The nurse is admitting an 84-year-old client with heart failure to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data are most concerning? A. Digoxin therapy daily B. Daily metoprolol C. Furosemide twice daily D. Currently taking an antacid for upset stomach

A. Digoxin therapy daily

CH35: The nurse is assessing a client who had a coronary artery bypass graft yesterday. Which assessment finding indicates the client is at risk for decreased perfusion? A. Heart rate of 50 beats/min B. Potassium level of 4.2 mEq/L C. Systolic blood pressure of 120 mm/Hg D. 50 mL of bloody drainage in chest tube over 4 hours

A. Heart rate of 50 beats/min

CH35: The nurse is caring for a client with chest pain. What assessment data would cause the nurse to suspect unstable angina? Select all that apply. A. ST changes B. Troponin T 0.6 ng/mL C. Pain lasts 15 to 25 minutes D. Increased number of angina attacks E. The intensity of the chest pain has increased

A. ST changes C. Pain lasts 15 to 25 minutes D. Increased number of angina attacks E. The intensity of the chest pain has increased

CH32: The nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement requires further nursing education? A. "I may need to take this drug every other day according to lab values." B. "I need to take potassium supplements with this medication." C. "I will try my best not to use table salt on my food." D. "This medication will cause me to urinate more often."

B. "I need to take potassium supplements with this medication."

CH32: A client is diagnosed with left-sided heart failure. Which client assessment findings will the nurse anticipate? Select all that apply. A. Peripheral edema B. Crackles in both lungs C. Tachycardia D. Ascites E. Tachypnea F. S3 gallop

B. Crackles in both lungs C. Tachycardia E. Tachypnea F. S3 gallop

CH35: The nurse assesses a client who had a coronary artery bypass graft yesterday. Which assessment finding will cause the nurse to suspect cardiac tamponade? A. Incisional pain with decreased urine output B. Muffled heart sounds with the presence of JVD C. Sternal wound drainage with nausea D. Increased blood pressure and decreased heart rate

B. Muffled heart sounds with the presence of JVD

CH32: The nurse is caring for a hospitalized client with infective endocarditis who has been receiving antibiotics for 2 days. The client is now experiencing flank pain with hematuria. What complication will the nurse suspect? A. Pulmonary embolus B. Renal infarction C. Transient ischemic attack D. Splenic infarction

B. Renal infarction

CH31: While suctioning a client with a tracheostomy, the client becomes diaphoretic and nauseous and the heart rate decreases to 37 beats/min. What is the priority nursing action? A. Continue to clear the airway. B. Stop suctioning the patient. C. Administer atropine. D. Call the health care provider immediately.

B. Stop suctioning the patient.

CH33: The nurse is caring for a client receiving intravenous heparin for treatment of DVT who begins to begins to vomit blood. What action should the nurse be prepared to take? A. Administer vitamin K B. Stop the infusion of heparin C. Administer an antiemetic D. Insert a nasogastric tube

B. Stop the infusion of heparin

CH33: A client is admitted to the hospital with an abdominal aortic aneurysm. Which assessment data would cause the nurse to suspect that the aneurysm has ruptured? A. Shortness of breath and hemoptysis B. Sudden, severe low back pain and bruising along the flank C. Gradually increasing substernal chest pain and diaphoresis D. Rapid development of patchy blue mottling on feet and toes

B. Sudden, severe low back pain and bruising along the flank

CH35: A 45-year-old male client having an annual physical asks the nurse about his risk for developing a myocardial infarction (MI). Which modifiable risk factors will the nurse assess to guide the client's teaching plan? Select all that apply. A. Age B. Tobacco use C. Gender D. Diet E. Family history F. Weight

B. Tobacco use D. Diet F. Weight

CH35: A client who is 9 days post-coronary artery bypass graft presents to a follow-up appointment. Which client statement requires nursing action? A. "My chest hurts when I sneeze or cough." B. "If I get tired when I walk, then I stop and rest for a bit." C. "I have a bandage on my sternum to collect the drainage." D. "I haven't had my normal appetite since the surgery."

C. "I have a bandage on my sternum to collect the drainage."

CH32: A client who recently had a heart valve replacement is preparing for discharge. Which client statement indicates that the nurse will need to do additional health teaching? A. "I need to brush my teeth at least twice daily and rinse with water." B. "I will eat foods that are low in vitamin K, such as potatoes and iceberg lettuce." C. "I need to take a full course of antibiotics prior to my colonoscopy." D. "I will take my blood pressure every day and call if it is too high or low."

C. "I need to take a full course of antibiotics prior to my colonoscopy."

CH31: The primary health care provider prescribes warfarin for a client with atrial fibrillation. Which client statement indicates that additional education is needed? A. "I need to go to the clinic once a week to have my blood level checked." B. "If my stools turn black, I will be sure to call my primary health care provider." C. "I'm glad I don't need to change my diet. Salads are my favorite food." D. "I need to stop taking my herbal supplement."

C. "I'm glad I don't need to change my diet. Salads are my favorite food."

CH33: A client who is receiving heparin therapy is started on warfarin. Which nursing explanation is appropriate? A. "You will need both drugs long-term to provide long-term anticoagulation." B. "Warfarin is easier on your stomach so you can take it long-term." C. "It takes several days for warfarin to begin working, so both drugs are required for a shorttime." D. "These drugs work the same, but one is taken by mouth, so it is easier to take at home."

C. "It takes several days for warfarin to begin working, so both drugs are required for a shorttime."

CH33: The nurse is caring for a diabetic client who will be discharged on hydrochlorothiazide (HCTZ). What information will the nurse include in the discharge teaching? Select all that apply. A. "This drug may cause a dry, nagging cough." B. "Take this drug with a snack, right before bed." C. "Try to increase your intake of potassium in your diet." D. "This drug can affect your glucose control." E. "Increased urination is expected with this drug."

C. "Try to increase your intake of potassium in your diet." D. "This drug can affect your glucose control." E. "Increased urination is expected with this drug."

CH31: The nurse is assessing the client's cardiac rhythm and notes the following: HR 64, regular rhythm, PR interval 0.20; QRS 0.10. How will the nurse document this rhythm interpretation in the electronic health record? A. Sinus tachycardia B. Sinus bradycardia C. Normal sinus rhythm D. Sinus arrhythmia

C. Normal sinus rhythm

CH31: Upon entering a client's room, the nurse finds the client unresponsive. In what order will the nurse provide care? A. Begin chest compressions B. Check carotid pulse C. Notify the Rapid Response Team D. Get the crash cart/AED E. Provide rescue breaths

C. Notify the Rapid Response Team D. Get the crash cart/AED B. Check carotid pulse A. Begin chest compressions E. Provide rescue breaths

CH32: The nurse is caring for a client with heart failure who is on oxygen at 2 L per nasal cannula with an oxygen saturation of 90%. The client states, "I feel short of breath." Which action will the nurse take first? A. Contact respiratory therapy. B. Increase the oxygen to 4 L. C. Place the client in a high-Fowler position. D. Draw arterial blood for arterial blood gas analysis.

C. Place the client in a high-Fowler position.

CH33: The nurse is teaching a client with stage 1 hypertension. Which client statement indicates understanding of dietary modifications? A. "I will reduce my sodium intake to 2500 mg per day." B. "I will restrict my intake of daily dietary lean protein." C. "I am only going to drink one cup of coffee to start my day." D. "I will drink a glass of low-fat milk with my breakfast."

D. "I will drink a glass of low-fat milk with my breakfast."

CH33: The nurse is caring for a client with intermittent claudication due to peripheral arterial disease. Which client statement indicates understanding of proper self-management? A. "I need to reduce the number of cigarettes that I smoke each day." B. "I'll elevate my legs above the level of my heart." C. "I'll use a heating pad to promote circulation." D. "I'll start to exercise gradually, stopping when I have pain."

D. "I'll start to exercise gradually, stopping when I have pain."

CH31: A client in the telemetry unit is on a cardiac monitor. The monitor technician alerts the nurse that there are no ECG complexes, and the alarm is sounding. What is the first action by the nurse? A. Suspend the alarm. B. Call the emergency response team. C. Press the record button to get an ECG strip. D. Assess the client and check lead placement.

D. Assess the client and check lead placement.

CH31: The nurse is caring for client who is experiencing occasional premature ventricular contractions. What assessment data are most concerning to the nurse? A. Potassium 4.8 mEq/L B. Magnesium 2 mEq/L C. Heart rate 90 D. History of smoking

D. History of smoking