NUR 220 EXAM 2 Perfusion

An adolescent tells a nurse that, while he was riding in a friend's car, the friend was stopped by the police for driving while intoxicated. Which assessment tool would be most appropriate to use with this adolescent? 1. Faces Pain Scale 2. Pediatric Symptom Checklist (PSC) 3. Guidelines for Adolescent Prevention (GAP) 4. Oucher Scales

3

Each year, a client takes many trips to other countries. The client reports leg swelling during the long flights. How should the nurse best advise this client when traveling? 1. relax in a reclining position 2. sit upright with legs extended 3. walk around at least every hour 4. sit in any position that relieves pressure on the legs

3

How does a nurse determine jugular vein pulsations? 1. Elevates the head of the bed about 90 degrees and looks for the jugular vein pulsation parallel to the sternocleidomastoid muscle as the head of the bed is slowly lowered 2. Looks for jugular vein pulsations at the jaw line as the patient turns from supine to a side-lying position 3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle 4. Positions the patient supine and asks him or her to cough; looks for jugular vein pulsations during the cough

3

On auscultation of the heart, the nurse recognizes which expected finding? 1. A low-pitched blowing sound is heard over the abdominal aorta. 2. A high-pitched vibration is heard over the base of the heart. 3. The S1 heart sound is louder at the apex of the heart. 4. The S3 heart sound sounds like "Ken-tuck-y."

3

Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain in the patient with stable angina. Which instruction should the nurse include when teaching the client about sublingual nitroglycerin? 1. once the tablet is dissolved, spit out the saliva 2. take tablets 3 minutes apart up to a maximum of five tablets 3. common side effects include headache and low blood pressure 4. once opened, the tablets should be refrigerated to prevent deterioration

3

Hct for females

37-47

Bilirubin

0.3-1.0

creatine range for female

0.5-1.1

creatine range for males

0.6-1.2

normal INR range

0.8-1.1

A client with heart failure has anxiety. Which effect of anxiety makes it particularly important for the nurse to reduce the anxiety of this client? 1. increases the cardiac workload 2. interferes with usual respirations 3. produces an elevation in temperature 4. decreases the amount of oxygen

1

A nurse is palpating the lymph nodes of an 18-month-old toddler and finds enlarged postauricular and occipital nodes. What is the significance of this finding? 1. This is a normal finding at this age. 2. The toddler may have an ear infection. 3. The toddler may have an inflammation of the scalp. 4. The toddler needs to be referred to a pediatrician.

1

A nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? 1. lips 2. sclera 3. conjunctiva 4. mucus membrane

1

During inspection of the mouth of a 72-year-old male patient, the nurse notices a red lesion at the base of his tongue. What additional information does the nurse obtain from this patient? 1. Alcohol and tobacco use 2. Date of his last dental examination 3. How well his dentures fit 4. A history of gum disease

1

Each patient has had consistent blood pressure readings during the last three clinic visits. Which patient has a blood pressure consistent with expected findings? 1. Mr. P, whose blood pressure has been 110/78 2. Ms. J, whose blood pressure has been 140/90 3. Mr. Q, whose blood pressure has been 130/76 4. Ms. Y, whose blood pressure has been 120/80

1

The nurse is caring for a client who is experiencing signs and symptoms of a cardiac dysrhythmia and is scheduled to wear a Holter monitor for 24 hours. What should the client should be instructed to do during the test? 1. keep a diary of activities 2. stay away from microwave ovens 3. avoid taking any nitroglycerin that day 4. take both blood pressure and pulse every 2 hours

1

To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices? 1. they help the venous blood return to the heart 2. they will not cause discomfort, but gently massage the legs 3. they are used instead of anticoagulant therapy 4. they must be worn until the first time the client gets out of bed

1

What would be an abnormal finding for a 7-year-old African American boy? 1. Abdominal distention 2. Umbilical hernia 3. Abdominal breathing 4. Tenseness of abdominal muscles

1

Which finding on a 2-month-old baby is considered abnormal and requires further follow-up? 1. The anterior fontanelle is not palpable. 2. The thyroid gland cannot be palpated. 3. The head circumference is slightly greater than the chest circumference. 4. Head lag is observed when the shoulders are lifted off the examination table.

1

Which would be an abnormal finding during an abdominal examination of an older adult? 1. Report of incontinence when sneezing or coughing 2. Loss of abdominal muscle tone 3. Bowel sounds every 15 seconds in all quadrants 4. Silver-white striae and a very faint vascular network

1

5 locations to auscultate for heart sounds

1. apical 2. pulmonary 3. erbs 4. tricuspid 5. mitral

steps of cardiac assessment

1. inspect- symmetry, color, warmth 2. palpate- apical pulse- look for lumps 3. auscultate @ erbs point

BUN range

10-20 mg/dL

normal PT time

11-12.5 sec

normal Hgb for females

12-16

Hgb for males

14-18 g/dL

normal platelet count

150,000-400,000/mm3

A 2-month-old infant is being treated with sequential casts for bilateral clubfoot (talipes equinovarus). New casts have just been applied. What should the nurse evaluate to determine that circulation to the feet remains sufficient? 1. alignment of legs on x-ray 2. warmth of the toes of both feet 3. mobility of the knees when flexed 4. presence of posterior tibial pulses

2

A Foley catheter was placed with an urimeter for a client with heart failure receiving furosemide. The output is 45 mL/hour, cloudy, and has sediment. How should the nurse interpret these findings? 1. the furosemide is causing dehydration 2. cloudy urine may be indicative of infection 3. the client has inadequate urine output 4. all of the indications are within normal findings

2

A client with a diagnosis of anemia is receiving packed red blood cells. What is the most important action by the nurse when administering the transfusion? 1. warning the client about the possibility of fluid overload 2. monitoring the clients response, particularly within the first 10 minutes 3. adjusting the clients transfusion flow rate so that it infuses a consistent rate during the procedure 4. having the client tested for human immunodeficiency virus (HIV) before administering the blood transfusion

2

A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing? 1. atrial fibrillation 2. sinus tachycardia 3. ventricular fibrillation 4. first-degree ventricular block

2

A nurse administers a parenteral preparation of potassium slowly and cautiously to avoid which complication? 1. acidosis 2. cardiac arrest 3. psychotic like reactions 4. edema of the extremities

2

A patient complains of pain in the calf when walking. Which question should the nurse ask for further data? 1. "Does your calf also swell when this pain occurs?" 2. "Does the pain go away when you stop walking?" 3. "Do you become short of breath when you're walking?" 4. "Do you feel dizzy when the pain occurs?"

2

In assessing the mood of older adult patients, a nurse documents which finding as abnormal? 1. Sadness and grief after returning from the funeral of a long-time friend 2. Depression that interferes with the ability to perform activities of daily living 3. Frustration about rearranging the day's schedule to attend a grandson's birthday party 4. Crying about the unexpected death of a pet that had been with the family 12 years

2

On inspection of the eye of an 82-year-old woman, the nurse notes which finding as normal? 1. Opaque coloring of the lens 2. Clear cornea with a gray-white ring around the limbus 3. Dilated pupils when looking at an item in her hand 4. Impaired perception of the colors yellow and red

2

The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is the next nursing action? 1. calling the primary healthcare provider 2. changing the maternal position 3. obtaining the maternal blood pressure 4. preparing the environment for an immediate birth

2

The nurse instructs a pregnant woman in labor that she must avoid lying on her back. The nurse bases this instruction on the information that the supine position is primarily avoided because it can do what? 1. prolong the course of labor 2. cause decreased placental perfusion 3. lead to transient episodes of hypertension 4. interfere with free movement of the coccyx

2

When a patient complains of chest pain, which question is pertinent to ask to gain additional data? 1. "What were you doing when the pain first occurred?" 2. "What does the pain feel like?" 3. "Do you have episodes of shortness of breath?" 4. "Has anyone in your family ever had a similar pain?"

2

Where does a nurse palpate to assess the posterior tibial pulse? 1. Behind the knee in the popliteal fossa 2. The inner aspect of the ankle below and slightly behind the medial malleolus 3. Over the dorsum of the foot between the extension tendons of the first and second toes 4. The outer side of the ankle below and slightly behind the lateral malleolus

2

Which finding of a preschooler during a cardiovascular system examination is abnormal? 1. Heart rate of 106 beats/min 2. Failure to gain weight because of fatigue while eating 3. Continuous low-pitched vibration heard over the jugular vein 4. Pulse increasing on inspiration and decreasing on expiration

2

A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen? 1. to prevent dyspnea 2. to prevent cyanosis 3. to increase oxygen concentration to heart cells 4. to increase oxygen tension in the circulating blood

3

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO 2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing? 1. metabolic acidosis 2. metabolic alkalosis 3. respiratory acidosis 4. respiratory alkalosis

3

3. Which patient has the greatest risk for hypertension? 1. An Asian man who is 5 ft 5 in (165 cm) tall, weighs 125 lbs (56.7 kg), and complains of a headache over his forehead and eyes 2. A Cheyenne Indian woman who complains of a gnawing, burning epigastric pain radiating to her neck and jaw 3. An African American man who has type 2 diabetes mellitus, exercises once a month, and drinks two-to-three alcoholic drinks a night with dinner 4. A Caucasian woman who has a family history of heart disease and complains of pain in her chest when she takes a deep breath

3

Which finding is an expected age-related change for a woman 80 years old? 1. Kyphosis 2. Back pain 3. Loss of height 4. Depression

3

Which patient has the greatest risk for hypertension? 1. An Asian man who is 5 ft 5 in (165 cm) tall, weighs 125 lbs (56.7 kg), and complains of a headache over his forehead and eyes 2. A Cheyenne Indian woman who complains of a gnawing, burning epigastric pain radiating to her neck and jaw 3. An African American man who has type 2 diabetes mellitus, exercises once a month, and drinks two-to-three alcoholic drinks a night with dinner 4. A Caucasian woman who has a family history of heart disease and complains of pain in her chest when she takes a deep breath

3

While examining the ear of an infant with an otoscope, the nurse pulls down on the ear for which reason? 1. Increases the depth that the otoscope can be inserted 2. Stabilizes the ear to avoid injury if the infant moves the head suddenly 3. Enhances visualization of the tympanic membrane by straightening the ear canal 4. Facilitates drainage of cerumen from the ear canal, allowing better visualization of inner ear structures

3

While inspecting the legs of a male patient, the nurse notes that the skin is shiny and taut with little hair growth. Which additional data would the nurse find to indicate that this patient has peripheral arterial disease? 1. Pitting edema of one or both feet or legs 2. Increased circumference in the thighs bilaterally 3. Pale, cool legs with diminished-to-absent dorsalis pulses 4. Pain when legs are dependent that is relieved when legs are elevated

3

Albumin range

3.5-5

PTT (partial thromboplastin time)

30-40 sec

triglycerides for females

35-135

A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care? 1. elevate the foot of the bed 2. perform urinary catheter care every 12 hours 3. place in the high-fowler position 4. perform a neurovascular assessment every 2 hours

4

A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which information will the nurse include in the teaching plan? 1. trimming toenails so that they are short and rounded 2. checking bathwater temperature by putting the toes in first 3. using alcohol to rub hands, feet, legs, and arms at least two times a day 4. seeking professional treatment for any injuries to the extremities

4

On assessment of the neurologic status of a 4-month-old infant, the nurse notes which finding as abnormal? 1. The infant abducts and extends arms and legs when startled. 2. When the infant's sole is touched, the toes flex tightly in an attempt to grasp. 3. When stroking the infant's foot from sole to great toes, there is fanning of the toes. 4. The infant steps in place when held upright with feet on a flat surface.

4

The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for? 1. increased appetite 2. clubbing of the nail beds 3. hypertension 4. weight gain

4

The nurse is listening to the patient's heart at the left sternal border (LSB) at the second intraclavicular space (ICS). Which area is being auscultated? 1. Erb's point 2. Mitral area 3. Aortic area 4. Pulmonic area

4

The nurse notes which finding as abnormal during a thoracic assessment of an older adult? 1. A skeletal deformity affecting curvature of the spine 2. Shortness of breath on exertion 3. An increase in anteroposterior diameter 4. Bronchovesicular breath sounds in the peripheral lung fields

4

What is an expected finding of the newborn's vision that the nurse teaches the parents? 1. Small tears will be noted when their newborn cries. 2. Peripheral sight does not develop until age 3 or 4 months. 3. The newborn can only distinguish the colors of blue and green. 4. The newborn is nearsighted and cannot see items unless they are close.

4

What is the most accurate technique for detecting a venous thrombosis at the bedside? 1. Dorsiflex the calf and note if the patient complains of pain. 2. Elevate one leg above the level of the heart to determine if the veins empty. 244 3. Palpate the pulses distal to the areas of the suspected thrombosis. 4. Measure the thigh circumference to detect an increase from the baseline.

4

When developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site, what should the nurse include? 1. ambulating the client 2 hours after the procedure 2. checking the vital signs every 15 minutes for 8 hours 3. keeping the client nothing by mouth for 4 hours after the procedure 4. maintaining the supine position for a minimum of 4 hours

4

When examining the genitalia of a 3-year-old boy, which position is ideal? 1. Prone position with legs flexed in a frog leg position 2. Supine position with knees spread and ankles spread apart 3. Lithotomy position with knees and ankles spread apart 4. Sitting position with knees spread and ankles crossed

4

Which are expected findings of a newborn's respiratory assessment? 1. Thoracic breathing 2. A 1:2 ratio of anteroposterior-to-lateral diameter 3. Flaring of the nares noted on inspiration 4. Bronchovesicular breath sounds in the peripheral lung fields

4

Which risk is associated with estrogen therapy in a client who smokes? 1. hypcalcemia 2. vaginal bleeding 3. multiple pregnancies 4. thromboembolic disorders

4

normal RBC range for females

4.2-5.4

normal RBC range for males

4.7-6.1

normal RBC range for newborns

4.8-7.1

normal RBC range for 8-12 y/o's

4.o-5.5

triglycerides for males

40-160 mg/dl

Hct for males

42-52%

murmurs normal up to _____ hours after birth

48

WBC for children and adults

5000-10000

What is the minimum heart rate of a 14 year old? Record your answer using a whole number. _____________ beats per minute

60 bpm

Glucose range

74-106

WBC for newborns

9000-30000

troponin T range

< 0.1 ng/dl

Troponin I range

<0.03 ng/dl

LDL value

<130mg/dl

cholesterol range

<200 mg/dL

HDL for men

>45mg/dl

HDL range for women

>55mg/dl

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments?

Quality of respirations and presence of pulses

A healthcare provider prescribes a diuretic for a client with hypertension. What should the nurse include in the teaching when explaining how diuretics reduce blood pressure?

Reduces the circulating blood volume

A client is admitted to the hospital and benazepril is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication?

Assess for dizziness.

A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the drug, the client complains of feeling dizzy. What action should the nurse take?

Place the client in the supine position and take the vital signs

Which heart sound is normally heard in a toddler that is considered abnormal in an adult over 30-years-old?

S3

A nurse determines that the client's apical pulse rate is higher than the radial pulse and documents the pulse deficit. What does the nurse consider is the primary reason for the pulse deficit?

The client may have atrial fibrillation.

A nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next?

Verify the pulse by using a Doppler.

Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client?

Yellow

capillary refill should be less than ____ for newborns

a second

Which complications does the nurse anticipate in the client who has blue-colored nail beds?

cardiopulmonary disease

________ pulses should be felt in children

femoral

jugular distention in adults is an indication of

heart failure

venous hum is normal for _______, and located in the _______vein.

kids, jugular

blanching includes..

pressing on nail bed, color should come back in less than 3 seconds