Test 1

The nurse is to obtain a sputum specimen from a patient. Select the correct set of statements instructing the patient in the proper technique for obtaining a sputum specimen. "Collect the specimen right before bed. Spit carefully into the container." "Rinse your mouth with water, then cough into the container. Do this first thing in the morning." "Right after lunch, cough and spit into the container." "Spit into the container then add two tablespoons of water."

"Rinse your mouth with water, then cough into the container. Do this first thing in the morning."

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect to note on assessment of this client? Select all that apply. Hypocapnia A hyperinflated chest noted on the chest x-ray Decreased oxygen saturation with mild exercise A widened diaphragm noted on the chest x-ray Pulmonary function tests that demonstrate increased vital capacity

A hyperinflated chest noted on the chest x-ray Decreased oxygen saturation with mild exercise

Metropolol (Toprol XL) is prescribed for a patient for the management of angina. The nurse will monitor the effectiveness of this medication by assessing which of the following? Improvement in the quality of the peripheral pulses. Ability to do daily activities without chest discomfort. Decreased BP and apical pulse rate. Fewer complaints of having cold hands and feet.

Ability to do daily activities without chest discomfort.

The nurse is caring for a patient with bacterial pneumonia. Which classifications of medications should the nurse expect to be prescribed for this patient? Standard Text: Select all that apply. Antibiotics steroids bronchodilators antiemetics Antihistamines

Antibiotics bronchodilators

A patient's blood pressure continues to be elevated despite being prescribed an ACE inhibitor for several weeks. What should the nurse do at this time? Schedule the patient to have the blood pressure checked again in a week. Ask if the patient is taking the prescribed medication. Suggest to the physician that another medication be added. Realize the patient is anxious because of the diagnosis.

Ask if the patient is taking the prescribed medication.

A patient with pneumonia is having difficulty maintaining a clear airway. Which actions should the nurse take to ensure this patient is adequately ventilated? Standard Text: Select all that apply. Assess skin color at least every four hours. Assess breath sounds at least every four hours. Assess vital signs daily. Assess respiratory rates every shift. Assess oxygen saturation level at least every four hours.

Assess skin color at least every four hours. Assess breath sounds at least every four hours. Assess oxygen saturation level at least every four hours.

A patient with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and cannot produce an effective cough, the nurse should monitor closely for which of the following complications? Pulmonary effusion Atelectasis Pulmonary edema Oxygen toxicity

Atelectasis

During the abdominal assessment of an elderly patient, the nurse identifies a pulsation in the midabdomen, What should the nurse do next? Palpate the pulsation Contact the Physician Ask the patient to cough Auscultate the pulsation

Auscultate the pulsation

The family of a patient who experienced a stroke after percutaneous coronary revascularization asks the nurse what caused the stroke to occur. How should the nurse respond to the family? "A stroke could have been caused by clot particles from the procedure." "Stroke is usually caused by ruptured plaque inside the coronary artery." "Stroke is caused by heart failure." "No one knows what causes strokes."

"A stroke could have been caused by clot particles from the procedure."

Following an acute myocardial infarction, a 67-year-old African-American client develops clinical manifestations of heart failure and is started on lisinopril. Which of the following statement indicates that more teaching is needed is? "I will call the doctor if I notice that I have a frequent non-productive cough." The medication may not work as well if I take any aspirin." "I won't worry if I have a little swelling around my lips and face." "The doctor may order a blood potassium level occasionally."

"I won't worry if I have a little swelling around my lips and face."

An adult is receiving oxygen by nasal prongs. Which statement by the patient indicates that patient teaching regarding oxygen therapy has been effective? "I was feeling fine so I removed my nasal prongs." "I've increased my fluids to six glasses of water daily." "Don't forget to come back quickly when you get me out of bed; I don't like to be without my oxygen for too long." "My family was angry with I told them they could not smoke in my room."

"My family was angry with I told them they could not smoke in my room."

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? Dry cough Hematuria Bronchospasm Blood-streaked sputum

Bronchospasm

Fifteen hours after admission, a patient's CK-MB level is markedly increased. What should this indicate to the treatment team? Cellular necrosis of myocardial tissue has occurred. Lactic acid is present. Thrombolytic therapy is indicated Cardiac function has returned to normal.

Cellular necrosis of myocardial tissue has occurred.

Aspirin has been prescribed for a patient following a myocardial infarction. What should the nurse include when teaching about this drug? Check with your healthcare provider before taking any herbal remedies. Report any itching that develops after seven days of taking the drug Take at a different time of day than warfarin (Coumadin). Do not skip any scheduled appointments to have blood drawn for labs.

Check with your healthcare provider before taking any herbal remedies.

Terbutaline is prescribed for a client with bronchitis. The nurse understands that this medication should be used with caution if which medical condition is present in the client? Osteoarthritis Hypothyroidism Diabetes mellitus Polycystic disease

Diabetes mellitus

A patient who is being treated for a deep vein thrombosis (DVT) complains of chest pain and shortness of breath. What should the nurse do first? Elevate the head of the bed and begin oxygen therapy. Measure the patient's blood pressure. Assess the extremity with the thrombosis. Assess the pulses on the extremity with the thrombosis

Elevate the head of the bed and begin oxygen therapy.

The nurse is caring for a patient who has had a chest tube inserted and connected to a portable water-seal drainage. The nurse determines the drainage system is functioning correctly when which of the following is observed? Continuous bubbling in the water seal chamber Fluctuation in the water-seal chamber Suction tubing attached to a wall unit Vesicular breath sounds throughout the lung fields

Fluctuation in the water-seal chamber

A patient diagnosed with tuberculosis is prescribed ethambutol (EMB). Prior to initiating this medication, what should the nurse instruct the patient? Avoid this medication if allergic to eggs. Have an influenza (flu) vaccination. Have a baseline ECG (electrocardiogram). Have a baseline visual exam.

Have a baseline visual exam.

A patient is being discharged to home on Coumadin (Warfarin) 2.5 mg daily. The nurse recognizes that the patient understands the effects of coumadin? I will use an electric razor to shave my legs I will use a straight blade to cut my toenails I need to eat more salads and fresh fruits I will take aspirin instead of Tylenol (acetaminophen) for headaches

I will use an electric razor to shave my legs

The nurse is planning care for a patient who is in acute heart failure. Which of the following goals are appropriate? Select all that apply Increase in cardiac output An elevation in renal blood flow A reduction in the workload of the heart A decrease in myocardial contractility

Increase in cardiac output An elevation in renal blood flow A reduction in the workload of the heart

A nurse teaches a patient about the use of a metered dose inhaler (MDI). Which action by the client indicates a need for further teaching? Removes the cap and shakes the inhaler well before use Presses the canister down with the finger as he breathes in Inhales the mist and quickly exhales Waits 1 to 2 minutes between puffs if more than one puff has been prescribed

Inhales the mist and quickly exhales

A patient is recovering from a bronchoscopy. What care should the nurse provide to this patient? Standard Text: Select all that apply. Instruct the patient to avoid eating and drinking until the gag reflex returns. Report light blood-tinged respiratory secretions to the physician. Notify the physician with any breathing difficulty. Administer pain medications immediately following the procedure. Instruct the patient on use of incentive spirometry to use following the procedure.

Instruct the patient to avoid eating and drinking until the gag reflex returns. Report light blood-tinged respiratory secretions to the physician. Notify the physician with any breathing difficulty.

The nurse calls a patient at home with the laboratory results from his visit of earlier in the day. Based on a review of these results, what does the nurse expect the healthcare provider to advise? Lab results PT (prothrombin) Within therapeutic range INR 2.4 Maintain the same daily dose of heparin. Maintain the same daily dose of warfarin (Coumadin). Increase the dose of warfarin (Coumadin) according to the previous instructions by the physician. Stop taking the warfarin (Coumadin) until the next clinic appointment.

Maintain the same daily dose of warfarin (Coumadin).

The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles? Mask Gown Gloves Eye protection

Mask

The nurse is planning care for a patient who was diagnosed with deep vein thrombosis (DVT). What should be included in this plan of care? Activity as tolerated. Measure and apply elastic antiembolism stockings. Encourage the patient to sit out of bed several hours every day. Assist patient with putting on tight-fitting pants.

Measure and apply elastic antiembolism stockings.

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic, thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? Palpation and clubbing Percussion and vibration Hyperoxygenation and suctioning Administer a bronchodilator and monitor peak flow

Percussion and vibration

The nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the Promote oxygen intake Strengthen the diaphragm Strengthen the intercostal muscles Promote carbon dioxide elimination

Promote carbon dioxide elimination

A patient is exhibiting signs of heparin overdose. Which of the following should the nurse anticipate the patient will receive? Platelets Vitamin K Calcium Protamine zinc sulfate

Protamine zinc sulfate

Which of the following systems is the most likely origin of pain the client describes as knife-like chest pain that increases in intensity with inspiration? Cardiac origin Gastrointestinal origin Pulmonary origin Musculoskeletal

Pulmonary origin

The nurse administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? Respiratory rate of 21 breaths/minute Dilated and reactive pupils Urine output of 40 ml/hour Heart rate of 100 beats/minute

Respiratory rate of 21 breaths/minute

The nurse is instructing a patient with hypertension about lifestyle modifications. What would be appropriate to include in the teaching for this patient? Standard Text: Select all that apply. Review low sodium, high fiber, low saturated fat diet Begin a walking program, and progress to 30 minutes 5 to 6 days each week. Plan a weight lifting regimen. Eliminate dairy products from the diet. Restrict fluid intake.

Review low sodium, high fiber, low saturated fat diet Begin a walking program, and progress to 30 minutes 5 to 6 days each week.

The nurse instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? Sitting up in bed Side-lying in bed Sitting in a recliner chair Sitting on the side of the bed and leaning on an overbed table

Sitting on the side of the bed and leaning on an overbed table

The nurse is preparing medications for a patient with hyperlipidemia. What information should the nurse consider when administering these medications? Such medications include bile acid sequestrants as first-line drugs to lower cholesterol levels These medications do not include angiotensin-converting enzyme (ACE) inhibitors. These medications act by increasing the LDL levels and decreasing the HDL levels. Such medications include the statins, which act by lowering LDL levels.

Such medications include the statins, which act by lowering LDL levels.

The nurse is instructing a patient on nitroglycerin tablets prescribed to treat angina. Which statement(s) should be included in the nurse's instructions? Standard Text: Select all that apply. Take a second dose if the angina is not relieved within five minutes." "The drug should remain in this brown bottle since it is sensitive to light." "Store this medication in your bathroom medicine cabinet so it is readily available to you." . "Eating or drinking will not interfere when taking the medication." "Call your doctor immediately if you develop a headache when taking this drug."

Take a second dose if the angina is not relieved within five minutes." "The drug should remain in this brown bottle since it is sensitive to light."

A client has a prescription to take guaifenesin (Mucinex). The nurse determines that the client understands the proper administration of this medication if the client states that he or she will perform which action? Take an extra dose if a fever develops Take the medication with meals only Take the tablet with a full glass of water Decrease the amount of daily fluid intake

Take the tablet with a full glass of water

The nurse is monitoring a male client who is taking propranolol. Which of the following would warrant immediately holding the administration of propranolol? The development of complaints of impotence. The development of audible expiratory wheezes. A decrease in the baseline BP from 150/80 mmHg to 112/75 mmHg after two doses of medication. A baseline resting heart rate of 88 bpm followed by a resting heart rate of 72 bpm after two doses of the medication.

The development of audible expiratory wheezes.

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed? Face tent Venturi mask Aerosol mask Tracheostomy collar

Venturi mask

After an assessment the nurse is concerned that an older patient is at risk for developing pneumonia. What age-related changes did the nurse assess to make this clinical decision? Standard Text: Select all that apply. Weak cough Poor skin turgor Smoked a ppd for 30 years Body mass index 22.6 Diagnosed with right-sided heart failure

Weak cough Poor skin turgor Smoked a ppd for 30 years Diagnosed with right-sided heart failure

A patient who is taking rifampin (Rifadin) as part of his treatment for tuberculosis asks about making an appointment for a urologist because his urine is "bright orange." What should the nurse realize this patient is experiencing? a secondary urinary tract infection a common side effect of rifampin therapy the onset of a kidney stone early renal failure

a common side effect of rifampin therapy

A patient with chronic heart failure who has been following a low-sodium diet tells the nurse at the clinic about a 5-pound weight gain in the last 3 days. Which of the following should be the nurse's first action? educate the patient about the use of diuretic therapy because it is likely that the patient will need medications to reduce the hypervolemia. instruct the patient in a low-calorie, low-fat diet because the weight gain has likely been caused by excessive intake of inappropriate foods. assess the patient for clinical manifestations of acute heart failure because an exacerbation of the chronic heart failure may be occurring. ask the patient to recall the dietary intake for the last 3 days because there may be hidden sources of sodium in the patient's diet.

assess the patient for clinical manifestations of acute heart failure because an exacerbation of the chronic heart failure may be occurring.

The nurse suspects a patient recovering from an abdominal aortic aneurysm repair is experiencing graft leaking. What findings did the nurse use to make this clinical decision? Standard Text: Select all that apply. urine output 45 mL/hr complaint of groin pain abdominal dressing dry and intact respiratory rate 16 and regular complaint of back discomfort

complaint of groin pain complaint of back discomfort

The nurse suspects that a patient is experiencing the effects of peripheral atherosclerosis (PAD). What did the nurse most likely assess in this patient? rubor with extremity elevation normal hair distribution bilaterally over lower extremities peripheral pulses present bilaterally complaints of leg pain upon rest

complaints of leg pain upon rest

What diagnostic test should the nurse anticipate as the priority for a patient admitted with chest pain to determine coronary artery status? coronary angiography stress electrocardiography echocardiography radionuclide testing

coronary angiography

The nurse enters the room of a patient who has a chest tube attached to a water-seal drainage system and notices the chest tube is dislodged from the chest. The most appropriate nursing intervention to do first is notify the physician. insert a new chest tube. cover the insertion site with an occlusive gauze. instruct the patient to breathe deeply until help arrives.

cover the insertion site with an occlusive gauze.

A patient is seen for increasing edema in his left lower extremity and pain in the limb with ambulation. What should the nurse suspect is occurring in this patient? arterial occlusion deep vein thrombosis superficial vein thrombosis varicose veins

deep vein thrombosis

Coronary heart disease (CHD) is a major problem in the United States. What information on the medical history would alert the nurse to closely evaluate a patient for CHD? Standard Text: Select all that apply. diabetes hyperlipidemia positive family history a premenopausal woman hypotension

diabetes hyperlipidemia positive family history

The nurse is concerned that a patient recovering from surgery to repair an abdominal aneurysm is developing bowel ischemia. What assessment findings did the nurse use to come to this conclusion? Select all that apply diarrhea obvious bloody stool abdominal distention onset of abdominal pain hyperactive bowel sounds

diarrhea obvious bloody stool abdominal distention onset of abdominal pain

A patient reports the following symptoms to the nurse: nausea, loss of appetite, blurred and double vision, green yellow halos, vomiting and "feeling uneasy." What situation should the nurse suspect? lidocaine toxicity amiodarone toxicity procainamide toxicity digoxin toxicity

digoxin toxicity

A patient with a pleural effusion most often presents to the hospital with which of the following? pain. swelling. dyspnea. increased sputum production.

dyspnea.

During patient teaching about cardiac risk factors, the nurse knows that which laboratory test, if abnormal, requires further instruction due to the risk for the development of coronary artery disease? elevated homocysteine elevated creatinine elevated high density lipoprotein (HDL) elevated INR

elevated homocysteine

The nurse is reviewing the results of the patient's diagnostic tests. Using the information provided as a reference, determine which physician order the nurse should question based on the patient's most likely diagnosis. Diagnostic Tests Results WBC with differential 32,000/mm3 left shift present Chest X ray Lower-Right lung, infiltrate present Sputum culture Staphylococcus aureus Oxygen saturation level 88% when admitted to hospital, on room air Temperature 102.2o F Respiratory Rate 28 per minutes fluid restriction of 1500 mL per 24 hours administer acetylcysteine (Mucomyst) perform endotracheal suctioning as needed administer azithromycin

fluid restriction of 1500 mL per 24 hours

After inspecting a patient's left lower leg, the nurse leaves the patient's room and asks the charge nurse to notify the patient's healthcare provider regarding a possible arterial thrombosis. What did the nurse assess to make this decision? Standard Text: Select all that apply. absent pedal pulses skin cold to the touch +4 edema on the ankle foot unresponsive to sensation line of demarcation across the foot

foot unresponsive to sensation skin cold to the touch absent pedal pulses line of demarcation across the foot

A patient with a deep vein thrombosis (DVT) is going to be weaned from intravenous heparin. When should the nurse anticipate that oral warfarin sodium would be prescribed? the same day the heparin is discontinued the day before the heparin is discontinued four to five days before the heparin is discontinued the same day as the heparin is started

four to five days before the heparin is discontinued

Upon auscultating the chest of a 75-year-old patient who recently experienced a myocardial infarction (MI), the nurse hears an S3 and lung crackles. Because of these findings, the nurse should assess for what other condition? heart failure extension of the MI renal failure . liver failure

heart failure

While discussing coronary heart disease risk factors with a group of factory employees, the nurse includes which options as modifiable risk factors? Standard Text: Select all that apply. hypertension diabetes mellitus obesity age heredity

hypertension diabetes mellitus obesity

A patient who was admitted with symptoms of hypoxia is changed from a face mask to a nasal cannula for oxygen delivery. The nurse realizes that this patient's condition is deteriorating. improving. compounded with another health issue. stabilizing

improving.

A patient who had a Mantoux test for tuberculosis two days ago has a 2 mm area of erythema at the site of the test. The nurse concludes that this patient's response is positive for tuberculosis. should be followed up with a tine test. is negative. . is unable to determine the presence of tuberculosis.

is negative.

A patient is prescribed atorvastatin (Lipitor). For which adverse effect should the nurse monitor this patient? blood glucose and uric acid level alteration renal function alteration liver enzyme alteration . sudden back pain and constipation

liver enzyme alteration

An adult is ordered oxygen via nasal prongs. The nurse administering oxygen via this low-flow systm recognizes that this method of delivery mixes room air with oxygen. delivers a precise concentration of oxygen. requires humidity during delivery. is less traumatic to the respiratory tract.

mixes room air with oxygen.

A patient enters the emergency department complaining of chest pain that is radiating down the left arm. The emergent treatment plan for this patient should include which nursing actions? Standard Text: Select all that apply. morphine intravenously and oxygen aspirin160 to 325 mg orally (chewed) open heart surgery heparin drip at 100 units per hour Foley catheter insertion

morphine intravenously and oxygen aspirin160 to 325 mg orally (chewed)

While caring for a patient admitted with chest pain, the nurse recognizes that what factor places the patient at the highest risk for heart disease? overweight and carries the weight around the waist mother died at age 70 of an acute myocardial infarction a single mother of four young children with a low income has a desk job and works long hours

overweight and carries the weight around the waist

The nurse assessing a middle-aged patient experiencing chest pain realizes that presence of what symptom would be most characteristic of an acute myocardial infarction? colic-like epigastric pain sharp, well-localized unilateral chest and left arm pain substernal pressure type pain, radiating down the left arm sharp, burning chest pain moving from place to place

substernal pressure type pain, radiating down the left arm

While caring for a patient with COPD, the nurse observes that the patient's SpO2 drops from 94% to 85% when the patient ambulates in the hall. The nurse determines which of the following interventions are most appropriate? An arterial blood gas analysis should be done to verify the patient's SpO2. supplemental oxygen should be used whenever the patient exercises. This response is normal and the patient should continue at this activity level. All patient activity should be limited until the disease process is resolved.

supplemental oxygen should be used whenever the patient exercises.

A patient reports chest pain, nausea, and vomiting off and on for the last 4 days, which the patient interpreted as the flu. What laboratory test(s) will provide information about acute cardiac damage for this patient? troponin I and T red blood cells CK-MB homocysteine and platelets

troponin I and T

A patient diagnosed with active tuberculosis is in a negative pressure room for respiratory airborne isolation. How long should the nurse maintain the patient in this type of isolation? until sputum specimens for acid-fast bacilli are negative until the Mantoux test (PPD) converts from positive to negative until the patient has orders for discharge until the patient has orders for discharge

until sputum specimens for acid-fast bacilli are negative

When caring for a patient who has intermittent claudication, the nurse should advise the patient to do which of the following? apply graduated compression stockings elevate the legs when sitting refrain from exercise walk as tolerated

walk as tolerated

A patient is prescribed isoniazid (INH) and rifampin for treatment of tuberculosis. Which adverse effects should the nurse instruct the patient to report to the healthcare provider? Standard Text: Select all that apply. fever yellow tint to the skin episodic pain in the upper-left quadrant change in stool color

yellow tint to the skin change in stool color