Unit 3 Adaptive quizzing

Which statement indicates that further teaching is needed after the nurse completes teaching for a client w/ foot pain who has PAD? A. "i will wear socks" B. "i will elevate my foot" C. "i will increase fluid intake" D. "i will drink a moderate amount of alcohol"

B

Which lab finding would the nurse expect in a toddler w/ iron-deficiency anemia in addition to decreased Hgb and Hct levels? SELECT ALL THAT APPLY A. microcytic RBCs B. hyperchromic RBCs C. low total iron binding capacity D. slightly reduced reticulocyte count E. increased ESR

A, D (hypochromic RBC, TIBC is increased, ESR not r/t iron deficiency anemia)

Which clinical manifestation indicates a possible PE in a client after a total hip replacement? SELECT ALL THAT APPLY A. sudden chest pain B. flushing of the face C. elevation of temp D. abrupt onset of SOB E. hip pain rating increased from 2 to 8

A, D (low O2, sudden chest pain, SOB, dyspnea, tachypnea) -fever is not a sign of PE

Which client would the nurse provide care for first based on priority of condition and findings? A. condition= cardiomyopathy; lower extremities swollen, weight gain B. condition= PAD; painful cramping in hip region, weakness and numbness in leg C. condition= aortic aneurysm; breathing difficulty, chest pain D. condition= chest trauma; breathing difficulty, coughing up blood

D

Which medication will the nurse be prepared to administer to a client admitted to the hospital of DVT who is prescribed IV heparin sodium if the client experiences excessive bleeding? A. vitamin K B. oprelvekin C. warfarin sodium D. protamine sulfate

D

Which client statement demonstrates an understanding of cyanocobalamin (vitamin B12) prescribed for pernicious anemia? A. "I should have a vitamin B12 injection every month" B. "i'll take vitamin B12 supplements every morning w/ my breakfast" C. "i'll eat a diet high in green vegetables" D. "i will increase my intake of processed foods fortified w/ vitamin B12"

A

Which finding would the nurse expect when assessing an 11 month old infant w/ iron-deficiency anemia whose Hgb is 8? A. pallor B. tremors C. cyanosis D. spasticity

A

Which lab test result would the nurse expect to be decreased in a client w/ iron-deficency anemia? A. ferritin level B. platelet count C. WBC D. total iron binding capacity

A

Which respiratory test would be most useful to differentiate between obstructive and restrictive pulmonary dysfunction? A. pulmonary function testing B. chest x-ray C. spiral CT D. ABGs

A

Which response will a nurse give to the parents of a child w/ sickle cell anemia who ask about their child taking iron supplements to help treat the anemia? A. taking supplements will not help w/ this condition B. it is advised that iron be taken w/ OJ to aid in absorption C. an OTC multivitamin w/ iron should meet the needs of the child D. it is advised that liquid iron supplements be given thru a straw to prevent staining of the teeth

A

Which finding would be of most concern when the nurse is assessing a client w/ PE diagnosis who is receiving IV heparin? A. client reports stools are black B. O2 = 93% C. RR is 25 D. client has an ecchymosis on the ankle

A (GI bleed)

Which diagnosis increases the r/f development of a PE? A. a-fib B. forearm laceration C. migraine headache D. respiratory infection

A (a-fib leads to pooling of blood in both atria that may result in thrombus formation)

Which risk factor is the highest priority when teaching a 68-year-old client who has multiple risk factors for PAD, including client age, siblings w/ DM, a sedentary lifestyle, and family hx of heart disease? A. older age B. low activity level C. blood glucose control D. family history of cardiac disease

B (blood glucose control may be a concern in the future for this client, but it is not a current risk factor)

Which symptoms would the nurse expect in a 3 year old child w/ mild iron-deficiency anemia and fatigue? A. cold, clammy skin B. increased HR C. increased BP D. cyanosis of nail bed

B (body is trying to compensate for hypoxia)

Which response by a client w/ a platelet cound of 50,000 indicates to the nurse that additional teaching is required? A. "i should always walk w sturdy shoes" B. "i should avoid blowing my nose frequently" C. "i can use a soft-bristle toothbrush" D. "i can shave w/ a straight blade razor"

D

A client develops a DVT in her leg 3 weeks after giving birth and is admitted for anti-coagulant therapy. The nurse would anticipate developing a teaching plan for which drug? A. heparin B. warfarin C. clopidogel D. enoxaparin

A

Which clinical finding would the nurse expect to identify when caring for a client w/ a left leg venous thrombosis? SELECT ALL THAT APPLY A. pain in the left calf B. intermittent claudication C. redness in the affected area D. swelling of the lower left leg E. ecchymotic areas at the left ankle F. localized warmth in the lower left leg

A, C, D, F

Which dietary choice would the nurse teach for the client w/ PAD? SELECT ALL THAT APPLY A. limit salt intake B. choose foods high in calcium C. eat whole-grain breads D. use liquid vegetable oils E. reduce fresh fruits and vegetables F. avoid processed meats

A, C, D, F (prevent athlersclerosis)

Which finding by the nurse would be most important to report to the HCP before a client undergoes a spiral CT for possible PE? A. hx of anaphylactic reaction to penicillin B. poor skin turgor and dry oral mucosa C. creatinine of 0.6 D. pulse ox reading range from 92-95%

B (contrast causes diuresis and dehydrated pts may develop acute kidney injury)

Which education would the nurse provide the mother of an exclusively breast-fed infant about recommendations to offer solid foods by 5 or 6 months of age? SELECT ALL THAT APPLY A. solid foods help control weight B. fetal iron reserves are depleted C. food can be taken from a spoon D. bone marrow activity has diminished E. breast milk lacks nutrients after 5 months

B, C

Which factor is the most likely cause of anemia in a child w/ celiac disease? SELECT ALL THAT APPLY A. lack of gluten in the diet B. inadequate caloric intake C. absence of intrinsic factor D. incomplete absorption of iron E. incomplete absorption of folic acid

D, E (quantity consumed does not matter, pernicious anemia is not associated with celiac disease)

In which order will the nurse perform these prescribed actions for a client who is in the ED w/ sudden onset of dyspnea and possible PE? A. administer heparin B. obtain blood for coagulation studies C. place client on cardiac monitor D. check O2 using pulse ox E. administer O2 to keep saturation higher than 93%

D, E, C, B, A

The nurse suspects a thrombus after assessing a client who has pain in her R calf 2 days after a c-section birth. Which is the nurse's immediate action? A. confine client to bed B. apply warm soaks C. perform leg exercises D. massage the affected area

A

When a client who has thrombophlebitis tells the nurse, "I am worried about getting a clot in my lungs that will kill me," which action will the nurse take next? A. ask what the client already knows about complications of thrombophlebitis B. tell the client that most people w/ thrombophlebitis do not develop PE C. teach the client that anti-coagulant use helps decrease the r/f a PE D. instruct the client to tell the nursing staff about any chest pain or SOB

A

A client sustains a crushing injury to the lower L leg, and a below-the-knee amputation is performed. For which common clinical manifestation of a PE would the nurse assess for in this client? SELECT ALL THAT APPLY A. sharp chest pain B. acute onset of dyspnea C. pain in the residual limb D. absence of the popliteal pulse E. blanching of the affected extremity

A, B

Which action will the nurse take for a client w/ a suspected PE? SELECT ALL THAT APPLY A. administer O2 at high flow rates B. notify the rapid response team C. lower the HOB D. place the client on a cardiac monitor E. anticipate rapid administration of warfarin

A, B, D (always rapid b/c PE pts may develop hypoxia and hypotension) -heparin not warfarin

When teaching a health awareness class, which situation would the nurse teach as being the highest risk factor for the development of a DVT? A. pregnancy B. inactivity C. aerobic exercise D. tight clothing

B (venous stasis) -pregnancy and tight clothing are also risk factors but inactivity is the biggest one

A 60 year old client w/ gastric cancer has a shiny tongue, parasthesiasa of the limbs, and ataxia. The lab results show cobalamin levels of 125. Which medication would the nurse expect to be prescribed for this client? A. oral hydroxyurea B. vitamin B12 injections C. oral iron supplements D. EPO injections

B

A client has a platelet count of 49,000. The nurse would instruct the client to avoid which activity? A. ambulation B. blowing the nose C. visiting w/ children D. eating fresh fruits and veggies

B

Which assessment beyond the standard would the nurse complete at each prenatal visit when a client has sickle cell anemia? SELECT ALL THAT APPLY A. signs of hypothyroidism B. evidence of UTI C. symptoms of hypoglycemia D. presence of hyperemesis gravidarum E. evidence of carpal tunnel syndrome

B, D (infections, monitor hydration)

Which clinical findings can the nurse expect to identify when assessing a client w/ varicose veins? SELECT ALL THAT APPLY A. discolored toenails B. reports of leg fatigue C. localized heat in a calf D. reddened areas of a calf E. tortuous veins in the legs F. pain in LE when standing

B, E, F (venous stasis)

Which assessment finding in a client w/ acute lymphoblastic leukemia receiving chemo would alert the nurse to the possible development of thrombocytopenia? SELECT ALL THAT APPLY A. fever B. diarrhea C. melena (digested blood in stools) D. hematuria E. ecchymosis

C, D, E

Which statement by an adolescent about sickle cell anemia would cause the nurse to conclude that the teaching has been understood? A. "i'll start to have symptoms when i drink less fluid" B. "I'll start to have symptoms when I have fewer platelets" C. "I'll start to have symptoms when I decrease the iron in my diet" D. "I'll start to have symptoms when I have fewer WBCs"

A (dehydration precipitates sickling of RBCs and is a major causative factor for painful episodes associated w/ sickle cell anemia)

Which client has the highest r/f developing a PE? A. an obese client w/ leg trauma B. a pregnant client w/ acute asthma C. a client w/ DM who has cholecystitis D. a client w/ pneumonia who is immunocompromised

A (obesity and leg trauma put pt at risk) -pregnancy and DM are both risk factors for PE

Which teaching intervention would be a nursing priority to reduce the risk for bleeding in the client w/ purpuric lesions on the skin and a thrombocyte count of 100,000 cells per microliter? A. drink plenty of fluids B. perform bending exercises C. use super absorbent tampons D. use alcohol-based mouthwashes

A (prevent constipation and straining while having a BM, therefore preventing bleeding)

A client w/ Chron's disease is admitted to the hospital w/ a hx of chronic, bloody diarrhea, weight loss, and signs of general malnutrition. the client has anemia, a low serum albumin level, and signs of negative nitrogen balance. the nurse concludes that the client's health status is r/t which major deficiency? A. ferrous sulfate B. protein C. ascorbic acid D. linoleic acid

B

A client who has renal failure asks the nurse why anemia keeps recurring. Which reason would the nurse explain to the client? A. increase in BP B. decrease in EPO C. increase in serum phosphate levels D. decrease in sodium concentration

B

When teaching a client w/ PAD about the prescribed walking program, which action will the nurse advise if client says she experiences leg cramps while walking? A. chew 1 aspirin to relieve pain B. stop to rest until the pain resolves C. walk more slowly while pain is present D. notify the HCP about the pain

B

Which action by a client w/ PAD indicates that more teaching about how to manage the disease is needed? A. applying a hot water bottle to the abd B. using a heating pad to warm the extremities C. drinking a warm cup of tea when feeling chilly D. turning the room thermostat above 72 degrees

B

Which instruction would the nurse give to the pregnant client w/ anemia? A. take an iron and calcium supplement together daily B. drink OJ w/ an iron supplement C. include fresh fruit at every meal D. include 4 servings of calcium-rich foods daily

B (taking calcium at the same time as iron will reduce absorption of iron)

When a pt w/ suspected PE is scheduled for a spiral CT, which action would the nurse take before the procedure? A. check the pt's blood glucose level B. obtain informed consent from the client C. assess if the client is allergic to shellfish D. instruct the client to remove dentures

C

When caring for a client w/ a possible PE, the nurse will anticipate preparing the client for which test? A. chest x-ray B. thoracic ultrasound C. helical CT D. MRI

C

An adolescent child w/ sickle cell anemia is admitted to the peds unit during a vaso-occlusive crisis. Which patho is correct? A. severe depression of the circulating thrombocytes B. diminished RBC production by the bone marrow C. pooling of blood in the spleen w/ splenomegaly as a consequence D. blockage of small blood vessels as a result of clumping RBCs

D

When the home health nurse is caring for a client w/ chronic occlusive arterial disease, which finding will be of most concern? A. pedal pulses not palpable B. decreased sensation in both feet C. thick and yellowed toenails bilaterally D. pale and dry-appearing ulcer on great toe

D (because arterial ulcers do not get an adequate blood supply to promote wound healing, the presence of an ulcer indicates the need for interventions to improve arterial blood supply such as bypass surgery or angioplasty)

Which finding is most important to communicate to the HCP when the nurse is caring for a client who has had a femoropopliteal bypass for PAD? A. pain at the incisional site B. non-palpable popliteal pulse C. erythema of the incision D. pallor of the lower leg

D (because the graft bypasses the popliteal area the popliteal pulse may not be palpable)

A postpartum client is being treated w/ SQ enoxaparin for DVT of the L calf. Which client cue is of most concern to the nurse? A. dyspnea B. HR = 62 bpm C. BP = 136/88 D. positive homan sign of left leg

A

Which action would the nurse take next when a 78 year old client comes to the health clinic presenting w/ fatigue, and lab results indiacte a Hct of 32% and Hgb of 10.5? A. conduct a complete nutritional assessment of the client B. plan to teach the client about taking daily iron supplements C. schedule the client to return to have the test repeated in 3 months D. explain that mild anemia is an expected response to the aging process

A

Which child is the best roommate option for a child admitted in vaso-occlusive sickle cell crisis? A. child w/ thalassemia B. child w/ osteomyelitis C. child w/ pneumonia D. child w/ acute pharyngitis

A

Which finding would the nurse expect when assessing a client w/ PAD? SELECT ALL THAT APPLY A. pallor of feet B. warm extremities C. ulcers on the toes D. thick, hardened skin E. delayed cap refill

A, C, E (venous disease= warm extremities and hardened skin)

Which condition can be prevented when a client w/ CKD receives medication to manage anemia? A. uremic frost B. chronic fatigue C. tubular necrosis D. dependent edema

B

Which lab finding on a client at 24 weeks gestation would the nurse report to the HCP? A. platlets 230,000 B. Hgb 10.8 C. fasting blood glucose 90 D. WBC count 10,000

B

Which medication can cause hemolytic anemia? A. famotidine B. methyldopa C. levothyrozine D. ferrous sulfate

B

Which topic will the nurse include in the discharge teaching of a client who has had a total gastrectomy? A. daily use if stool softener B. injection of vitamin B12 for life C. monthly injections of iron dextran D. replacement of pancreatic enzymes

B

In which way does a sequestration crisis differ from a painful episode (vaso-occlusive crisis) in a child w/ sickle cell disease? A. peripheral ischemia occurs along w/ the pain B. blood volume decreases and signs of shock appear C. RBC production diminishes w/ severe anemia D. destruction of RBCs is accelerated and jaundice becomes evident

B (pooling of blood in the liver and spleen, with subsequent decreased circulating blood volume and shock)

Which condition in a client's hx would lead to the nurse to assess for the development of pernicious anemia? A. acute gastritis B. DM C. partial gastrectomy D. unhealthy dietary habits

C

Which prescribed tx would the nurse question when a client who has sickle cell anemia has been admitted w/ acute chest syndrome? A. O2 administration B. daily folic acid tablet C. daily iron supplement D. morphine sulfate as needed

C (No iron b/c no iron deficiency, folic acid is recommended)

Which assessment finding indicates that disseminated intravascular coagulation (DIC) is occurring in a postpartum client who has experiences an abruptio placentae? A. boggy uterus B. hypovolemic shock C. multiple vaginal clots D. bleeding at the venipuncture sites

D

Which condition would the nurse consider as the most likely cause of pain for a client who tells the nurse, "My legs begin to hurt after walking for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking."? A. spinal stenosis B. Buerger disease C. Rheumatoid arthritis D. intermittent claudication

D

Which direction will the nurse include in the teaching plan for a client w/ lower extremity arterial disease (LEAD)? A. trimming toenails so they are short and rounded B. checking bathwater temp by putting the toes in first C. using alcohol to rub hands, feet, legs, and arms at least 2 times a day D. seeking professional treatment for any minor injuries to the extremities

D (diminished circulation leads to inadequate healing so early treatment of injuries is essential)

A 25 year old women on estrogen therapy has a hx of smoking. Which is a potential complication for this individual? A. osteoporosis B. hypermenorrhea C. endometrial cancer D. PE

D (estrogen therapy increases the r/f PE in clients who have a hx of smoking)

Which lab result in a client who has just been admitted w/ anemia of unknown etiology requires the most rapid action by the nurse? A. Hct 30% B. Hgb 10 C. platelet count 120,000 D. WBC count 950

D (pancytopenia/aplastic anemia)

Which common concern of most parents of children w/ sickle cell anemia would the nurse address at a family education conference? A. finding special school facilities B. planning to move to a more therapeutic climate C. choosing effective birth control measures in the future D. sharing feelings regarding the transmission of the disorder

D (talking with parents who have similar problems help ease their guilt)

A pregnant client and her husband tell the nurse they have a 1 year old daughter w/ sickle cell anemia, but they themselves do not have the disease. Which response would correctly answer the clients' question, "Will this baby also have sickle cell anemia?" A. "the chance that another child will have sickle cell anemia is 25%" B. "only 1 child in a family is affected, so the others will probably be all right" C. "the most likely conclusion is that your children will have sickle cell anemia" D. "if your partner has the sickle cell gene, 50% of your children will have sickle cell anemia"

A

The nursing student, under the supervision of the RN, plans to perform a pulse assessment. While preparing to assess the client, the RN asks the student to check the apical pulse after assessing the radial pulse. Which rationale supports the RN's request? A. the client may have a dysrhythmia B. the client may have physiologic shock C. the client underwent surgery earlier in the day D. the client may have PAD

A

When assessing a client w/ a diagnosis of PAD before a scheduled arteriogram, the nurse is unable to palpate the pedal pulses. Which action would the nurse take next? A. check the pulses w/ a Doppler device B. notify the PCP C. notify the staff in the catheterization lab D. document the findings in the client's medical record

A

Which action would the nurse take when a client w/ CAD and a recent diagnosis of venous thrombosis calls the outpatient clinic to report sudden onset of SOB? A. suggest that the client call 911 B. have the client take sloe, deep breaths C. schedule the client to be seen in the clinic in 1 hour D. have the client take a low dose aspirin tablet immediatley

A

Which client in the pulmonary clinic will the nurse plan to teach about pulmonary function testing? A. client who has COPD B. client who is being evaluated for lung histoplasmosis C. client who is recovering after PE D. client who has had positive TB skin testing

A

Which statement by the student nurse demonstrates correct understanding of anemia r/t chronic disease? A. "RBCs are normal in size and color; however, the number of cells produced is decreased" B. "RBC indices are usually low, indicating a need for oral iron supplementation" C. "administration of vitamin B12 and folate will help treat this type of long-term anemia" D. "this is the mildest form on anemia and is easily corrected thru administration of blood products"

A

Whihc lab finding of a pregnant client would alert the nurse to the need for further assessment? A. Hgb of 10 B. urine specific gravity of 1.020 C. glucose level of 1+ in the urine D. WBC count of 9000

A

After the nurse has finished teaching a post-op client about prevention of PE, which client statement indicates that the teaching has been effective? A. "i will avoid crossing my legs" B. "pillows placed under my knees will help avoid clots" C. "staying on bed rest as long as possible is best for me" D. "three times a day i will massage my lower legs to get blood moving"

A (avoid constriction of blood flow)

Which client action indicates that the teaching has been effective after the nurse provides discharge teaching for a client who had a femoropopliteal bypass graft? A. walking for 10 minutes twice a day B. elevating the legs when sitting or lying C. taking a hot bath before going to bed D. discontinuing prescribed daily aspirin

A (avoid extreme cold or hot)

The nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent PE? A. 59 year old who had a knee replacement B. 60 year old who has bacterial pneumonia C. 68 year old who had emergency dental surgery D. 76 year old who has a hx of thrombocytopenia

A (decreased mobility)

Which finding would the nurse expect when assessing the nasal passages of a client w/ thrombocytopenia? a. blood clots b. nasal polyps c. purulent discharge d. pale, swollen turbinates

A (thrombocytopenia increases the r/f epistaxis (nosebleed) and the nurse may see bleeding or clots)

Which statement indicates to the nurse providing discharge medication education to a client prescribed warfarin that teaching was effective? A. "i will avoid taking aspirin and NSAIDs" B. "i will need to develop a more sedentary routine" C. "i will need to have regular CBCs to guide warfarin dosage" D. "before going to the dentist, i will ask my HCP for antibiotics"

A (use Tylenol)

Which instruction will the home health nurse include when teaching a client w/ PAD? SELECT ALL THAT APPLY A. "avoid crossing you legs" B. "inspect your feet daily" C. "change positions slowly" D. "do not use compression stockings" E. "avoid green leafy vegetables in your diet"

A, B, D (crossing legs and compression stockings will restrict blood flow)

Which assessment finding will the nurse expect when caring for a client w/ PAD? SELECT ALL THAT APPLY A. absence of hair on the toes B. pink and moist ankle ulcers C. pitting edema of the lower legs D. reports of pain associated w/ exercising E. increased pigmentation of the medial malleolus area

A, D

Which finding in a client who has had major abd surgery indicates a possible venous thrombosis of the leg? SELECT ALL THAT APPLY A. edema of the ankle B. skin breakdown over the shin C. pruritus on the side of the calf D. tender area in the posterior lower leg E. warmth along the course of the involved vessel

A, D, E (s/s of venous thrombosis= swelling distal to the thrombus, pain and warmth over the area of the thrombus) -skin breakdown w/ CVI not acute -pruritus w/ CVI

Which lab value will the nurse review when caring for a client w/ a megaloblastic anemia? A. serum iron B. folate level C. transferrin level D. platelet count

B

Which possible complication would the nurse monitor for when a client develops a venous thrombosis in the L calf? A. embolic stroke B. PE C. MI D. ischemia of the L foot

B

Which explanation will the nurse give when a client asks about what causes varicose veins? A. "abnormal configurations of the veins" B. "incompetent valves of superficial veins" C. "decreased pressure within the deep veins" D. "athlersclerosis plaque formation in the veins"

B -family hx and standing for long periods of time can cause varicose veins -smoking does not cause varicose veins

Which action would the home health nurse suggest to decrease risk for injury for an older adult w/ PAD? A. move into an assisted living community B. lower the thermostat setting on the hot water tank C. reduce fluid intake to less than 2500 ml/day D. limit physical activity to a short daily walk

B (PAD decreases the ability to feel extreme temperatures)

Which symptom requires the most rapid action by the nurse when caring for a client with known PAD who calls the clinic and tells the nurse about experiencing several symptoms? A. anxiety B. chest pain C. weak pulse quality D. cool and pale lower legs

B (chest pain may indicate acute coronary syndrome and the nurse should notify the HCP or have the client activate the emergency response system immediately) -CAD is common with PAD

Which topic would the nurse include when doing discharge teaching about ways to avoid another venous thrombosis when caring for a client hospitalized w/ DVT? A. daily aspirin use B. frequent ambulation C. warm soaks to legs D. avoidance of cold

B (frequent ambulation decreases venous stasis and helps prevent recurrent venous thrombosis)

After the nurse has taught a client w/ PAD about a heart-healthy diet, which client statement best indicates that the teaching has been effective? A. "i have a weight loss goal of 20 lbs" B. "i will need to eat more vegetables and less streak" C. "thank you for taking the time to teach me about diet" D. "my spouse will need to buy more healthy foods to cook"

B (less red meat is good)

Which parent education would the nurse provide when teaching an infant's parents about the major cause of iron-deficieny anemia? A. blood disorders B. overfeeding of milk C. lack of adequate iron reserves from the mother D. introduction of solid foods too early for adequate absorption

B (milk is an inadequate source of iron)

Which statement by a client who has an ischemic ulcer on the left foot indicates a need for intervention by the nurse? A. "i drink about 3 liters of water every day" B. "i smoke about 1 pack per day of cigarettes" C. "i have 1 glass of wine at supper every night" D. "i drop my left foot off the edge of the bed at night"

B (nicotine will further decrease blood supply to the left foot ulcer)

a postpartum client receiving a continuous heparin infusion for a DVT has an aPTT of 128 seconds. Which action would the nurse take in response to this situation? A. increase the IV rate of heparin B. interrupt the infusion and notify the PCP of aPTT result C. document the result on the medical record and recheck the aPTT in 4 hours D. call the PCP to obtain a prescription for a low-molecular-weight-heparin

B (therapeutic range is 45-75)

Which mechanism would the nurse attempt to increase to prevent post-op DVT? A. coagulability of the blood B. velocity of the venous return C. effectiveness of internal respiration D. o2-carrying capacity of the blood

B (venous stasis is the major predisposing factor of PE, venous flow velocity should be increased through activity)

When performing a focused assessment on a client w/ a possible diagnosis of iron deficiency anemia, which locations would the nurse examine? SELECT ALL THAT APPLY A. sclera B. nail beds C. conjunctivae D. palms of hands E. bony prominences

B, C, D (nail beds lose their pink color, decreased pink color of the lining of the eyelids, palms of hands will become pale) -sclera for jaundice

Which info will the nurse plan to include in the discharge teaching plan for a client who has been admitted for PE and has a new prescription for an oral anti-coagulant? SELECT ALL THAT APPLY A. floss twice daily to prevent the need for dental work B. avoid eating hot food or liquid that can burn your mouth C. use an electric shaver instead of a straight-bladed razor D. apply ice to any areas of trauma like bumps and scrapes E. use enemas to prevent straining during bowel movements

B, C, D (no flossing, brush w/ soft toothbrush, make sure dentist knows they are on anti-coagulant, use stool softeners)

The nurse would monitor post-op clients for which clinical manifestation of a PE? SELECT ALL THAT APPLY A. somnolence B. dyspnea C. hemoptysis D. bronchial wheezes E. feeling of impending doom

B, C, E (crackles not bronchial wheezes occur)

Which clinical manifestation would the nurse expect to identify when performing an admission hx and physical for a client w/ chronic PAD? A. edema of the feet and ankles B. redened and painful areas on the claves C. pain when exercising and thickening of the toenails D. ulcers around the ankles and reports of a dull ache in the legs

C

Which condition would the nurse suspect in an ED client w/ C8 tetraplegia, BP of 80/40, HR of 48 bpm, and RR of 18? A. autonomic dysreflexia B. hemorrhagic shock C. neurogenic shock D. PE

C

Which diagnostic study is used to detect DVT in the client's lower extremities? A. thermography B. plethysmography C. Duplex venous doppler D. somatosensory evoked potential

C

Which response by the nurse is best when a client w/ intermittent claudication has been instructed to stop smoking and says, "i don't understand why this is necessary,"? A. "tobacco smoking causes many health problems" B. "nicotine use is a risk factor for heart and lung diseases" C. "nicotine makes blood vessels smaller and will worsen your pain" D. "smoking is prohibited for both clients and staff members in the hospital"

C

Which term will a nurse use to document when a client w/ PAD tells the nurse about having leg pain and weakness after walking a short distance? A. rest pain B. Raynaud phenomenon C. intermittent claudication D. phantom limb sensation

C

Which action by a client who requires an above-the-knee amputation for PAD best indicates emotional readiness for the surgery? A. explains the goals of the procedure B. displays few signs of anticipatory grief C. participates in learning peri-op care D. verbalizes acceptance of permanent dependency needs

C (active participation in learning self-care indicates emotional acceptance of the need for surgery and planning for future after surgery)

Which cause of anemia would the nurse recognize as the most common cause of anemia in 1 year olds? A. thalassemia B. lead poisoning C. iron deficiency D. sickle shape of blood cells

C (breast milk and unfortified formula increase the r/f iron deficiency anemia)

The nurse is caring for an older adult who had an open reduction and internal fixation of a fractured hip. Which clinical finding requires the nurse to notify the PCP? A. lack of productive cough 2 days post-op B. rectal temp of 100.2 3 days post-op C. companies of R-sided chest pain 6 days post-op D. fatigue in leg on the unaffected side 5 days post-op

C (chest pain, dyspnea, cough, hemoptysis, and apprehension are classic signs of PE)

Which client would the nurse assess first? A. 40 year old w/ 30 pack year cigarette history who reports tingling in both feet B. 42 year old who takes anti-hypertensive medication and reports bilateral 4+ ankle swelling C. 65 year old who reports tearing abd pain and has a hx of uncontrolled HTN D. 70 year old w/ PAD who reports severe lower leg burning and numbness

C (dissecting aortic aneurysm)

Which finding in a client w/ R calf venous thrombosis is most important to communicate to the HCP? A. severe R calf pain B. R calf redness and swelling C. O2= 89% D. HR=136 bpm

C (low O2 may indicate a PE)

Which action would the nurse take first when caring for a client w/ a possible PE? A. auscultate the chest B. obtain VS C. elevate the HOB D. notify the rapid response team

C (promotes gas exchange)

The nurse, providing care for a client who had a hysterectomy, is concerned about the client's r/f post-op thrombosis. The nurse remembers that, after pelvic surgery, the majority of PE begin as DVT in which area? A. calf B. thoracic cavity C. pelvis and thighs D. extremities and abdomen

C (whatever the surgery is on is where the PE will begin)

The nurse assists a client who has bariatric surgery to become more mobile. Which complication is the nurse attempting to prevent? A. incisional pain B. wound dehiscence C. anastomosis leakage D. PE

D

Which abnormal lab value will the nurse expect when caring for a client w/ iron-deficency anemia? A. macrocytic RBCs B. thrombocytopenia C. decreased folate levels D. increased TIBC

D

Which action would the nurse include in the post-op plan of a client w/ PAD who is scheduled for a femoral angiogram? A. elevate the foot of the bed B. place in the high-fowler position C. perform urinary catheter care every 12 hours D. check pedal pulses every 15 minutes post-op

D

Which priority action would the nurse instruct a woman who recently under went a hysterectomy to take after she calls the clinic and states that she has tenderness, redness, and swelling in her R calf? A. "stay in bed for at least 3 days" B. "keep the legs elevated while sitting" C. "apply a warm compress to the affected calf twice a day" D. "go to the ED immediately"

D

Which response would the nurse give when the spouse of a client w/ chest pain repeatedly express concern about the client's pallor? A. "paleness is not always a sign that something is wrong" B. "skin color really varies quite a bit from person to person" C. "we will be drawing blood to check your spouse for anemia" D. "tell me why you are concerned about your spouse's paleness"

D

On the 2nd day after surgery, a client reports pain in the R calf. Which action would the nurse take first? A. apply a warm soak to the leg B. document the symptom C. elevate the leg above heart level D. notify the PCP

D (calf pain may be a sign of thrombophlebitis, which can lead to a PE)

Which response by the nurse is best when a client who has PAD of the lower extremities tells the nurse, "I walk so slowly that no one wants to walk with me,"? A. "many people enjoy walking alone" B. "you will be able to walk faster eventually" C. "it is important that you keep walking to improve circulation" D. "perhaps you might consider a supervised exercise training program"

D (exercise and walking programs that encourage new growth of vessels around the obstructed artery)

A 3 year old child is admitted to the peds unit w/ a Hgb of 6.4. Which would the nurse's priority assessment be? A. manifestations of shock B. increased WBC C. presence of hemoglobinuria D. signs of cardiac decompensation

D (heart attempts to maintain tissue oxygenation by increasing its workload)

Which response would the nurse make when a client who has begun an exercise program, after experiencing acute coronary syndrome, asks the nurse how to tell whether the exercise is helping? A. "intermittent claudication will be reduced" B. "your breathing will become regular and shallow" C. "perspiration will be less when you run, and you'll use less energy" D. "you will be able to walk progressively longer distances before tiring"

D (heart is adapting to an increased workload)

Which postpartum client is at the highest risk for disseminated intravascular coagulation (DIC)? A. gravida III w/ twins B. gravida V w/ endometriosis C. gravida II who had a 9-lb baby D. gravida I who has had an intrauterine fetal death

D (intrauterine fetal death is a risk factor for DIC, other risk factors are abruptio placentae, anmiotic fluid embolism, sepsis, and liver disease)

Which action will the nurse take first when a client w/ PAD returns to the nursing unit after a femoral angiogram? A. check the oral temp B. encourage the client to void C. place the HOB flat D. assess the client's affected leg

D (most common complication is bleeding so the nurse needs to assess leg pulses temp, and color for adequate perfusion) - HOB is usually elevated about 30 degrees