Adult Care I Exam 2
A client is getting ready to go home after a myocardial infarction (MI). The client is asking questions about his medications, and wants to know why metoprolol (Lopressor) was prescribed. The nurse's best response would be which of the following? A. "This medication helps make your heart beat stronger to supply more blood to your body." B. "It slows your heart rate and decreases the amount of work the heart has to do so it can heal." C. "Lopressor helps to increase the blood supply to the heart by dilating your coronary arteries" D. "Your heart was beating too slowly, and Lopressor increases your HR"
B. "It slows your heart rate and decreases the amount of work the heart has to do so it can heal."
In teaching a patient about coronary artery disease (CAD), the nurse explains that the changes that occur in this disorder involve A. Chronic vasoconstriction of coronary arteries leading to permanent vasospasm B. Accumulation of lipid and fibrous tissue within the coronary arteries C. Formation of fibrous tissue around coronary artery orifices D. Diffuse involvement of plaque formation in coronary veins
B. Accumulation of lipid and fibrous tissue within the coronary arteries
During a head-to-toe assessment, the nurse notes the apical pulse is 128 and irregular. The patient is not in any distress and does not have any history of dysrhythmia. The nurse contacts the physician for an order to obtain a 12-lead EKG. Which of the following rhythms does the nurse anticipate being diagnosed? A. Sinus bradycardia B. Atrial fibrillation C. Ventricular tachycardia D. Ventricular fibrillation E. Junctional escape rhythm
B. Atrial fibrillation
A semiconscious client in the postanesthesia care unit (PACU) is experiencing dyspnea (difficulty breathing). Which action should the nurse perform FIRST? A. Place a pillow under the client's head B. Administer oxygen by mask C. Reposition the client to keep the tongue forward D. Remove the oral pharyngeal airway
C. Reposition the client to keep the tongue forward
A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give? A. "It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level." B. "The oral medication you will take after this IV will dissolve the clot." C. "A pharmacist is the person to answer that question." D. "Heparin does not dissolve clots. It stops new clots from forming."
D. "Heparin does not dissolve clots. It stops new clots from forming."
A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity? A. Jaundice B. Photosensitivity C. Ataxia D. Anorexia
D. Anorexia
A client is being evaluated for a possible myocardial infarction. The nurse performs a 12-lead ECG for an episode of new chest pain. The nurse will monitor for which sign of acute myocardial injury? A. Prolonged QRS complex B. Prolonged PR interval C. PR depressions D. ST elevation
D. ST elevation
A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period? A. Instruct the client on use of crutches B. Perform neurovascular checks of the extremities C. Direct the client to perform exercises of the ankle and toes D. Medicate the client for pain
B. Perform neurovascular checks of the extremities
The surgeon ordered sequential compression devices (SCDs) to be applied postoperatively. The client asks why the SCDs are needed. Which is the best response by the nurse when teaching the client about the purpose of SCDs? A. They promote arterial circulation B. They promote venous return from the legs C. They decrease afterload D. They decrease postoperative pain
B. They promote venous return from the legs
Mrs. Jones just finished her rotator cuff repair and is brought into your unit. Your responsibilities include monitoring her vital signs, ensuring patient safety, and monitoring her airway until she is fully awake. You know that she is now in what operative phase? A. Perioperative phase B. Intraoperative phase C. Postoperative phase D. Preoperative phase
C. Postoperative phase
A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instructions should the nurse include in the teaching? a. Apply a new transdermal patch once a week. b. Apply a new transdermal patch when chest pain is experienced. c. Apply the transdermal patch in the same location as the previous patch. d. Apply the transdermal patch in the morning
d. Apply the transdermal patch in the morning
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply) A. Increased heart rate B. Increased hematocrit C. Increase blood pressure D. Increase respiratory rate E. Increased temperature
A. Increased heart rate C. Increase blood pressure D. Increase respiratory rate
Which laboratory test is the BEST resource for determining the preoperative status of a client's liver function? A. Serum albumin B. Serum electrolytes C. Alanine aminotransferase (ALT), aspirate aminotransferase (AST), and bilirubin D. BUN and creatine
C. Alanine aminotransferase (ALT), aspirate aminotransferase (AST), and bilirubin
The nurse is answering questions after a presentation on sleep at a lcoal senior citizen's center. A woman in her late 70's asks for an opinion about the advisability of allowing her husband to nap for 15-20 minutes each afternoon. the nurse's BEST response would be which of the following? A. "unless your husband has trouble falling asleep at night, a brief afternoon nap is fine." B. "encourage him to consume coffee or some other caffeinated beverage at lunch to prevent drowsiness in the afternoon." C. "He shouldn't need to take an afternoon nap if he's getting enough sleep at night" D. "Taking an afternoon nap will interfere with his being able to sleep at night/ If he's tired in the afternoon, see if you can interest him in some type of stimulating activity to keep him awake."
A. "unless your husband has trouble falling asleep at night, a brief afternoon nap is fine."
Which of the following clients are at risk for the development of dysrhythmias? (SELECT ALL THAT APPLY.) A. A client 3 hours post myocardial infarction B. A client with COPD C. A client with an SaO2 of 96% D. Metabolic acidosis E. A client with a serum potassium level of 4.3 mEq/L
A. A client 3 hours post myocardial infarction B. A client with COPD D. Metabolic acidosis
A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? A. Assess the apical pulse for a full minute B. Assess the pedal pulses for a full minute C. Assess the apical pulse with a Doppler device D. Assess the pedal pulses with a Doppler device
A. Assess the apical pulse for a full minute
A client has a history of sleep apnea. Which is the most appropriate question for the nurse to ask? A. Do you have difficulty with daytime sleepiness? B. Do you have a history of any kind of nasal obstruction? C. Have you had a chest pain with or without activity? D. Do you have a history of cardiac irregularities
A. Do you have difficulty with daytime sleepiness?
Which of the following are allowed on a full liquid diet? SELECT ALL THAT APPLY A. Hard candy B. Chocolate pudding C. Fruit smoothies D. Tomato juice E. Mashed potatoes F. Cream of wheat cereal G. Oatmeal cereal H. Scrambled eggs
A. Hard candy B. Chocolate pudding C. Fruit smoothies D. Tomato juice F. Cream of wheat cereal
An older Asian client has mild dysphagia from a recent stroke. The nurse plans the client's meals based on the need to: A. Include as many of the client's favorite foods as possible B. Have at least one serving of thick dairy C. Eliminate the beer usually ingested every morning
A. Include as many of the client's favorite foods as possible
A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2 mg/min. When the client asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions? A. Prevents dysrhythmias B. Slows intestinal motility C. Dissolves blood clots D. Relieves pain
A. Prevents dysrhythmias
Which of the following interventions would be the first priority when treating a client experiencing anginal chest pain while walking? A. Sit the client down B. Get the client back to bed C. Administer sublingual nitroglycerine D. Obtain and ECG
A. Sit the client down
A nurse is reviewing the health history for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the history should the nurse report to the provider? A. The client has a history of bronchial asthma B. The client has a history of hypothyroidism C. The client has a history of hypertension D. The client has a history of migraine headaches
A. The client has a history of bronchial asthma
A client reports to the nurse that she has been taking barbiturate sleeping pills every night for several months and now wishes to stop taking them. Which statement is the most appropriate advice for the nurse to provide the client? A. Take the last pill on a Friday night so disrupted sleep can be compensated on the weekend B. Continue taking the pills and discuss tapering the door with the primary care provider C. Continue to take the pills since sleeping without them after such a long time will be difficult and perhaps impossible D. Discontinue taking the pills
B. Continue taking the pills and discuss tapering the door with the primary care provider
A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? A. Differences between oral and axillary temperatures B. Different apical and radial pulses C. Differences in upper and lower lung sounds D. Different blood pressures in the upper limbs
B. Different apical and radial pulses
A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication? A. Ototoxicity B. Hypotension C. Hyperthermia D. Muscle pain
B. Hypotension
The nurse assesses a postoperative client who has a rapid, weak pulse; urine output less than 30 mL/hr; and decreased blood pressure. The client's skin is cool and clammy. What complication should the nurse suspect? A. Pneumonia B. Hypovolemic shock C. Thrombophlebitis D. Wound dehiscence
B. Hypovolemic shock
Which of the following is not a function of water in the body A. A solvent for chemical processes B. Promotes electrical conduction in the heart C. Transports substances in the blood D. Fills in spaces in the tissue E. Maintains body temperature
B. Promotes electrical conduction in the heart
During admission to a hospital unit, the clinet tells the nurse that her sleep tends to be very light and that is is difficult for her to get back to sleep if she is awakened at night. which interventions should the nurse implement? SELECT ALL THAT APPLY A. Encourage the client's family members to bring in a radio to play soft music at night B. Remind colleagues to keep their conversations to a minimum at night C. Deliver necessary medications and procedures at 1.5 to 3 hour intervals between 2300 and 0600 D. Encourage the client to ask family members to bring a fan to provide white noise E. Increase the temperature in the room
B. Remind colleagues to keep their conversations to a minimum at night C. Deliver necessary medications and procedures at 1.5 to 3 hour intervals between 2300 and 0600 D. Encourage the client to ask family members to bring a fan to provide white noise
Your patient is admitted to the ICU and is unable to eat by mouth. The physician has ordered Total Parenteral Nutrition. The physician has ordered the following to be given D10% as the base. He also orders amino acids, electrolytes, and insulin to be added to the solution. Prior to administering the TPN you need to have which of the following? A. A peripheral line with an 18 g or larger B. A blood glucose done 1 minute before administering it C. A central line D. Lipids
C. A central line
Which would most likely be included in the evaluation of the client goal of "Demonstrated adequate tissue perfusion"? A. Symmetrical chest expansion B. Use of pursed lip breathing C. Brisk capillary refill D. Activity intolerance
C. Brisk capillary refill
You are a nurse who has just finished receiving morning report. A 74-year-old female client two days post-op after knee-replacement surgery is having shortness of breath. She has a history of type II diabetes, chronic renal failure, and CHF. You auscultate crackles in all lung fields. Her respirations are 36/min. and O2 sats are 90% on 10L by venti-mask. Which of the following should the nurse do FIRST? A. Call respiratory therapist and ask for suctioning B. Check patient's ABG's from yesterday morning C. Check patient's I&O D. Check patient's blood glucose
C. Check patient's I&O
Your patient was admitted to the hospital and you are reviewing their lab values. You note that the hemoglobin is normal however the hematocrit is very high. What condition would these values indicate? A. Anemia B. Leukemia C. Dehydration D. Overhydration
C. Dehydration
The client's postoperative orders state "diet as tolerated." The client has been NPO. The nurse will advance the client's diet to clear liquids based on which assessment? SELECT ALL THAT APPLY. A. Expresses feeling hungry B. Pain is maintained at a 2-3 on a scale of 10 C. Does not complain of nausea or vomiting D. Ambulates with minimal assistance E. Passing flatus
C. Does not complain of nausea or vomiting E. Passing flatus
During a well-child visit, a mother tells the nurse that her 4-year old daughter typically goes to bed at 10:30 PM and awakens each morning at 7 AM. She does not take a nap in the afternoon. Which is the best response by the nurse? A. Recommend that her daughter be allowed to sleep later in the morning B. Reassure the mother that it is normal for a 4-year-old to resist napping, but encourage her to insist that she rest quietly each afternoon C. Encourage the mother to consider putting her daughter to bed between 8 and 9 PM D. Reassure her that her daughter's sleep pattern is normal and that she has outgrown her need for an afternoon nap
C. Encourage the mother to consider putting her daughter to bed between 8 and 9 PM
Which of the following assessment findings by the nurse indicates RIGHT ventricular failure in a client? A. Crackles B. Pink frothy sputum C. Jugular vein distention D. Paroxysmal nocturnal dyspnea
C. Jugular vein distention
Your patient is receiving TPN. Which of the following guidelines for administering TPN is NOT correct. A. Change the IV tubing daily B. Attach an extension with a filter to the IV tubing C. Piggyback lipids above the filter in the TPN tubing D. Notify the pharmacist as soon as possible with any changes in the order for the TPN
C. Piggyback lipids above the filter in the TPN tubing
Mrs. Jones just arrived to the same day surgery unit where she is scheduled to have a rotator cuff repair. You are to complete her teaching regarding the surgery, start her IV and discuss aftercare. What phase is this referring to? A. Postoperative phase B. Perioperative phase C. Preoperative phase D. Intraoperative phase
C. Preoperative phase
A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make? A. "The IV heparin increase the effects of the warfarin and decrease the length of your hospital stay B. "Both heparin and warfarin work together to dissolve the clots" C. "I will call the provider to get a prescription for discontinuing the IV heparin today" D. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level"
D. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level"
Which of the following classes of medications protects the ischemic myocardium by blocking cathecholamines and sympathetic nerve stimuation? A. ACE inhibitors B. Calcium channel blockers C. Nitrates D. Beta-adrenergic blockers
D. Beta-adrenergic blockers
The client is admitted to the emergency department with the chief complaint of "my heart is racing." Upon initiated cardiac monitoring the nurse discovers the client has a sustained heart rate of 170 beats per minute. The nurse then assesses the client for which of the following? A. Increased cardiac output B. Increased preload C. Decrease afterload D. Decreased cardiac output
D. Decreased cardiac output
Your patient was diagnosed with dilated cardiomyopathy with an ejection fraction of 40%. What is the best nursing diagnosis for this patient? A. Ineffective tissue perfusion (peripheral) B. Pain C. Impaired gas exchange D. Decreased cardiac output
D. Decreased cardiac output
A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis? A. Cataract extraction B. Laparoscopic appendectomy C. Myringotomy D. Hip arthroplasty
D. Hip arthroplasty
Mrs. Jones has been prepped for surgery and has just arrived to the operating room. You assist Mrs. Jones to the table and begin to prepare for the surgery. You know that Mrs. Jones is in which operative phase at this time? A. Perioperative phase B. Preoperative phase C. Postoperative phase D. Intraoperative phase
D. Intraoperative phase
During a yearly physical, a 52-year-old male client mentions that his wife frequently complains about his snoring. During the physical exam, the nurse notes that his neck size is 18 inches, his soft palate and uvula are reddened and swollen, and he is overweight. What is the most appropriate nursing intervention for the nurse to recommend to this client? A. Recommend that he and his wife sleep in separate bedrooms so that his snoring does not disturb his wife B. Refer him to a dietician for a weight loss program C. Caution him not to drink or take sleeping pills since they make his snoring worse D. Refer him to a sleep disorders center for evaluation and treatment of his symptoms
D. Refer him to a sleep disorders center for evaluation and treatment of his symptoms
This type of diet is used to mange electrolytes and fluids A. Diabetic B. High protein C. Low fat D. Renal
D. Renal
A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? a. "Cardiac enzymes will identify the location of the MI" b. "These tests help determine the degree of damage to the heart tissues." c. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." d. "These tests will enable the provider to determine the heart structure and mobility of the heart valves."
b. "These tests help determine the degree of damage to the heart tissues."
You are the nurse on the surgical floor caring for Mr. Smith after a lobectomy. You are going to do teaching with him regarding the use of the incentive spirometer. Which instructions should be included in the teaching? a. Try not to cough after using the device b. You should use the device at least twice a shift c. Close your lips around the mouthpiece d. Blow into the canister slowly and evenly
c. Close your lips around the mouthpiece
