ATI Questions 2

A nurse is caring for a client who has hypertension and develops epistaxis. Which of the following actions should the nurse take? (SATA). a. Apple pressure to the nares b. Place ice to the bridge of the client's nose c. Instruct the client to blow his nose d. Tilt the client's head backward e. Move the client into high-fowler's position

A B E

Which nursing responsibilities are priorities when caring for a patient returning from a cardiac catheterization (select all that apply)? a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses c. Helping the patient to ambulate to the bathroom to void d. Telling the patient that he will be sleepy from the general anesthesia e. Teaching the patient about the risks of the radioactive isotope injection

A B

A patient has a severe blockage in his right coronary artery. Which heart structures are most likely to be affected by this blockage (select all that apply)? a. AV node b. Left ventricle c. Coronary sinus d. Right ventricle e. Pulmonic valve

A, B, D

A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse give the client before the procedure? (Select all that apply.) a. "You'll have to lie flat for several hours after the procedure." b. "You'll receive medication to relax you before the procedure." c. "You'll feel a cool sensation after the injection of the dye." d. "You'll have to keep your leg straight after the procedure." e. "You'll have to limit the amount of fluid you drink for the first 24 hr."

A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." D. "You'll have to keep your leg straight after the procedure."---Depending on the provider's prescription, the client should remain flat or with the head of the bed elevated to no more than 30° for 2 to 6 hours after the procedure. The amount of time depends on the type of closure device the provider uses. The client will receive a mild sedative for relaxation and comfort prior to the procedure. A soft knee brace can help keep the client from bending the knee after the procedure.

A nurse is caring for a client who is undergoing conservative treatment for deep-vein thrombosis. The client asks the nurse what will happen to the clot. Which of the following responses should the nurse make? A. "Your body has a process called fibrinolysis that will eventually dissolve the clot." B. "Your body has a mechanism that will keep the clot stable in its present location." C. "The clot will break into tiny fragments and float harmlessly in your bloodstream." D. "Treatment with heparin will dissolve the clot and keep other clots from forming."

A. "Your body has a process called fibrinolysis that will eventually dissolve the clot."--- Fibrinolysis is a process that breaks down a clot over time in the body. This process is a treatment option for clots that are not immediately life-threatening.

A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0-10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take? a. Admin another nitroglycerin tablet b. Initiate a peripheral IV c. Call the Rapid Response Team d. Obtain an ECG

A. Admin. Another nitroglycerin tablet--- Admin guideline for sublingual nitroglycerin indicate that it is appropriate to admin another tablet 5 min after the first one if the client is still reporting pain

A nurse is administering subcutaneous heparin to a client who is at risk for deep vein thrombosis. Which of the following actions should the nurse take? a. Administer the medication into the client's abdomen b. Inject the medication into a muscle c. Massage the site after administering the medication d. Use a 22-gauge needle to administer the medication

A. Administer the medication into the client's abdomen---The heparin should be administered into the client's abdomen.

A nurse is assessing a client who has deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find? (Select all that apply.) a. Hardening along the blood vessel b. Absence of a peripheral pulse c. Tenderness in the calf d. Cool skin on the leg e. Increased leg circumference

A. Hardening along the blood vessel C. Tenderness in the calf E. Increased leg circumference--- Deep-vein thrombosis can cause hardening along the affected blood vessel and prominence of superficial veins, pain or tenderness in the calf, and an increase in the circumference of the leg due to swelling.

A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? a. Hypokalemia b. Hypophosphatemia c. Hypercalcemia d. Hypermagnesemia

A. Hypokalemia---- Furosemide can cause the loss of potassium, sodium, calcium, and magnesium. Manifestations of hypokalemia can include shallow respirations, muscle weakness, lethargy, and ectopic heartbeats.

A nurse is preparing to administer a sublingual nitroglycerin tablet to a client who is reporting chest pain. For which of the following adverse effects should the nurse monitor after giving this medication? a. Hypotension b. Myalgia c. Diarrhea d. Ototoxicity

A. Hypotension---Nitroglycerin is a coronary vasodilator and antianginal agent. A major adverse effect of this medication is hypotension; therefore, blood pressure and pulse must be monitored before and after administration.

A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction (MI). Which of the following manifestations should the nurse identify as indications of MI? (Select all that apply.) a. Nausea and vomiting b. Diaphoresis and dizziness c. Chest and left arm pain that subsides with rest d. Anxiety and feelings of doom e. Bounding pulse and bradypnea

A. Nausea and vomiting B. Diaphoresis and dizziness D. Anxiety and feelings of doom--- Nausea, vomiting, epigastric distress, diaphoresis (sweating), dizziness, fatigue, anxiety, and feelings of doom and fear are common manifestations of MI.

A nurse is examining the ECG of a client who is having an acute myocardial infarction. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alterations? a. Necrosis b. Hypokalemia c. Hypomagnesemia d. Insufficiency

A. Necrosis---- ST-segment elevation during an acute myocardial infarction indicates necrosis. This ECG change reflects a clot at the site of injury. Therefore, the client requires immediate revascularization of the artery.

A nurse is caring for an older adult client who had an acute myocardial infarction (MI). When assessing this client, the nurse should identify that older adults are prone to complications of MI from poor tissue perfusion because of which of the following age-related factors? a. Peripheral vascular resistance increases. b. The sensitivity of blood pressure-adjusting baroreceptors increases. c. Blood is hypercoagulable and clots more quickly. d. Cardiac medications are less effective.

A. Peripheral vascular resistance increases.----Older adult clients are more prone to complications from poor tissue perfusion following an acute MI because peripheral vascular resistance increases with aging. This results from calcification and loss of elasticity of the blood vessels.

A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change? a. Potassium 2.8 mEq/L b. Digoxin level 0.7 ng/mL c. Hemoglobin 9.8 g/dL d. Calcium 8.0 mg

A. Potassium 2.8 mEq/L---A flattened T wave or the development of U waves is indicative of a low potassium level.

A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial infarction (MI). Which of the following indicators should the nurse identify to confirm reperfusion? a. Ventricular dysrhythmias b. Appearance of Q waves c. Elevated ST segments d. Recurrence of chest pain

A. Ventricular dysrhythmias---The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery.

A nurse at a provider's office receives a phone call from a client who reports nausea and unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse? a. Tell the client to take an antacid b. Instruct the client to call 911 c. Tell the client to take another nitroglycerin tablet in 15 min d. Advise the client to come to office

B) Instruct the client to call 911-- The nurse should instruct the client to call 911 for transportaition to the emergency department because the client is having unstable angina or an acute MI.

After teaching about ways to decrease risk factors for CAD, the nurse recognizes that further instruction is needed when the patient says a. "I can keep my blood pressure normal with medication." b. "I would like to add weight lifting to my exercise program." c. "I can change my diet to decrease my intake of saturated fats." d. "I will change my lifestyle to reduce activities that increase my stress."

B

The nurse is caring for a patient who is 2 days post MI. The patient reports that she is experiencing chest pain when she takes a deep breath. Which action would be a priority? a. Notify the provider STAT and obtain a 12-lead ECG. b. Obtain vital signs and auscultate for a pericardial friction rub. c. Apply high-flow O2 by face mask and auscultate breath sounds. d. Medicate the patient with as-needed analgesic and reevaluate in 30 minutes.

B

Erectile dysfunction drugs such as sildenafil (Viagra) are contraindicated in clients taking nitrates for angina. What is the primary concern with concurrent administration of these drugs? a. They contain nitrates, resulting in an overdose. b. They decrease blood pressure and may result in prolonged and severe hypotension when combined with nitrates. c. They will adequately treat the patient's angina as well as erectile dysfunction. d. They will increase the possibility of nitrate tolerance developing and should be avoided unless other drugs can be used.

B) They decrease blood pressure and may result in prolonged and severe hypotension when combined with nitrates. Erectile dysfunction drugs such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) decrease BP. When combined with nitrates, severe and prolonged hypotension may result.

A nurse is providing teaching for a client who has hypertension and a prescription change from metoprolol/hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching? a. "Now I will not have to diet to lose weight." b. "With the new medication, I should experience fewer side effects." c. "I will not have to do anything different because it is the same medication." d. "The extra letters after the name of medication means it is a stronger dose."

B. "With the new medication, I should experience fewer side effects."--- The client has states an understanding of the purpose of the addition of the hydrochlorothiazide to the metoprolol dosage. When used in combo with thiazide diuretic, a lower dose of the beta-blocker can be used. The benefit is there are fewer side effects when beta-blockers (and other antihypertensives) are used in lower dosages.

A nurse is reviewing the medical record of a client who has hypertension and a new prescription for metoprolol. Which of the following findings should the nurse investigate further? a. Diet-controlled type 2 diabetes mellitus b. A hx of left-sided heart failure c. A concurrent prescription for tadalafil d. Recently treated bilateral pneumonia

B. A hx of left-sided heart failure--- The nurse should further investigate the client's hx of heart failure. Although metoprolol can be used to treat heart failure, it can also cause heart failure, so this medication should be used with great caution with a client who has a hx of heart failure. The nurse should teach the client to watch for signs of increasing left-sided heart failure, such as shortness of breath & wt gain indicating fluid retention, & report these findings to the provider.

A nurse completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? (Select all that apply.) a. Hypothyroidism b. Hypertension c. Diabetes mellitus d. Hyperlipidemia e. Tobacco smoking

B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking--- A client who has hypertension, diabetes mellitus, hyperlipidemia, or a history of smoking tobacco is at risk for coronary artery disease (CAD). Hypertension and hyperlipidemia can be controlled by diet and exercise, along with medication if needed. Diabetes can cause damage to large and small blood vessels, which leads to poor perfusion, cell death, and organ damage. Diabetes mellitus can be managed by monitoring glucose levels and implementing diet and exercise recommendations. Cholesterol levels, such as total HDL and LDL levels, should be monitored since elevated total serum cholesterol levels increase the risk of a myocardial infarction. Finally, smoking accelerates the rate of the narrowing of the coronary arteries and increases the risk of clot formation. Smoking cessation classes or other forms of treatment can be offered to help the client quit smoking.

A nurse is caring for a client who has unstable angina. The nurse should anticipate a prescription from the provider for which of the following medications? a. Epinephrine b. Nitroglycerin c. Lidocaine d. Atropine

B. Nitroglycerin--- The nurse should anticipate a prescription for nitroglycerin, which is indicated for a client who has unstable angina. Nitroglycerin is an organic nitrate and a vasodilator that acts by relaxing or preventing spasms in the coronary arteries, thereby decreasing the oxygen demand of the heart along with ventricular filling.

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEw/L. Which of the following actions should the nurse take? a. Suggest that the client use a salt substitute b. Obtain a 12-lead ECG c. Advise the client to add citrus juices and bananas to her diet d. Obtain a blood sample for a serum sodium level

B. Obtain a 12-lead ECG--- The pt is at risk for dysrhythmias as well as cardiac arrest. The nurse should obtain a 12-lead ECG to monitor for cardiac changes

A nurse is establishing health promotion goals for a female client who smokes cigarettes. Has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? a. The client will list foods that are high in calcium, which should be avoided b. The client will walk for 30 min/5 days a week c. The client will increase calorie intake by 200 cal per day d. The client will replace cigarettes with smokeless tobacco products

B. The client will walk for 30 min/5 days a week--- CDC recommends include engaging in a moderate exercise, such as walking, for a total of 150 min each week.

A patient is recovering from an uncomplicated MI. Which rehabilitation guideline is a priority to include in the teaching plan? a. Refrain from sexual activity for a minimum of 3 weeks. b. Plan a diet program that aims for a 1- to 2-lb weight loss per week. c. Begin an exercise program that aims for at least 5 30-minute sessions per week. d. Consider the use of erectile agents and prophylactic NTG before engaging in sexual activity.

C

A nurse is reviewing the laboratory values of a client who had a MI 3 hr ago. The nurse should expect which of the following lab values to be elevated? a. Aspartate aminotransferase (AST) b. Unconjugated bilirubin c. Troponin I d. Serum amylase

C) Troponin I--- Cardiac troponin I & cardiac troponin T are biochemical markers that are specific to myocardial cell injury. A client who has myocardial cell damage can have elevated troponin levels within 2-3 hr. Cardiac troponin I levels can peak in 10-24 hr & stay elevated for 7-10 days. Cardiac troponin T levels can peak within 10-24 hr stay elevated for 10-14 days.

A home health nurse is performing an assessment on a client who is 1 week postoperative following a total knee replacement. Which of the following statements by the client indicates an understanding of the teaching? a. "I will discontinue the blood thinner my doctor prescribed once I am at home." b. "I will keep a pillow under my knee when I am in bed." c. "I plan to use a walker to help me get around." d. "I will discontinue using the CPM machine when I get home."

C. "I plan to use a walker to help me get around."--- The nurse should identify that the client will receive a prescription for a walker, cane, or crutches to promote ambulation following a total knee replacement.

A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect? a. Pitting edema b. Areas of reddish-brown pigmentation c. Dry, pale skin with minimal body hair d. Sunburned appearance with desquamation

C. Dry, pale skin with minimal body hair--- A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses.

A nurse is preparing to administer digoxin to a client. Which of the following findings should the nurse identify as a contraindication to the client receiving this medication? a. Blood pressure 180/70 mmHg b. Oxygen saturation rate 94% c. Heart rate 51/min d. Respiratory rate 21/min

C. Heart rate 51/min---- The nurse should identify that if the client's heart rate is less than 60/min, the medication should be withheld, and the provider should be notified.

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first? a. Attach the leads for a 12-lead ECG b. Obtain a blood sample c. Initiate O2 therapy d. Insert the IV catheter

C. Initiate O2 therapy--- The greatest risk to the client's safety is myocardial ischemia and cellular death; therefore, the priority action the nurse should take is to admin. O2 to help minimize this possibility.

A nurse is caring for a client who is having a possible myocardial infarction (MI). Which of the following findings should the nurse identify as an associated manifestation of an MI? a. Headache b. Hemoptysis c. Nausea d. Diarrhea

C. Nausea---Nausea is an associated manifestation of MI. Manifestations of MI include chest pain and pain in the jaw, shoulder, or abdomen.

A nurse is caring for a client who reports crushing chest pain. The nurse reviews the client's ECG results and notes ST changes. Which of the following medications should the nurse administer? a. Simvastatin b. Furosemide c. Nitroglycerin d. Sildenafil

C. Nitroglycerin---The nurse should identify the need to administer nitroglycerin, which is used to treat angina. Nitroglycerin acts directly on vascular smooth muscle to promote vasodilation.

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a MI? a. Check the client's BP b. Auscultate heart tones c. Perform a 12-lead ECG d. Determine if pain radiates to the left arm

C. Performs a 12-lead ECG--- The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a MI.

A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). What is the most common assessment finding with acute MI? a. Dyspnea b. Pain in the shoulder and left arm c. Substernal chest pain d. Palpitations

C. Substernal chest pain---Evidence-based practice indicates that the most common manifestation of acute MI is substernal chest pain that does not subside with rest or nitroglycerin. Therefore, nurses should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation.

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a MI. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? a. Troponin is an enzyme that indicates damage to the brain, heart, & skeletal muscle tissue b. Troponin is a lipid whose levels reflect the risk for coronary artery disease c. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart d. Troponin is a protein that helps transport O2 throughout the body

C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart--- Troponin is a myocardial muscle protein that releases into the bloodstream when there is injury to the myocardial muscle. Troponin levels are specific point-of-care testing for clients who are having a myocardial infarction.

A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of myocardial infarction? a. Sudden hemoptysis b. Acute diarrhea c. Frontal headache d. Acute confusion

D. Acute confusion--- Acute confusion is a manifestation of myocardial infarction in clients age 65 or older. Other manifestations can include nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness, palpitations, and fatigue.

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take? a. Administer aspirin b. Tilt the child's head back and apply pressure c. Have the child lie down and rest d. Apply continuous pressure to the lower part of the child's nose

D. Apply continuous pressure to the lower part of the child's nose----With the child sitting up and breathing through the mouth, the nurse should apply continuous pressure with the thumb and forefinger to the soft lower area of the nose for 10 minutes. Most bleeding from the nose stops within this period.

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? a. Have the client gently blow clots from the nose every 5 min b. Instruct the client to sit with his head hyperextended c. Apply ice compresses to the back of the client's neck d. Apply lateral pressure to the client's nose for 10 min

D. Apply lateral pressure to the client's nose for 10 min----The nurse should apply direct, lateral pressure to the nose for 10 minutes to control epistaxis. If after 10 minutes the epistaxis continues, the client might require nasal packing or other interventions.

A nurse is caring for a client who has congestive heart failure and is taking digoxin. The client reports nausea and refuses to eat breakfast. Which of the following actions should the nurse take first? a. Encourage the client to eat the toast on the breakfast tray b. Administer an antiemetic c. Inform the client's provider d. Check the client's apical pulse

D. Check the client's apical pulse---- Nausea, anorexia, fatigue, visual effects, and cardiac dysrhythmias (often caused by a slow pulse rate) are possible findings in digoxin toxicity. Caring for this client requires the application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider about a change in the client's status, the nurse must first collect adequate data from the client. Assessing will provide the nurse with the knowledge to make an appropriate decision.

A nurse is caring for a client who has a vitamin K deficiency. Which of the following manifestations should the nurse expect? a. Irregular bone formation b. Abnormal movements c. Blurred vision d. Excessive bruising

D. Excessive bruising--- The nurse should identify that excessive bruising can indicate bleeding under the skin. Vitamin K is needed by clotting factors to coagulate the blood. Therefore, a client who has a deficiency in vitamin K is at risk for excessive bruising and bleeding.

A nurse is applying antiembolic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings? a. Roll the stocking partially down if too long b. Remove the stocking once per day c. Bunch and pull the stocking halfway up the calf d. turn the stocking inside out up to the heel before applying

D. Turn the stocking inside out up to the heel before applying--- The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause fewer constrictive wrinkles.

A nurse is planning postoperative education for a client who will undergo a radial neck dissection for cancer of the larynx. The nurse should include which of the following topics? (select all that apply) a. NPO status b. alterative methods of communication c. endotracheal intubation d. changes in body image e. swallowing exercises

a. b. d. e.

A nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel. Which of the following information should nurse include? a. "You will need to apply a cold pack to the site 3 times a day." b. "Your provider might ask you to walk frequently to increase circulation to the area." c. "You will need to limit your consumption of high-protein foods." d. "Your provider might prescribe a central catheter line for a long-term antibiotic therapy."

d. "Your provider might prescribe a central catheter line for long-term antibiotic therapy."

A charge nurse is observing a newly licensed nurse administer an IV medication to a client who has an implanted venous access port. Which of the following observations requires intervention by the charge nurse? a. a dressing is not applied to the port after use b. a 22-gauge non coring needle is used to access the port c. blood return is noted prior to administering the medication d. a solution of 5 mL heparin 1,000 units/mL has prepared

d. a solution of 5 mL heparin 1,000 units/mL has been prepared

A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis. Which of the following laboratory values is consistent with diabetic ketoacidosis? a. blood glucose 30 mg/dL b. negative urine ketones c. blood pH 7.38 d. bicarbonate level 12 mEq/L

d. bicarbonate level 12 mEq/L

A nurse is triaging clients during a mass casualty event. Which of the following labels should the nurse assign to the client who has a head injury with fixed, dilated pupils? a. red tag b. yellow tag c. green tag d. black tag

d. black tag the nurse should assign a black tag, or a class IV label, to client who are not expected to live and will be allowed to die naturally. dilated pupils that are fixed or nonreactive to light are a poor prognostic sign an indicate severely increased intracranial pressure. in a mass casualty situation, the overall goal is to provide lifesaving treatment to the greatest number of people possible

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make? a. "A headache is an indication of an allergy to the medication" b. "A headache is an expected adverse effect of the medication" c. "A headache indicates tolerance to the medication" d. "A headache is likely due to the anxiety about the chest pain"

B. "A headache is an expected adverse effect of the medication"--- The vasodilation nitroglycerin induces increases blood flow to the head & typically results in a headache.

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, "All this equipment is making me nervous." Which of the following responses should the nurse offer? a. "You won't need the equipment for very long." b. "All of this equipment can be frightening." c. "Why does the equipment bother you?" d. "Let me tell you about what each machine does."

B. "All of this equipment can be frightening."---This statement is therapeutic because the nurse is reflecting the client's statement. The client is feeling fearful, and this response shows the nurse understands those feelings, which will encourage the client to communicate more.

A nurse is teaching a client about the proper placement of a nitroglycerin patch. Which of the following statements by the client indicates an understanding of the teaching? a. "I'll apply the patch over areas of my body with little fatty tissue." b. "I can place the patch on any area of my body without hair." c. "I'll put the patch on the same site as the previous patch." d. "I have to apply the patch directly over my heart."

B. "I can place the patch on any area of my body without hair."--- The nitroglycerin transdermal patch should be applied to skin that is free from hair because hair creates a physical barrier to absorption.

A nurse is providing discharge teaching for a client who had a left total hip arthroplasty. Which of the following client statements indicates the teaching was effective? a. "I should expect swelling of the affected leg for several weeks." b. "I should not cross my legs at the ankles or knees." c. "I will inspect my hip incision every other day for redness." d. "I can bend over at the hip to pick up objects."

B. "I should not cross my legs at the ankles or knees."---The nurse should instruct the client to avoid crossing the legs at the knees or ankles because this can result in the dislocation of the femoral head

A nurse is teaching a client who has a new prescription for hydrochlorothiazide for management of hypertension. Which of the following instructions should the nurse include? a. "Take this med before bedtime" b. "Monitor for leg cramps" c. "Avoid grapefruit juice" d. "Reduce intake of potassium-rich foods"

B. "Monitor for leg cramps"--- Hydrochlorothiazide can cause hypokalemia. The client should monitor for manifestations of hypokalemia, such as fatigue,tachycardia, leg cramps, & muscle weakness

A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity? a. Absent pedal pulses b. Ankle swelling c. Hair loss d. Skin atrophy

B. Ankle swelling--- The nurse should identify that swelling of the ankle is a manifestation of venous insufficiency due to poor venous return. Other manifestations can include brown pigmentations and cellulitis.

A nurse is preparing to administer nitroglycerin topical ointment to a client who has angina. Which of the following actions should the nurse take? a. Cover the applied ointment with cotton gauze b. Apply the ointment using a dose-measuring applicator c. Apply the ointment using the index finger d. Massage the ointment into the client's skin

B. Apply the ointment using a dose-measuring applicator---The nurse should apply the ointment using a dose-measuring applicator. This allows the nurse to measure the correct dose the client is to receive.

A nurse is assessing a client who is experiencing chest pain. Which of the following medications should the nurse expect to administer to suppress the aggregation of platelets? a. Nitroglycerin b. Aspirin c. Morphine d.Metoprolol

B. Aspirin---Aspirin suppresses platelet aggregation, producing an immediate antithrombotic effect. The client should chew the first dose of aspirin to allow rapid absorption.

A nurse is providing discharge teaching to a client who has venous thrombosis and a prescription for warfarin. Which of the following instructions should the nurse include in the teaching? a. Take ibuprofen as needed for headaches or other minor pains b. Carry a medical alert ID card c. Report to the laboratory weekly to have blood drawn for aPTT d. Increase intake of dark green vegetables

B. Carry a medical alert ID card---A client who is taking warfarin is at increased risk for bleeding. In the case of an emergency, any medical personnel must be aware of the client's medication history.

A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications? a. Cardiogenic shock b. Dysrhythmias c. Heart failure d. Pulmonary edema

B. Dysrhythmias---- According to evidence-based practice, dysrhythmias (specifically ventricular fibrillation) are the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately.

A nurse is caring for a client who has severely elevated blood pressure. Which of the following findings should the nurse identify as a manifestation of hypertension? a. Vertigo b. Epistaxis c. Exophthalmos d. Spondylolisthesis

B. Epistaxis---Epistaxis (a nosebleed) is a manifestation of elevated blood pressure. Hypertension is often asymptomatic, but when it is severely elevated, it can also cause headaches, dizziness, facial flushing, and fainting.

A nurse is admitting a client who is scheduled to undergo a cardiac catheterization. The client says, "My coworker died last week from a heart attack." Which of the following responses should the nurse offer? a. "Your provider will not let that happen because she knows how to treat your condition." b. "Do you think the same thing might happen to you?" c. "You appear to be feeling anxious." d. "Has anyone in your family had a heart attack?"

C. "You appear to be feeling anxious."---The nurse is sharing observations that will encourage the client to be more specific about these feelings.

A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider? a. Temperature 37.5°C (99.5°F) b. Apical pulse rate 140/min c. BP 86/40 mmHg d. Respiratory rate 32/min

C. BP 86/40 mmHg---A BP of 86/40 mmHg is indicative of hypotension and bleeding in a 6-month-old infant and should be immediately reported to the provider.

A nurse is reviewing the medical record of a client who is receiving hydrochlorothiazide (HCTZ). The nurse should expect to find an improvement in which of the following conditions as a result of this medication? a. Gouty arthritis b. Dehydration c. Diabetes insipidus d. Hypokalemia

C. Diabetes insipidus--- A thiazide diuretic such as HCTZ is administered to treat diabetes insipidus. Diabetes insipidus is a condition in which there is an overproduction of urine. Thiazides reduce urine production by 30% to 50%.

A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr? a. Infective endocarditis b. Pericarditis c. Ventricular dysrhythmias d. Pulmonary emboli

C. Ventricular dysrhythmias---- After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system.

A nurse is assessing a client who has heart failure and is receiving digoxin. Which of the following findings should indicate to the nurse the client is experiencing digoxin toxicity? a. Suppression of dysrhythmias b. Increased atrioventricular (AV) conduction c. Visual disturbances d. Weight gain

C. Visual disturbances----The nurse should recognize that nausea, vomiting, abdominal discomfort, fatigue, and visual disturbances are common manifestations that can indicate that the client is experiencing digoxin toxicity.

A nurse is caring for an adult male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder? a. Cholesterol level 195 mg/dL b. Elevated HDL levels c. Elevated LDL levels d. Triglyceride level 135 mg

c. Elevated LDL levels---An elevated LDL level increases a client's risk of atherosclerosis. The client's desirable LDL level is <100 mg/dL.

A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the client's brain? a. occipital b. temporal c. frontal d. limbic

c. frontal the nurse should identify that the posterior portion of the frontal lobe is responsible for the verbal expression of thought

A nurse is providing teaching for a client who has a new prescription for nitroglycerin administered through a transdermal patch. Which of the following client statements indicates an understanding of the teaching? a. "I need to wear the patch continuously for it to be effective." b. "I will stop using the patch immediately if it gives me a headache." c. "I should change the patch whenever I have chest pain." d. "I need to rotate the location of my patch every few days."

D. "I need to rotate the location of my patch every few days."---The nitroglycerin patch should be rotated to different hairless areas of the client's body every few days to avoid local skin irritation.

A nurse is providing discharge teaching to a client who has heart failure and a prescription for digoxin 0.125 mg PO daily and furosemide 20 mg PO daily. Which of the following statements by the client indicates an understanding of the teaching? a. "I know that blurred vision is expected to happen while I'm taking digoxin." b. "I will measure my urine output each day and document it in my diary." c. "I will skip a dose of my digoxin if my resting heart rate is below 72 beats per minute." d. "I will eat fruits and vegetables that have a high potassium content every day."

D. "I will eat fruits and vegetables that have a high potassium content every day."--- Hypokalemia is an adverse effect of diuretic therapy. Because the client is taking digoxin, it is important to maintain a potassium level between 3.5 to 5.0 mg/dL to avoid digoxin toxicity.

A nurse is teaching a 70-year-old client about risk factors for heart failure. The client has mild asthma, diabetes mellitus, and coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? a. "My diabetes will not increase my risk of heart failure." b. "My asthma makes it more likely for me to have heart failure." c. "My age does not increase my risk of heart failure." d. "My coronary artery disease is a risk factor for heart failure."

D. "My coronary artery disease is a risk factor for heart failure."---- Coronary artery disease is a primary risk factor for the development of heart failure. Other risk factors include hypertension, cardiomyopathy, tobacco use, family history, and hyperthyroidism.

A nurse is providing teaching to a client who has a new prescription for hydrochlorothiazide 50 mg PO daily to treat hypertension. Which of the following instructions should the nurse include in the teaching? a. "Take hydrochlorothiazide as needed for edema." b. "Check your weight once each week." c. "Take hydrochlorothiazide on an empty stomach." c. "Take hydrochlorothiazide in the morning."

D. "Take hydrochlorothiazide in the morning."---The client should take hydrochlorothiazide in the morning to allow for diuresis during the day and to prevent nocturia.

A nurse is providing teaching to a client who is scheduled to start taking hydrochlorothiazide for hypertension. The nurse instructs the client to eat foods that are rich in potassium. Which of the following statements by the client indicates an understanding of the teaching? a. "This medication will not work unless I have enough potassium." b. "Potassium will increase the therapeutic effect of my blood pressure medication." c. "Potassium will lower my blood pressure. d. "This medication can cause a loss of potassium."

D. "This medication can cause a loss of potassium."--- Hydrochlorothiazide can result in hypokalemia caused by excessive potassium excretion from the kidneys. The client should supplement his diet with potassium-rich foods to avoid the occurrence of hypokalemia. Foods that are high in potassium include bananas, raisins, baked potatoes, pumpkins, and milk.

A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? a. Chest pain is relieved soon after resting. b. Nitroglycerin relieves chest pain. c. Physical exertion does not precipitate chest pain. d. Chest pain lasts for longer than 15 min.

D. Chest pain lasts for longer than 15 min--- A client who has unstable angina will have chest pain lasting longer than 15 minutes. This is due to reduced blood flow in a coronary artery from atherosclerotic plaque and thrombus formation causing partial arterial obstruction or from an artery spasm.

A nurse is teaching a client who has a cast on his left arm to treat a forearm fracture. Which of the following statements indicates that the client understands the teaching? a. "I'll call the doctor's office if my fingers get colder on the arm with the cast" b. " If I have any itching under the cast, I'll try to reach them and rest" c. "If my fingers swell, I should put a heating pad on them and rest" d. "If I have nay tingling under my cast, I'll know I need to move my fingers more"

a. "I'll call the doctor's office if my fingers get colder on the arm with the cast." the nurse should emphasize the importance of doing neurovascular checks and notifying the provider of any unexpected findings, such as temperature variances

A nurse is teaching a client who has HIV about the early manifestations of AIDS. Which of the following statements should the nurse include in the teaching? a. "You can expect a persistent fever and swollen glands" b. "You can expect an elevated white blood count" c. "You can expect increased blood pressure and edema" d. "You can expect weight gain"

a. "You can expect a persistent fever and swollen glands"

A nurse is talking with an older adult client who has elevated risk for osteoporosis about strategies for preventing bone loss. Which of the following instructions should the nurse provide? a. begin a program of brisk walking b. take 800 mg of calcium per day c. drink plenty of sparkling water d. drink 8 oz of red wine each day

a. begin a program of brisk walking weight-bearing exercises help maintain bone mass and prevent osteoporosis. walking is generally a safe activity for older clients

A nurse is caring for a group of client on a medical-surgical unit. Which of the following disorders should the nurse identify as increasing the client's metabolic needs? (select all that apply) a. COPD b. hypothyroidism c. cancer d. Parkinson's disease e. major burns

a. c. d. e.

A nurse is determining a client's risk of developing osteoporosis. The nurse should identify which of the following as risk factors for bone loss? a. small body frame b. hypertension c. african-american ethnicity d. low vitamin D intake e. smoking

a. d. e.

A nurse is providing teaching about degenerative complications to the partner of a client who has a new diagnosis of Parkinson's disease. Which of the following manifestations is the priority? a. dysphagia b. emotional lability c. impaired speech d. self-care dependency

a. dysphagia

A nurse is caring for a client who has a femoral thrombophlebitis and a prescription for enoxaparin. Which of the following actions should the nurse take? a. elevate the affected leg b. place the client on bed rest c. massage the affected leg d. administer aspirin for discomfort

a. elevate the affected leg

A nurse is caring for a client with a history of cirrhosis who has been admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? a. gamma-glutamyl transferase (GGT) b. alkaline phosphatase (ALP) c. serum bilirubin d. alanine aminotransferase (ALT)

a. gamma-glutamyl transferase (GGT)

A nurse is teaching a client who has iron deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods? a. lentils b. avocados c. cabbage d. broccoli

a. lentils the nurse should encourage the client to increase her consumption of iron-rich foods, including meat, fish, poultry, and dried beans and peas. A 1-cup serving of lentils contains 3.6 mg of iron

A nurse is teaching a client who has chronic kidney disease. Which of the following instructions should the nurse include? a. limit fluid intake b. limit caloric intake c. eat a diet high in phosphorus d. eat a diet high in protein

a. limit fluid intake a client who has CKD should limit fluid intake to prevent hypervolemia

A nurse in a medication-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestations of pulmonary embolism? a. stabbing chest pain b. calf tenderness c. elevated temperature d. bradycardia

a. stabbing chest pain a manifestation of pulmonary embolism is sudden chest pain that is sharp and stabbing. other manifestations include dyspnea, coughing, hemoptysis, tachypnea, tachycardia, diaphoresis, and a feeling of impending doom

A nurse is caring for a client who is recovering from a recent stroke. Which of the following assessments is the nurse's priority? a. the client's ability to clear oral secretions b. the client's ability to communicate verbally c. the client's ability to move all extremities d. the client's ability to remain continent of urine

a. the client's ability to clear oral secretions the first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to check the client's ability to clear secretions in order to protect the airway and reduce the risk of aspiration.

A nurse is providing discharge instructions to a client who is postoperative following surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a mole's potential malignancy? a. ulceration b. blanching of surrounding skin c. dimpling d. fading of color

a. ulceration ulceration, bleeding, and exudation are indications of a mole's potential malignancy. increasing size is also a warning sign. the nurse emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-examination of the skin every month.

A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following pieces of information should the nurse include in the teaching? a. hospitalization is required when administering each treatment b. the maximum effect of the medication will occur in 6 months c. hypertension is a common adverse effect of this medication d. blood transfusions are needed with each treatment

c. hypertension is a common adverse effect of this medicaiton

A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? a. jaundice b. anorexia c. dark urine d. pale feces

b. anorexia anorexia is an early manifestation of a hepatitis A and is often severe. it is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product.

A nurse is planning dietary teaching dietary teaching for a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? a. obtain sample menus from the dietician to give to the client b. ask the client to identify the types of foods she prefers c. identify the recommended range of the client's blood glucose level d. discuss long-term complications that can result from non-adherence to the dietary plan

b. ask the client to identify the types of foods she prefers

A nurse in a emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? a. estimation of burn injury b. characteristics of the cough and sputum c. extent of peripheral edema d. amount of urine output

b. characteristics of the cough and sputum

A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? a. depressed fracture of the forehead b. clear fluid coming from the nares c. motor loss on one side of the body d. bleeding from the top of the scalp

b. clear fluid coming from the nares

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? a. pitting edema b. crackles in the lung bases c. jugular vein distention d. hepatomegaly

b. crackles in the lung bases left-sided heart failure precipitates pulmonary congestion and edema, causing crackles in the lungs

A nurse is preparing to administer packed RBCs to a client who is anemic. Which of the following actions should the nurse take? (select all that apply) a. insert a 23-gauge angiocatheter with an IV adaptor b. check to determine the packed RBCs are less 1 week old c. ask another nurse to check the packed RBCs label against the medical record e. prime the transfusion tubing with 0.9% sodium chloride

b. d. e.

A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Which of the following actions requires the charge nurse to intervene? a. visualizing the eardrum before irrigating b. instilling 50 mL of fluid with each irrigation c. using firm, continuous pressure while irrigating d. warning the irrigation fluid to least 37

b. instilling 50 m: of fluid with each irrigation

A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take? a. Obtain blood samples to test platelet function b. prepare for replacement of the missing clotting factor c. administer aspirin for the client's pain d. place the bleeding joint in the dependent position

b. prepare for replacement of the missing clotting factor

A nurse is teaching a client who has AIDS about the transmission of PCP. Which of the following pieces of information should the nurse include in the teaching? a. "PCP is sexually transmitted from person to person" b. "you were most likely exposed to a contaminated surface such as a drinking glass" c. "PCP results from an impaired immune system" d. "you might have contracted PCP from a family pet"

c. "PCP results from an impaired immune system" the organism that causes PCP exists as part of the normal flora of the lungs and develops into a fungus. it becomes an aggressive pathogen when the immune system is compromised, causing infection.

A nurse is teaching a client who has leukemia and has developed thrombocytopenia. Which of the following instructions should the nurse include in the teaching? a. "limit flossing your teeth to once a week" b. "gently blow your nose if needed" c. "use an electric razor when shaving" d. "wear shoes that have a soft sole"

c. "use an electric razor when shaving the nurse should instruct the client to use an electric razor to prevent nicks and cuts caused by conventional razors that can increase the risk of bleeding

A nurse is assessing a client who is receiving a transfusion of packed red blood cells. Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? a. severe hypertension b. low body temperature c. sudden oliguria d. decreased respirations

c. sudden oliguria the nurse should identify sudden oliguria as an indication of an acute intravascular hemolytic reaction. this type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. this reaction results from the client's antibodies reacting to the transfused RBCs

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood, and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? a. first-degree frostbite b. second-degree frostbite c. third-degree frostbite d. fourth-degree frostbite

c. third-degree frostbite when a client has third-degree frostbite, the skin of the affected area has small blisters that are blood-filled, and the skin does not blanch

A nurse is assessing a client who has acute kidney injury. According tot he RIFLE classification system, which of the following findings indicates that the client has end-stage kidney disease? a. <0.5 mL/kg of urine output for 12 hr b. no urine output for 12 hr c. no urine output without renal replacement therapy for 4-12 weeks d. no urine output without renal replacement therapy for more than 3 months

d. no urine output without renal replacement therapy for more than 3 months

A nurse is caring for a client who will receive brachytherapy to treat uterine cancer. The nurse should ensure the client understands that she will receive which of the following interventions? a. chemotherapy via a central venous access device b. radiation to the tumor from an external source c. precise delivery of high-dose radiation after tumor imaging d. radioactive infusions or insertions into or near the tumor

d. radioactive infusions or insertions into or near the tumor brachytherapy is a type of radiation therapy during which the radiation source, either an implant or via infusion is in direct contact with the client's tumor continuously for a specific duration

A nurse is preparing to administer a Mantoux skin test a client. What is the purpose of a Mantoux skin test using purified protein derivative (PPD)? a. to identify if a client lacks immunity to tuberculosis b. to find out if a client ahs active tuberculosis c. to decrease the hypersensitivity of the client's reaction to PPD d. to identify if a client has been infected with mycobacterium tuberculosis

d. to identify if a client has been infected with mycobacterium tuberculosis the nurse should inform the client that the Mantoux skin test is used to identify individuals who have been infected with Mycobacterium tuberculosis