dani julie jas #2

33) An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken into his head. Which nursing intervention is indicated? 1.Help the client determine ways to increase his fluid intake. 2.Obtain an appointment for the client to have an eye examination. 3.Instruct the client to use oxygen at night and increase the humidification. 4.Schedule the client for tests to determine his sensitivity to cat hair.

1. Help the client determine ways to increase his fluid intake.

130) The health care provider is discharging a client with a diagnosis of primary hypertension. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply. 1. Monitor the blood pressure at home. 2. Restrict sodium intake as prescribed. 3. Take a calcium supplement to lower blood pressure. 4. Eye examinations with an ophthalmoscope should be routine. 5. Follow-up appointments for blood pressure checks are important

1. Monitor the blood pressure at home. 2. Restrict sodium intake as prescribed. 4. Eye examinations with an ophthalmoscope should be routine. 5. Follow-up appointments for blood pressure checks are important

The nurse is preparing for a health fair about tobacco use and the development of coronary heart disease. Which information should the nurse include? Select all that apply. 1. Nicotine decreases oxygen to the heart. 2. Hypnosis may be helpful to stop smoking. 3. Avoid exposure to environmental tobacco smoke. 4. Cigars or pipes are healthier than cigarette smoking 5. Tobacco smoking to environmental tobacco smoke

1. Nicotine decreases oxygen to the heart. 2. Hypnosis may be helpful to stop smoking. 3. Avoid exposure to environmental tobacco smoke.

Which clinical signs are most important for the nurse to communicate to the health care provider? Select all that apply. 1. Pink-tinged frothy sputum 2. Increase in respiratory rate 3. Ankle and lower leg swelling 4. Paroxysmal nocturnal dyspnea 5. Auscultation of crackles throughout the lungs

1. Pink-tinged frothy sputum 2. Increase in respiratory rate 5. Auscultation of crackles throughout the lungs

126) The nurse is caring for a client with a new onset of atrial fibrillation. Which prescribed treatments should the nurse expect? Select all that apply. 1. Defibrillation 2. Digoxin (Lanoxin) 3. Warfarin (Coumadin) 4. Electrical cardioversion 5. Amiodarone (Cordarone)

2. Digoxin (Lanoxin) 3. Warfarin (Coumadin) 4. Electrical cardioversion

131) The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care? 1.Restore skin integrity. 2.Prevent infection. 3.Promote healing. 4.Improve nutrition.

2.Prevent infection.

A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which typical characteristic? 1. dark, pink bas 2.deep and painful 3.accompanied by very slight pain 4. brown pigmentation of surrounding skin

2.deep and painful

129) The nurse is admitting a client with acute pericarditis who reports chest pain. When planning the client's care, which position should the nurse encourage the client to assume to alleviate the chest pain? Select all that apply. 1. Lying supine 2. Right side-lying 3. Sitting up and leaning forward 4. semi-fowlers with knees bent 5. Head of bed elevated to 45 degrees

3. Sitting up and leaning forward 5. Head of bed elevated to 45 degrees

The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up? 1.Urine specific gravity of 1.03 2.Frothy, tea-colored urine 3.Clay-colored stools 4.Elevated serum amylase and lipase levels

4. Elevated serum amylase and lipase levels

138) The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic? 1.Tall, spiked T waves 2.A prolonged QT interval 3.A widening QRS complex 4.Presence of a U wave

4.Presence of a U wave

136) The LPN/LVN is interviewing a client who is taking interferon- alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse implement first? 1.Recommend mental health counseling. 2.Review the medication actions and interactions. 3.Assess for the client's daily activity level. 4.Provide information regarding a support group.

Correct Answer: 2. Review the medication actions and interactions.

139) When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly? 1.Albumin 2.Calcium 3.Glucose 4.Alkaline phosphatase

GLUCOSE!

120) The nurse is assisting in the care of a client with myocardial infarction who should reduce intake of saturated fat and cholesterol. The nurse should help the client comply with diet therapy by selecting which food items from the dietary menu? 1. Cheeseburger, pan-fried potatoes, whole kernel corn, sherbet 2. Pork chop, baked potato, cauliflower in cheese sauce, ice cream 3. Baked haddock, steamed broccoli, herbed rice, sliced strawberries 4. Spaghetti and sweet sausage in tomato sauce, vanilla pudding (with 4% milk)

Correct Answer: 3. Baked haddock, steamed broccoli, herbed rice, sliced strawberries

124) The health care provider is discharging a client with a diagnosis of chronic heart failure. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply. 1. Obtain annual influenza vaccination. 2. Restrict fluid intake to 1000 mL per day. 3. Avoid adding salt to foods or in cooking. 4. Report a weight gain of 3 or more pounds in a week. 5. Take an extra dose of prescribed diuretic for swollen ankles.

Correct Answer: 1. Obtain annual influenza vaccination. 3. Avoid adding salt to foods or in cooking. 4. Report a weight gain of 3 or more pounds in a week.

123) A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin 0.4 mg sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure is still stable, the nurse should take which action next? 1. Administer another nitroglycerin tablet. 2. Apply 1 to 3 L/minute of oxygen via nasal cannula. 3. Call for a 12-lead electrocardiogram (ECG) to be performed. 4. Wait an additional 5 minutes, then give a second nitroglycerin tablet.

Correct Answer: 1. Administer another nitroglycerin tablet.

116) The nurse is told during shift report that a client is having occasional ventricular dysrhythmias. The nurse reviews the client's laboratory results, recalling that which electrolyte imbalance could be responsible for this development? 1. Hypokalemia 2. Hypernatremia 3. Hypochloremia 4. Hypercalcemia

Correct Answer: 1. Hypokalemia

115) A client has a history of left-sided heart failure. The nurse should look for the presence of which finding to determine whether the problem is currently active? 1. Presence of ascites 2. Bilateral lung crackles 3. Jugular vein distention 4. Pedal edema bilaterally

Correct Answer: 2. Bilateral lung crackles

137) A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. In what position should the nurse immediately place the client to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg? 1.Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow. 2.Turn the client prone to place pressure on the abdominal wound to help staunch the bleeding. 3.Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound. 4.Put the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging.

Correct Answer: 3. Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound.

140) A 62-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur? 1.Failing eyesight resulting in an unsafe environment 2.Renal osteodystrophy resulting from chronic kidney disease (CKD) 3.Osteoporosis resulting from declining hormone levels 4.Cerebral vessel changes causing transient ischemic attacks

Correct Answer: 3. Osteoporosis resulting from declining hormone levels

111) A hypertensive client who has been taking metoprolol (Lopressor) has been prescribed to decrease the dose of the medication. The client asks the nurse why this must be done over a period of 1 to 2 weeks. In formulating a response, the nurse incorporates the understanding that abrupt withdrawal could affect the client in which way? 1. Result in hypoglycemia 2. Give the client insomnia 3. Precipitate rebound hypertension 4. Cause enhanced side effects of other prescribed medications

Correct Answer: 3. Precipitate rebound hypertension

117) A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN should assist the RN by placing the bed in which position for the reading? 1. Flat 2. Semi-Fowler's 3. Trendelenburg's 4. Reverse Trendelenburg's

1. flat

14) A client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned, knowing that this level could lead to which complication? 1. Stroke 2. Cardiac arrest 3. High blood pressure 4. Urinary stone formation

Correct Answer: 2. Cardiac arrest

127) A client with hyperlipidemia is seen in the clinic for a follow-up visit. Which dietary modifications should the nurse include to lower the risk of coronary heart disease? Select all that apply. 1. Use liquid vegetable oil. 2. Increase intake of fruits. 3. Choose whole grain foods. 4. Remove skin from poultry. 5. Select whole milk products.

1. Use liquid vegetable oil. 2. Increase intake of fruits. 3. Choose whole grain foods. 4. Remove skin from poultry.

132. the lvn is conducting an osteoporosis screening clinic at a health fair. what information should the nurse provide to individuals who are at risk for osteoporosis? 1.Encourage alcohol and smoking cessation 2.Suggest supplementing diet with vitamin E. 3.Promote regular weight-bearing exercises. 4.Implement a home safety plan to prevent falls. 5.Propose a regular sleep pattern of 8 hours nightly.

1.Encourage alcohol and smoking cessation. 3.Promote regular weight-bearing exercises. 4.Implement a home safety plan to prevent falls.

135) Which content about self-care should the lvn include in the teaching plan of a female client who has genital herpes? (Select all that apply.) 1.Encourage annual physical and Pap smear. 2.Take antiviral medication as prescribed. 3.Use condoms to avoid transmission to others. 4.Warm sitz baths may relieve itching. 5.Use Nystatin suppositories to control itching. 6.Use a douche with weak vinegar solution to decrease itching. 1, 2, 3, 4

1.Encourage annual physical and Pap smear. 2.Take antiviral medication as prescribed. 3.Use condoms to avoid transmission to others. 4.Warm sitz baths may relieve itching

122) The nurse is assisting in the care of a client diagnosed with rheumatic heart disease. The nurse should reinforce instructions to the client to notify the dentist before dental procedures for which reason? 1. The client requires prophylactic antibiotics before treatment. 2. The dentist should use a low-speed drill to avoid dysrhythmias. 3. The dentist should use a lidocaine solution without epinephrine. 4. The client is at risk for episodes of heart failure triggered by stressful events.

Correct Answer: 1. The client requires prophylactic antibiotics before treatment.

121) The nurse is assisting a client admitted to the hospital with pulmonary edema to prepare for discharge. The nurse should reinforce with the client the importance of complying with which measure to prevent a recurrence? 1. Weigh self every morning before breakfast. 2. Sleep with the head elevated on only one pillow. 3. Adjust diuretic dose based on severity of peripheral edema. 4. Take additional digoxin (Lanoxin) if respiratory distress occurs.

Correct Answer: 1. Weigh self every morning before breakfast.

118) The nurse is assisting a client who will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. The nurse takes which action to assist the client? 1. Shaves the front of the client's chest 2. Gives the client a device holder to wear around the waist 3. Teaches the client to rest as much as possible during the next 24 hours 4. Tells the client to cover the monitor in plastic wrap before taking a bath

Correct Answer: 2. Gives the client a device holder to wear around the waist

113) A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed, the nurse places a sign above the bed stating that the client should remain on bed rest and in which position? 1. In semi-Fowler's position 2. With the head of the bed elevated 45 degrees 3. With the head of the bed elevated no more than 15 degrees 4. With the foot of the bed elevated as much as tolerated by the client

Correct Answer: 3. With the head of the bed elevated no more than 15 degrees

The nurse inspects the ulcer expecting to note which observation? 1. The ulcer has a pale-colored base. 2. The ulcer is deep, with even edges. 3. The ulcer has little granulation tissue. 4. The ulcer has a brownish or "brawny" appearance.

Correct Answer: 4. The ulcer has a brownish or "brawny" appearance.