Exam 1 Nur. 114

When a patient who has been diagnosed with angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the pain to occur, the nurse recognizes that the patient is describing which type of angina? a) Refractory b) Intractable c) Unstable d) Variant

C

When providing care for a client with glomerular disorders, the nurse teaches the client which of the following? A. "You will be cured when you leave the hospital." B. "You will face activity restrictions for the rest of your life." C. "Healing takes a long time, so you will learn self-management." D. "You will be free of infection in the future."

C

Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty? a) Assess distal pulses. b) Remove hair from skin insertion sites. c) Withhold anticoagulant therapy. d) Inform client of diagnostic tests.

C

Which of the following findings is associated with right sided HF? a. Shortness of breath b. Nocturnal polyuria c. Daytime oliguria d. Crackles in the lungs

C

Which of the following is a key diagnostic indicator of heart failure? a) CBC b) Creatinine c) BNP d) BUN

C

A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the clients care plan? a. Monitoring the temperature b. Monitoring for complaints of heartburn c. Giving warm gargles for a sore throat d. Assessing for the return of the gag reflex

D

The nurse is caring for a child diagnosed with nephrotic syndrome. Which of the following is the most appropriate nursing diagnosis for the child? A. Activity Intolerance B. Risk for Impaired Skin Integrity C. Ineffective Coping D. Risk for Loneliness

B

The nurse is reinforcing diet teaching for a patient s diagnosed with IBS. The nurse instructs the patient to include which of the following in his diet? a) Caffeinated products b) High-fiber diet c) Spicy foods d) Fluids with meals

B

The nurse performing an admission assessment on a 2 year old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome? a. Hypertension b. Generalized edema c. Increased urinary output d. Frank, bright red blood in the urine

B

The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding that is associated with this diagnosis? a. Hypotension b. Brown colored urine c. Low urinary specific gravity d. Low blood urea nitrogen level

B

The physician has ordered prednisone 50 mg to promote diuresis in a client with nephrotic syndrome. The nurse should administer the medication: a. In a single dose at bedtime b. With a snack or glass of milk c. With water to promote absorption d. As soon as they wake up

B

Understanding atherosclerosis, the nurse identifies which of the following to be both a risk factor for the development of the disorder and an outcome? a) Obesity b) Hyperlipidemia c) Hypertension d) Glucose intolerance

C

Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? a) White rice b) Hot roast beef sandwich with gravy c) Mashed potatoes d) Vanilla pudding

B

When the postcardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient's serum electrolytes anticipating which abnormality? a) Hypercalcemia b) Hyperkalemia c) Hyponatremia d) Hypomagnesemia

B

The nurse is reviewing discharge instructions with a patient who underwent a left groin cardiac catheterization 8 hours ago. Which of the following instructions should the nurse include? a) "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." b) "If any discharge occurs at the puncture site, call 911 immediately." c) "You can take a tub bath or a shower when you get home." d) "Contact your primary care provider if you develop a temperature above 102°F."

A

The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to note documented in the client's record" a. Diarrhea b. Constipation c. Constipation alternating with diarrhea d. Stool constantly oozing from the rectum

A

Which of the following are characteristics of arterial insufficiency? a) Superficial ulcer b) Diminished or absent pulses c) Pulses are present, may be difficult to palpate d) Aching, cramping pain

B

Which of the following is a cerebrovascular manifestation of heart failure? a) Ascites b) Dizziness c) Nocturia d) Tachycardia

B

Which of the following is a characteristic of an arterial ulcer? a) Edema may be severe b) Border regular and well demarcated c) Brawny edema d) Ankle-brachial index (ABI) > 0.90

B

Which of the following is also termed preinfarction angina? a) Silent ischemia b) Unstable angina c) Variant angina d) Stable angina

B

When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain to his right shoulder. The intial appropriate action by the nurse is to a) Assess the client's abdomen and vital signs. b) Notify the health care provider. c) Place the client in the high-Fowler's position. d) Irrigate the client's NG tube.

A

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (less than 25 mL per hour) with high specific gravity (greater than 1.025), the nurse suspects which of the following conditions? a) Inadequate fluid volume b) Anuria c) Overhydration d) Normal glomerular filtration

A

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? a) Echocardiogram b) Electrocardiogram (ECG) c) Serum electrolytes d) Blood urea nitrogen (BUN)

A

Which of the following are signs/symptoms of perforation? a) Sudden, severe upper abdominal pain b) Soft abdomen c) Bradycardia d) Hypertension

A

Which of the following statements correctly identifies a difference between duodenal and gastric ulcers? a) Weight gain may occur with a gastric ulcer. b) Vomiting is uncommon in patients with duodenal ulcers. c) Malignancy is associated with duodenal ulcer. d) A gastric ulcer is caused by hypersecretion of stomach acid.

B

A client has been symptomatic for several months and is seeing a cardiologist for diagnostics to determine the cause of his cardiac symptoms. You review the diagnostic procedures the cardiologist will perform. How will the client's ejection fraction be measured? a) Echocardiogram b) Electrocardiogram c) Cardiac ultrasound d) Cardiac catheterization

A

A client is admitted to the hospital with chest pain and a history of type 2 diabetes and is scheduled for cardiac catherization. Which medication would need to be withheld for 24 hours the procedure and 48 hours after the procedure? a. Metformin b. Regular Insulin c. Glipizide d. Repaglinide

A

A client who has ulcerative colitis has persistent diarrhea, and has lost 12 pounds since the exacerbation of the disease. Which of the following will be most effective in helping the client meet nutritional needs? a. TPN b. high calorie, high protein diet c. eating six small meals a day d. continuous enteral feedings

A

A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following? a) Arterial insufficiency b) Trauma c) Neither venous nor arterial d) Venous insufficiency

A

A middle-aged obese female presents to the ED with severe radiating right-sided flank pain, nausea, vomiting, and fever. The nurse understands that a likely cause of her symptoms is ________. a) acute cholecystitis b) hepatitis B c) hepatitis A d) pancreatitis

A

A patient has been diagnosed with systolic heart failure. The nurse would expect the patient's ejection fraction to be at which level? a) Severely reduced b) Slightly reduced c) High d) Normal

A

Anasarca, a characteristic finding in clients with nephritic syndrome, is due to renal changes that result in: a. Hypoalbuminemia b. Hypertension c. Hyperalbumiemia d. Hyperthermia

A

Following a coronary artery bypass, a client develops a temp of 102. The nurse should notify the doctor because an elevation in temp: a. Increases in the CO b. Decreases in the CO c. Indicate cardiac tamponade d. Increases diaphoresis and the likelihood of hypothermia

A

The nurse is monitoring a client for early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? a. Sweating and pallor b. Bradycardia and indigestion c. Double vision and chest pain d. Abdominal cramping and pain

A

The nurse is planning care for a patient following an incisional cholecystectomy for cholelithiasis. Which of the following interventions is the highest nursing priority for this patient? a) Assisting the patient to turn, cough, and deep breathe every 2 hours b) Teaching the patient to choose low-fat foods from the menu c) Assisting the patient to ambulate the evening of the operative day d) Performing range-of-motion (ROM) leg exercises hourly while the patient is awake

A

A nurse is monitoring a client with peptic ulcer disease. Which of the following assessment findings would most likely indicate perforation of the ulcer? Choose all that apply. a) A rigid, board-like abdomen b) Mild epigastric pain c) Hypotension d) Diarrhea e) Tachycardia

ACE

A 76-year-old client has a significant history of congestive heart failure. During his semiannual cardiology examination, for what should you, as his nurse, specifically assess? Select all that apply. a) Examine the client's neck for distended veins. b) Examine the client's joints for crepitus. c) Examine the client's eyes for excess tears. d) Monitor the client for signs of lethargy or confusion.

AD

Which of the following terms refers to a muscular, cramplike pain in the extremities consistently reproduced with the same degree of exercise and relieved by rest? a) Bruit b) Intermittent claudication c) Aneurysm d) Ischemia

B

A client with cancer of the stomach is admitted to the hospital and scheduled for a subtotal gastrectomy. The nurse is providing preoperative teaching. What should the nurse teach the client to do postoperatively to minimize the complication of dumping syndrome? a. ambulalte after every meal b. remain on a diet low in fat c. eat in semi recumbent position d. increase fluid intake when eating food

C

The nurse is administering nitroglycerin, which he knows decreases preload as well as afterload. Preload refers to which of the following? a) The force of the contraction related to the sympathetic nervous system b) The amount of blood presented to the ventricles just before systole c) Fluid overload and tissue perfusion status d) The amount of resistance to the ejection of blood from the ventricles

B

The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool, which of the following characteristics would the nurse be most likely to find? a) Clay-like quality b) Black and tarry appearance c) Green color and texture d) Bright red blood in stool

B

The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? SATA a. Pallor b. Edema c. Anorexia d. Proteinuria e. Weight loss f. Decreased serum lipids

ABCD

A nurse is educating a community group about coronary artery disease. One member asks about how to avoid coronary artery disease. Which of the following items are considered modifiable risk factors for coronary artery disease? Choose all that apply. a) Tobacco use b) Hyperlipidemia c) Gender d) Race e) Obesity

ABE

A 78-year-old client has been diagnosed with right-sided heart failure from her symptomology. Her cardiologist will confirm his suspicions through diagnostics. Which of the following diagnostics are used to reveal right ventricular enlargement? Select all that apply. a) Echocardiography b) Chest radiograph c) Pulmonary arteriography d) Electrocardiogram

ACD

A patient with ulcerative colitis is scheduled for treatment with sulfasalazine. Which of the following are correct about this drug? SATA a. can cause folate deficiency b. can cause hyperchloremia c. can cause megaloblastic anemia d. can cause anaphylaxis e. can cause blindness f. can cause thrombocytopenia g. can cause kidney damage

ACDFG

A 38 year old woman was hospitalized with a diagnosis of cholecystitis. The nurse would expect the history of her present illness to include intolerance to which of the following? a. carbohydrates b. fat c. protein d. dark green vegetables

B

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities? a) Use a heating pad to promote warmth. b) Participate in a regular walking program. c) Keep the extremities elevated slightly. d) Massage the calf muscles if pain occurs

B

A client hospitalized with acute glomerulonephritis has a positive ASO titer. The nurse understands that the client's current illness is due to a: a. History of uncontrolled hypertension b. Prior bacterial infection c. Prolonged elevation of blood glucose d. Drug reaction that led to muscle breakdown

B

A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often at rest in the abscence of precipitating factors. How would the nurse best describe this type of anginal pain? a. Stable angina b. Variant angina c. Unstable angina d. Intraceable angina

B

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gater area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect? a) Arterial insufficiency b) Venous insufficiency c) Neither venous nor arterial insufficiency d) Trauma

B

A patient complains about chest pain and heavy breathing when exercising or when stressed. Which of the following is a priority nursing intervention for the patient diagnosed with coronary artery disease? a) Assess the blood pressure and administer aspirin b) Assess chest pain and administer prescribed drugs and oxygen c) Not important to assess the patient or to notify the physician d) Assess the physical history of the patient

B

Nephrotic syndrome will result in: a. decreased HCT b. decreased serum protein c. hyperglycemia d. hypercalcemia

B

Nursing care for a child admitted with acute glomerulonephritis should be directed towards: a. enforcing bed rest b. promoting diuresis c. encouraging fluids d. removing dietary salt

B

The client is admitted to the hospital with a diagnosis of acute glomerulonephritis. Which clinical manifestation would the nurse expect to find? a) Peripheral neuropathy b) Cola-colored urine c) Hypotension d) Hyperalbuminemia

B

The nurse determines that teaching for the client with peptic ulcer disease has been effective when the client states: a) "I should stop all my medications if I develop any side effects." b) "I have learned some relaxation strategies that decrease my stress." c) "I should continue my treatment regimen as long as I have pain." d) "I can buy whatever antacids are on sale because they all have the same effect."

B

A client with acute glomerulonephritis requests a snack. Which snack is suitable given the client's dietary restrictions? a. orange b. banana c. applesauce d. raisins

C

A client with ulcerative colitis is placed on Azulfidine. Which of the following instructions should be included in the nurse's teaching? a. Avoid exposure to sunlight because the drug causes sun sensitivity b. Take the medication with meals c. Continue taking the medication even when they feel well d. Take medication as prescribed because it will stop the loss of blood in the stool

C

A nurse is caring for a patient who has a diagnosis of GI bleed. During shift assessment, the nurse finds the patient to betachycardic and hypotensive, and the patient has an episode of hematemesis while the nurse is in the room. In addition to monitoring the patient's vital signs and level of conscious, what would be a priority nursing action for this patient? a) Provide the patient with ice water to slow any GI bleeding. b) Prepare for the insertion of an NG tube. c) Notify the physician. d) Place the patient in a prone position.

C

A nurse is developing a nursing care plan for a client with peripheral arterial disease. Which of the following will be the priority nursing diagnosis? a) Ineffective self-health management b) Impaired tissue integrity c) Ineffective peripheral tissue perfusion d) Ineffective thermoregulation

C

A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. The nurse suspects: a) Dehiscence of the surgical wound b) A normal reaction to surgery c) Vasomotor symptoms associated with dumping syndrome d) Peritonitis

C

A patient presents to the emergency room with characteristics of atherosclerosis. What characteristics would the patient display? a) Blood clots in the arteries b) Cholesterol plugs in the lumen of veins c) Fatty deposits in the lumen of arteries d) Emboli in the veins

C

Heparin therapy is usually considered therapeutic when the patient's activated partial thromboplastin time (aPTT) is how many times normal? a) .5 to 1 b) .25 to .75 c) 2 to 2.5 d) 2.5 to 3

C

One of your students asks what the consequences of uncorrected, left-sided heart failure would be. What would be your best response? a) Distention of the jugular vein b) Effort to lie down to breathe c) Right-sided heart failure d) Blood congestion in neck veins

C

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T tube has drained 750 ml of green brown drainage since the surgery. Which nursing intervention is most appropriate? a. Clamp the T tube b. Irrigate the T tube c. Document the findings d. Notify the HCP

C

The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool, which of the following characteristics would the nurse be most likely to find? a) Clay-like quality b) Green color and texture c) Black and tarry appearance d) Bright red blood in stool

C

The nurse is caring for a client who has just returned from the cadiac catheterization laboratory following a coronary angioplasty. Which of the following assessments will the nurse do immediately? a) Assess when the client last had a bowel movement. b) Assess for PERRLA. c) Check the temperature, color, and capillary refill of the affected extremity. d) Check the client's tolerance to ambulation to the bathroom.

C

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which of the following symptoms? a. Weight loss b. Nausea and vomiting c. Pain relieved after eating d. Pain radiating down the right arm

C

The nurse is obtaining information from a client with Crohn's disease about his medication history. What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response? a) Diuretics b) Ibuprofen (Advil) c) Corticosteroids d) Angiotensin-converting enzyme inhibitors (ACE-I)

C

The nurse is planning care for a patient following an incisional cholecystectomy for cholelithiasis. Which of the following interventions is the highest nursing priority for this patient? a) Assisting the patient to ambulate the evening of the operative day b) Performing range-of-motion (ROM) leg exercises hourly while the patient is awake c) Assisting the patient to turn, cough, and deep breathe every 2 hours d) Teaching the patient to choose low-fat foods from the menu

C

The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client? a) Low-fat diet b) Low-potassium diet c) Low-sodium diet d) Low-cholesterol diet

C

The nurse is providing discharge instructions to a client with unstable angina. The client is ordered Nitrostat 1/150 every 5 minutes as needed for angina. Which side effect, emphasized by the nurse, is common especially with the increased dosage? a) Dry mouth b) Rash c) Orthostatic hypotension d) Nausea

C

The nurse is providing discharge instructions to the client with acute post-streptococcal glomerulonephritis. Which statement by the client indicates a need for further teaching? a) "I should limit the amount of protein in my diet." b) "My intake of high sodium foods should be limited." c) "I should drink as much as possible to keep my kidneys working." d) "I should limit foods high in potassium in my diet, such as bananas."

C

The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes which of the following? a) Slowed heart rate b) Depression of the cough reflex c) Vasospasm d) Diuresis

C

The patient has had biomarkers drawn after complaining of chest pain. Which diagnostic of myocardial infarction remains elevated for as long as 3 weeks? a) Myoglobin b) CK-MB c) Troponin d) Total CK

C

The physician has prescribed hydralazine for a client with acute glomerulonephritis. Which finding indicates that the drug is having the desired effect? a. The client's appetite has improved b. Creatinine levels have returned to normal. c. The client's blood pressure has decreased d. Urinary output is amber in color

C

A nurse is preparing a patient for an endoscopic retrograde cholangiopancreatography (ERCP). The patient asks what this test is used for. Which of the following statements made by the nurse explains how an ERCP can determine the difference between pancreatitis and other biliary disorders? Select all that apply. a) It can assess for ecchymosis in the body. b) It is used in the diagnostic evaluation of acute pancreatitis. c) It can detects unhealthy tissues in the pancreas and assess for abscesses and pseudocysts. d) It can assess the anatomy of the pancreas and the pancreatic and biliary ducts. e) It can evaluate the presence and location of ductal stones and aid in stone removal.

CDE

The nurse is do patient teaching for a client with cholecystitis. What information would be considered relevant for this type of patient? SATA a. There is gradual onset of pain b. Weighing daily is required c. CBC will be ordered d. Shock wave lithotripsy will be ordered e. Fat intake will be limited f. Seizures occur intermittently g. Fatigue prevails throughout the day

CDE

A client recently started a new medication to treat a suspected ulcer. She asks the nurse how this medicine is helping. Which of the following would be the best response by the nurse regarding anti-ulcerative medications? a) "This medication helps to digest food more slowly, allowing acid to attach to the food particles." b) "The medication is allowing the acid to be eliminated more quickly in the stool." c) "This medication acts to reduce the volume of acid and foods that can enter the small intestine." d) "This medication reduces the acid secretion in your stomach."

D

A client who is scheduled for an open cholecystectomy has been smoking a pack of cigarettes a day for 20 years. For which postoperative complication is the client most at risk? a) prolonged immobility b) deep vein thrombosis c) delayed wound healing d) atelectasis

D

A client with a gastric ulcer is losing a significant amount of blood via the NG tube. The client's pulse is weak and thready, and she is hypotensive. A continuus irrigation of normal saline is ordered. How should the client be positioned? a. High fowler's b. Semi-fowlers c. Supine d. Left side lying

D

A client with a peptic ulcer is diagnosed with Heliobacter pylori infection. The nurse is teaching the client about the medications prescribed, including metronidazole (Flagyl), omeprazole (Prilosec), and clarithromycin (Biaxin). Which statement by the client indicates the best understanding of the medication regimen? a) "These medications will coat the ulcer and decrease the acid producation in my stomach." b) "I should take these medications only when I have pain from my ulcer." c) "My ulcer will heal because these medications will kill the bacteria." d) "The medications will kill the bacteria and stop the acid production."

D

A nurse is assessing a client with a diagnosis of cholecystitis. The client is becoming more jaundiced and reports clay-colored stools. Which of the following BEST explains these symptoms? a. The bile has stopped being produced b. The pancreatic duct has an obstruction c. The patient has cholelithiasis d. There is an obstruction in the common bile duct

D

A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client? a) Keep your feet elevated above your heart. b) Wear antiembolytic stockings daily to assist with blood return to the heart. c) Do not cross your legs for more than 30 minutes at a time. d) Stop smoking.

D

A nurse is teaching a patient newly diagnosed with arterial insufficiency. Which of the following terms should the nurse use to refer to leg pain that occurs when the patient is walking? a) Thromboangiitis obliterans b) Dyspnea c) Orthopnea d) Intermittent claudication

D

A patient presents to the emergency room complaining of chest pain. The patient's orders include the following elements. Which order should the nurse complete first? a) Oxygen 2 liters nasal cannula b) Troponin level c) Aspirin 325 mg orally d) 12-lead ECG

D

Pentoxifylline (Trental) is a medication used for which of the following conditions? a) Hypertension b) Elevated triglycerides c) Thromboemboli d) Claudication

D

Peptic ulcer disease occurs more frequently in people with which blood type? a) A b) AB c) B d) O

D

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain? a. Right lower quadrant, radiating to the back b. Right lower quadrant, radiating to the umbilicus c. Right upper quadrant, radiating to the left scapula and shoulder d. Right upper quadrant, radiating to the right scapula and shoulder

D

The nurse is conducting a gastrointestinal assessment. When the patient complains of the presence of mucus and pus in his stools, the nurse assesses for additional signs/symptoms of which of the following disease/conditions? a) Small-bowel disease b) Disorders of the colon c) Intestinal malabsorption d) Ulcerative colitis

D

The nurse understands that which information collected during the assessment of a child recently diagnosed with glomerulonephritis is most often associated with the diagnosis? a. Child fell off a bike onto the handlebars b. Nausea and vomiting for the last 24 hours c. Urticaria and itching for 1 week before diagnosis d. Streptococcal infection 2 weeks before diagnosis

D

Which of the following lab reports that a client with acute glomerulonephritis is improving? a. Positive ASO titer b. Increased C reactive protein c. Negative eosinophil count d. Decreased erythrocyte sedimentation rate

D