Exam 2

A 56- year-old male client at a screening event has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, the client states, "My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?" What is the nurse's best response?

"A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made."

A nurse is providing discharge instructions for a patient who has chronic obstructive pulmonary disease (COPD) with a new prescription for albuterol. Which of the following statements by the patient indicates an understanding of the teaching?

"I can have an increase in my heart rate while taking this medication."

A client has been diagnosed with prehypertension. The nurse instructs the client in lifestyle changes before leaving the clinic. The client understands the instructions when which of the following statements is made?

"I cannot change my age or gender, but if I stop smoking and increase my exercise, I can reduce my chances of developing worsening high blood pressure."

Which statement by the patient would make the nurse suspect a pulmonary embolus?

"I have sudden chest pain and feel like I am gasping for air."

The nurse is teaching the Dietary Approaches to Stop Hypertension (DASH) diet to a client diagnosed with essential hypertension. Which statement indicates that the client understands teaching concerning the DASH diet?

"I should eat at least four to five servings of vegetables a day."

A client who has been newly diagnosed with hypertension asks the nurse how long medication must be taken. The nurse knows the client requires more teaching when the client responds:

"I will stop the medication when I feel better."

A client's severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the client's statements suggests a need for further education?

"I'll make sure to use this each time I feel an asthma attack coming on."

A patient is being discharged after treatment of deep venous thrombosis. Coumadin (warfarin) 2.5 mg daily is prescribed. The nurse recognizes that which of the following statements indicates that the patient understands the effects of Coumadin?

"I'll use an electric razor to shave my legs."

A patient has been receiving oxygen per nasal cannula while hospitalized for COPD. The patient asks the nurse whether oxygen use will be needed at home. Which of the following would be the most appropriate response by the nurse?

"Oxygen will be needed when your oxygen saturation drops below 88% and you have symptoms of hypoxia."

A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation following an MI. The nurse's plan of care calls for the patient to walk for 10 minutes 3 times a day. The patient questions the relationship between walking and heart fuction. How should the nurse best reply?

"When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart."

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic therapy?

6 to 12 months

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

A client with a nasogastric tube

Which of the following should the nurse include in a plan of care for a patient with acute sinusitis?

Administer antibiotics as prescribed

The nurse is caring for a patient diagnosed with myocardial infarction (MI) who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply.

Administer morphine intramuscularly, Administer an aspirin orally, Apply oxygen via nasal cannula, Administer nitroglycerin subcutaneously

The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR of 2.8. What action should the nurse implement?

Administer the medication as ordered.

A hospital has been the site of an increased incidence of hospital acquired pneumonia (HAP). What is an important measure for the prevention of HAP?

Administration of pneumococcal vaccine to vulnerable individuals

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:

Ambulating the client as soon as possible

A patient is seen in the emergency department with acute shortness of breath, wheezing, and chest tightness, which started after exposure to a carpet-cleaning agent in her home. The nurse realizes this patient is most likely experiencing which of the following?

An acute asthma attack

When interpreting the results of a Mantoux test, to assess for tuberculosis (TB), the nurse explains to the patient that a reaction occurs when the intradermal injection site shows:

An area of redness and induration at the injection site

Which medication should the nurse expect the healthcare provider to prescribe for the patient diagnosed with peripheral arterial disease?

Antiplatelet medication

You are presenting a workshop at the senior citizens center about how the changes in aging predisposes clients to vascular occlusive disorder. What would you name the most common cause of peripheral arterial problems in the older adult?

Atherosclerosis

The nurse is planning instruction for a patient with seasonal allergic rhinitis. Which of the following should be included in this instruction?

Avoid exposure to strong perfumes, smoke and rapid changes in temperature

A patient states "I just can't stay awake in the afternoon. I don't think I sleep well at night." Which risk factors for sleep apnea would the nurse look for in the patient's history? Select all that apply.

BMI of 31.3, Impairment in the respiratory center drive, Drinks three beers every night before bedtime

A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristics signs and symptoms of asthma?

Bilateral wheezes

The nurse is caring for a client diagnosed with COPD. Which assessment data requires the nurse to intervene?

Blood-tinged sputum

A patient with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of medication right away?

Bronchodilators

The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine:

Causes vasospasm

A client's visit to the health care clinic reveals a blood pressure of 142/90. The nurse's next step would be to:

Check the client's record for the last several blood pressure readings

A middle-aged client presents to the ED reporting severe chest discomfort. Which finding is most indicative of a possible myocardial infraction (MI)?

Chest discomfort not relieved by rest or nitroglycerin

A nurse is working with a child who is undergoing a diagnostic workup for suspected asthma. What are the signs and symptoms that are consistent with a diagnosis of asthma? Select all that apply.

Chest tightness, Wheezing, Cough

The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply.

Chills, Crackles, Tachypnea

A patient with a 30-year history of cigarette smoking is seen in the clinic for a chronic cough and increasing amounts of thick sticky secretions. The nurse realizes this patient most likely is demonstrating signs of?

Chronic bronchitis

A clinic nurse is caring for a client who has just been diagnosed with chronic obstructive pulmonary disease (COPD). The client asks the nurse what he could have done to minimize the risk of contracting this disease. What should the nurse describe as the most significant modifiable risk factor?

Cigarette smoking

Which of the following is the most effective treatment for obstructive sleep apnea (OSA)?

Continuous positive airway pressure (CPAP)

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?

Coughing, deep breathing, frequent repositioning, and using an incentive spirometer

The nurse is reviewing the medication administration record of a client who takes a variety of medications for the treatment of hypertension. What potential therapeutic benefits of anti-hypertensives should the nurse identify? Select all that apply.

Decreased peripheral resistance, Decreased blood volume, Decreased strength and rate of myocardial contractions

The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise:

Decreases venous congestion

Along with persistent, crushing chest pain which sign/symptoms would make the nurse suspect that the patient is experiencing a myocardial infarction?

Diaphoresis and cool, clammy skin

Which of the following assessment findings ? in a patient with peripheral arterial disease (PAD)? Select all that apply

Diminished or absent pedal pulses, Soft, smooth skin on lower extremities, Loss of hair or diminished hair growth on lower extremities

A diabetic nurse educator is teaching a group of clients with type 1 diabetes about "sick day rules." What guidelines applies to periods of illness in a diabetic client?

Do not eliminate inulin when nauseated and vomiting

Which of these diagnostic tests would reveal findings that can diagnose an acute MI?

Electrocardiogram (ECG)

A client comes to the emergency department reporting chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see?

Elevated ST segment

A patient had labs drawn in the ED for sudden shortness of breath and abdominal pain. The nurse realizes the client had a myocardial infarction because the results from the blood work drawn show which of the following?

Elevated troponin levels

A diabetic older adult arrives at the clinic with a history of smoking, hypertension, family history of cardiac disease, COPD, and infrequent exercise. The nurse identifies which if these as the most significant risk factors for peripheral arterial disease (PAD)?

HTN and smoking

A patient is to receive Metoprolol 100mg 1 tablet by mouth daily, to treat coronary artery disease (CAD) and hypertension. Which clinical data will prompt you to hold the medication?

Heart rate of 50 bpm

A nurse is providing information about tuberculosis to a group of patients at a local community center. Which of the following symptoms should the nurse include in the teaching? Select all that apply.

Hemoptysis, Fatigue, Night sweats

A patient with exacerbation of chronic obstructive pulmonary disease (COPD) is gen IV hydrocortisone (Solu-Medrol). Which of the following side effect(s) would the nurse consider as a result of this therapy? Select all that apply.

Hyperglycemia, Hypertension, Edema

A nurse is preparing a teaching plan for a patient with hypertension. In the teaching the nurse should stress which characteristics of hypertension?

Hypertension commonly occurs without symptoms

A patient comes into the ED with complaints of dizziness, a severe headache, and blurry vision. A blood pressure is checked, and it reveals that his BP is 245/126. Based on this information, you suspect the patient is experiencing which of the following conditions?

Hypertensive crisis

Which statement indicates that a patient with diabetes mellitus understands proper foot care?

I'll wear cotton socks with well-fitting shoes

A patient is admitted to the hospital for treatment of chronic obstructive pulmonary disease (COPD). Which nursing diagnosis is most important for this patient?

Impaired gas exchange related to airflow obstruction

A client diagnosed with an myocardial infraction (MI) is being moved to the rehabilitation unit for further therapy. Which statements reflects a goal of rehabilitation for the client with an MI?

Improvement of the quality of life

Which of the following nursing interventions is the highest priority in helping a patient expectorate thick secretions related to pneumonia?

Increase fluid intake to 3L/day if tolerated

A nurse is teaching a patient about the assessment findings consistent with hyperthyroidism. The nurse identifies which of these symptoms? Select all that apply.

Increased appetite, hair thinning or loss, goiter

A client's medication regimen for the treatment of hypertension includes hydrochlorothiazide. Following administration of this medication, the nurse should anticipate what effect?

Increased urine output

Which nursing diagnosis would the nurse add to the care plan of a patient diagnosed with myocardial infarction (MI)?

Ineffective Tissue Perfusion

A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. What is the priority nursing concern with this client?

Ineffective breathing pattern

A nurse is developing a nursing care plan for a patient with peripheral arterial disease. Which of the following will be the priority nursing diagnosis?

Ineffective peripheral tissue perfusion

A nursing student is taking a pathophysiology examination. Which of the following factors would the student correctly identify as contributing to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Select all that apply.

Inflamed airways that obstruct airflow, Mucus secretions that block airways, Overinflated alveoli that impair gas exchange

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complaints of acute chest pain. What action should the nurse first take?

Initiate oxygen therapy

The nurse is caring for a patient with chronic obstructive pulmonary disease admitted with pneumonia. Which interventions would the nurse include in the teaching plan? Select all that apply.

Instruct the patient to utilize diaphragmatic purses lip breathing, Plan for periods of rest during ADLs, Administer a bronchodilator as ordered.

The nurse is planning the care for a client at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? Select all that apply.

Instructing the client to move the legs in a "pumping" exercise, Using elastic stockings, especially when decreased mobility would promote venous stasis, Applying a sequential compression device

A patient with a 30-year history of smoking tells the nurse that he can only walk a few blocks before the pain becomes severe in his lower legs. The nurse realizes this patient is describing?

Intermittent claudication

The nurse is educating a patient diagnosed with angina pectoris about the difference between the pain of angina and a myocardial infarction (MI). How should the nurse describe the pain experienced during an MI? (Select all that apply.)

It is viselike and radiates to the shoulders and arms, It is substernal in location, It is sudden in onset and prolonged in duration

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanosis, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should:

Keep the affected leg level or slightly dependent

Which of the following are appropriate nursing interventions when caring for a patient taking a thiazide diuretic for the management of hypertension and heart disease? Select all that apply.

Monitor daily weights, Record I&O's, Educate the patient on importance of following prescribed fluid restriction, Monitor for signs and symptoms of hypotension

A patient enters the emergency department complaining of chest pain that is radiating down the left arm. The emergency treatment plan for this patient include(s) which nursing actions? Select all that apply.

Morphine IV, Aspirin, Nitroglycerin tablet sublingual and oxygen

During assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to which of the following pathophysiologic changes?

Narrowing of the airway

A gerontological nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe?

Older adults often lack the classic signs and symptoms of pneumonia

A client with Raynaud's disease complains of cold and numbness in the fingers. Which of the following would the nurse identify as an early sign of vasoconstriction?

Pallor

A nurse is assessing a patient who has a history of asthma. Which of the following factors should the nurse identify as a risk factor for asthma?

Pet dander

The nurse is caring for a patient with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply.

Place the patient on oxygen delivered by nasal cannula, Plan for periods of rest during ADLs, Increase fluid intake to 2-3L per day.

A client presents to the ED experiencing symptoms of COPD exacerbation. The nurse understands that goals of therapy should be achieved to improve the client's condition. Which statements reflect therapy goals? Select all that apply.

Provide medical support for the current exacerbation, Treat the underlying cause of the event, Return the client to their original functioning abilities, Provide long-term support for medical management.

A triage team is assessing a client to determine if reported chest pain is a manifestation of angina pectoris or an MI. The nurse knows that a primary distinction of angina pain is?

Relieved by rest and nitroglycerin

The professional nurse and the nursing student are caring for a group of clients with hypertension. Which of these problems identified by the nursing student correctly identifies the client at risk for secondary hypertension?

Renal failure

The nurse is assessing a patient to learn self-administration of metered dose inhalers (MDI's) for his asthma. The nurse explains that the best way to prevent oral infection while taking this medication is to do which of the following as part of the self-administration techniques?

Rinse the mouth with water following the second puff of medication

A patient with primary hypertension is currently on an alpha-adrenergic blocker. He complains of dizziness with ambulation. The nurse assesses postural hypotension. When teaching this patient about risk associated with postural hypotension, emphasis should be placed on which of the following?

Rising slowly from a lying or sitting position

A patient with bacterial pneumonia is to be started on IV antibiotics. Which of the following diagnosis tests must be completed before antibiotic therapy begins?

Sputum culture

A nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse plans to tell the client to:

Stop smoking because it causes vasospasm

A 48-year-old man is brought to the ER with complaints of chest pain and the nurse performs an assessment. Which of the following symptoms would be most characteristic of an acute myocardial infarction?

Substernal pressure-type pain, radiating down the left arm

The nurse should include which of the following instructions when developing a teaching plan for a patient who is receiving Isoniazid and Rifampin for treatment of tuberculosis?

Take the medication as scheduled and finish until completed

A nurse is evaluating a client who had a myocardial infraction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy?

The client demonstrates ability to tolerate more activity without chest pain

The client diagnosed with essential hypertension is taking a loop diuretic daily. Which assessment data would require immediate interventions by the nurse?

The client has a weight gain of 10lbs. within 2 days

The nurse is caring for the patient diagnosed with chronic obstructive pulmonary disease (COPD). Which outcome requires a revision in the plan of care?

The patient demonstrates intolerance to activity

Which outcome is appropriate for the patient problem "ineffective gas exchange" for the patient recently diagnosed with chronic obstructive pulmonary disease (COPD)?

The patient demonstrates the correct way to pursed-lip breathe

The nurse is administering a calcium channel blocker to the patient diagnosed with coronary artery disease and hypertension. Which assessment data would cause the nurse to question administering this medication?

The patient's blood pressure is 90/58

A client with Raynaud's disease presents with symptoms of pallor of the fingers. The client states that her hands turn white, then blue, then red. The nurse instructs the client that these symptoms are a result of:

The vasospasm of the small arteries and arterioles in the hands

The nurse is providing care for a client who has been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis?

Unequal peripheral pulses between extremities

A patient is admitted with a low-grade fever, night sweats, increasing cough, blood streaked sputum, general malaise and weight loss. Which of the following should the nurse do until a diagnosis has been made for this patient?

Wear an N95 facemask when providing all patient care

An adult female experiences painful arterial spasms in her hands due to Raynaud's disease. Which of the following should the nurse include in the teaching plan for her?

Wear gloves when handling refrigerated foods

A nurse teaches a client with angina pectoris that he or she needs to take up to three sublingual nitroglycerin tablets at 5-minute intervals and immediately notify the health care provider if chest pain doesn't subside within 15 minutes. What symptoms may the client experience after taking the nitroglycerin?

headache, hypotension, dizziness, and flushing.