Exam 3- ATI & Davis Q&A

Which clinical manifestations should the nurse assess in any client diagnosed with long-term valvular heart disease? Select all that apply. 1. Paroxysmal nocturnal dyspnea 2. Orthopnea 3. Cough 4. Pericardial friction rub 5. Pulses paradoxus

1, 2, 3 Paroxysmal nocturnal dyspnea is a sudden attack of respiratory distress, usually occurring at night because of the reclining position, and occurs in Valvular disorders. Orthopnea is an abnormal condition In which a client must sit or stand to breathe comfortably and occurs in Valvular disorders. Coughing occurs when the client diagnosed with long-term valvular disease has difficulty breathing when walking or performing any type of activity

The female client is diagnosed with infective endocarditis. Which statements of clinical manifestations support the diagnosis of infective endocarditis? Select all that apply. 1. Osler's nodes 2. Chest pain. 3. Janeway lesions. 4. Splinter hemorrhages. 5. Rosacea.

1, 3,4 Osler's nodes are red, painful lesions on the pads of the fingers and toes. Osler's nodes are associated with infective endocarditis. Janeway lesions are painless lesions on the palms and souls, and are often indistinguishable from osler's nodes but both are associated with infective endocarditis. Splinter hemorrhages are tiny blood spots that appear vertically under the nails of the fingers or toes, and are associated with infective endocarditis.

The client has just had a pericardiocentesis. Which intervention should the nurse implement? Select all that apply. 1. Monitor vital signs every 15 minutes for the first hour. 2. Assess the clients heart and lung sounds. 3. Record the amount of fluid removed as output. 4. Evaluate the client cardiac rhythm. 5. Keep the client in the supine position.

1,2,3,4 The nurse should monitor the vital signs for any client after just undergoing surgery. A pericardiocentesis involves entering the pericardial sac. Assessing heart and lung sounds allows assessment for cardiac failure. The pericardial fluid is documented as output evaluating the clients. Cardiac rhythm allows the nurse to assess for cardiac failure, which is a complication of pericardiocentesis.

The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply. 1. Place the client on oxygen delivered by nasal cannula 2. Plan for periods of rest during activities of daily living. 3. Place the client on a fluid restriction of 1000 mL per day. 4. Restrict the clients smoking to two or three cigarettes per day. 5. Monitor the clients pulse oximetry readings every four hours.

1,2,5 The client diagnosed with pneumonia, will have some degree of gas exchange deficit. Administering oxygen would help the client. Activities of daily living, require energy and therefore oxygen consumption. Spacing the activities allows the client to rebuild oxygen reserves between activities. Pulse ox readings provide the nurse with an estimate of oxygenation in the periphery.

The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which clinical manifestations should the nurse expect to assess in the client? Select all that apply. 1. Confusion and lethargy. 2. High fever and chills. 3. Frothy sputum and edema. 4. Bradypnea and jugular vein distention 5. Low body temperature and cough.

1,2,5 The older adult client diagnosed with pneumonia may present with weakness, lethargy, fatigue, confusion, and poor appetite, but not have any of the classic clinical manifestations of pneumonia. Fever and chills are classic symptoms of pneumonia and can be present in the older client. Low body temperature is an atypical sign of pneumonia in older clients. Cough is a common symptom of pneumonia.

The client had open heart surgery to replace the mitral valve. Which interventions should the ICU nurse implement? Select all that apply. 1. Restrict the clients fluids as ordered 2. Keep the client in the supine position 3. Maintain oxygen saturation at 90% 4. Administer total parenteral nutrition 5. Monitor the cardiac telemetry rhythm

1,5 Fluid intake may be restricted to reduce the cardiac work load and pressures within the heart and pulmonary circuit. The client should be on continuous cardiac monitoring to assess for any irregular heart rhythm's. AFib is common in vascular disease

The nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The clients INR is 2.7. Which action should the nurse implement? 1. Administer the medication as ordered 2. Preparing to administer vitamin K 3. Hold the medication and notify the HCP 4. Assess the client for abdominal bleeding

1. Administer the medication as ordered The therapeutic range for most clients INR is 2 to 3 but for a client with a mechanical valve replacement, it is 2.5 to 3.5. The warfarin, an oral anticoagulant, should be given as ordered and not withheld

The nurse is assessing the client diagnosed with heart failure. Which laboratory data would indicate that the client is in heart failure? 1. an elevated BNP 2. An elevated CK- MB 3. A positive d-dimer 4. A positive ventilation perfusion (VQ) scan

1. An elevated BNP BMP is the specific diagnostic test to diagnose heart failure. Levels higher than normal indicate heart failure and the need for additional assessment such as echocardiography

The client is admitted to the telemetry unit diagnosed with left sided heart failure. Which clinical manifestations would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and crackles on auscultation 2. jugular vein distention and 4+ pitting edema on feet 3. The client sleeping with no pillow and eupnea 4. Radial pulse rate of 90 and CRT less than three seconds

1. Apical pulse rate of 110 and crackles on auscultation The client diagnosed with left sided heart failure with exhibit tachycardia, shortness of breath, crackles on auscultation, fatigue, third Heartsounds, and change in mental status

The client diagnosed with pericarditis is being discharged home. Which intervention should the nurse include in the discharge teaching? 1. Be sure to allow for uninterrupted rest and sleep. 2. Refer the client to outpatient occupational therapy. 3. Maintain oxygen via nasal cannula at 2L/min. 4. Discuss upcoming valve replacement surgery.

1. Be sure to allow for uninterrupted rest and sleep. Uninterrupted rest and sleep help decrease the workload of the heart and help ensure the restoration of physical and emotional health

The client is admitted to the medical unit to rule out myocarditis. Which question should the nurse ask the client during the admission interview to support this diagnosis? 1. Do you have a fever or sore throat? 2. Do you have atrial fibrillation? 3. Do you have a family history of myocarditis? 4. Do you take over-the-counter medications ?

1. Do you have a fever or sore throat? Fever, chills, and a sore throat can be symptoms of coxsackievirus in an adult, and is the most common cause of myocarditis

The client is diagnosed with acute pericarditis. Which clinical manifestation warrants immediate attention by the nurse? 1. Muffled heart sounds. 2. Non-distended jugular veins. 3. Bounding peripheral pulses 4. Pericardial friction rub.

1. Muffled heart sounds. Acute pericardial, effusion interferes with normal, cardiac filling and pumping, causing Venus congestion and decreased cardiac output. Muffled heart sounds, indicative of acute pericarditis, must be reported to the HCP.

The client is admitted to a medical unit with a diagnosis of pneumonia. Which clinical manifestations should the nurse assess in the client? 1. Pleuritic chest discomfort and anxiety 2. Asymmetrical chest expansion and pallor 3. Leukopenia and CRT less than 3 seconds 4. Substernal chest pain and diaphoresis

1. Pleuritic chest discomfort and anxiety from diminished oxygenation occur along with fever, chills, dyspnea, and cough

The client diagnosed with pericarditis is experiencing cardiac tamponade. Which collaborative intervention should the nurse anticipate for this client? 1. Prepare for a pericardiocentesis. 2. Request stat cardiac enzymes. 3. Perform a 12 lead electrocardiogram 4. Assess the clients heart and lungs sounds

1. Prepare for a pericardiocentesis. A pericardiocentesis removes fluid from the pericardial sac, and is the emergency treatment for cardiac tamponade

The nurse on the telemetry unit has just received the morning shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction with an audible S3 heart sound 2. The client diagnosed with right sided heart failure with 4+ sacral pitting edema 3. A client diagnosed with pneumonia with a pulse ox reading of 94% 4. The client diagnosed with chronic renal failure with an elevated creatinine level

1. The client diagnosed with MI with an audible S3 heart sound An S3 heart sound indicates left sided heart failure, and the nurse must assess this client first because it is an emergency situation

A client is being seen in the clinic to rule out mitral valve stenosis. Which assessment data would be most significant? 1. The client reports shortness of breath when walking. 2. The client has jugular vein distention and 3+ Pedal edema. 3. The client reports chest pain after eating a large meal. 4. The clients liver is enlarged and the abdomen is edematous.

1. The client reports shortness of breath when walking dyspnea on exertion is typically the earliest manifestation of mitral valve stenosis

The nurse is developing a discharge teaching plan for the client diagnosed with heart failure. Which intervention should be included in the plan. Select all that apply. 1. Notify the HCP of a weight gain of more than one pound in a week 2. Teach the client how to count the radial pulse when taking digoxin 3. Instruct the client to remove the salt shaker from the dinner table 4. Encourage the client to monitor your an output for a change to dark color 5. Discuss the importance of taking furosemide at bedtime

2 & 3 The client should not take digoxin, a cardiac glycoside, if the radial pulse is less than 60. The client should be on a low sodium diet to prevent water retention.

The HCP has ordered and angiotensin converting enzyme (ACE) Inhibitor for the client diagnosed with heart failure. Which discharge instructions should the nurse include? Select all that apply. 1. Instruct the client to take a cough suppressant if a cough develops 2. Teach the client how to prevent orthostatic hypotension 3. Encourage the client to eat bananas to increase potassium levels 4. Explain the importance of taking medication with food 5. Tell the client to avoid the use of NSAIDs

2,5 orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation. Therefore, the nurse should instruct the client to rise slowly and sit on the side of the bed until equilibrium is restored. ACE inhibitors taken with NSAIDs can cause an adverse effect in the kidneys and decrease the antihypertensive benefits of the ACE inhibitor

Which client would the nurse suspect of having a mitral valve prolapse? 1. A 60 year old female with heart failure 2. A 23-year-old male with Marfan's syndrome 3. A 80-year-old male with afib 4. A 33-year-old female with down syndrome

2. 23-year-old male with Marfan's syndrome clients with Marfan's syndrome have life-threatening cardiovascular problems, including mitral valve prolapse, progressive dilation of the aortic valve ring, and weakness to the arterial walls, and they usually do not live past age 40 because of dissection and rupture of the aorta

Which potential complication should the nurse assess for in the client diagnosed with infective endocarditis with embolization of vegetative lesions from the mitral valve? 1. Pulmonary embolism 2. Cerebrovascular accident. 3. Hemoptysis 4. Deep vein thrombosis.

2. Cerebrovascular accident. bacteria enter the bloodstream from invasive procedures, and sterile platelet fiber vegetation forms on the heart valves. The mitral valve is on the left side of the heart, and if the vegetation breaks off, it will go through the left ventricle into the systemic circulation, and may lodge in the brain, kidneys, or peripheral tissues.

Which assessment data would the nurse expect to auscultation in the client diagnosed with mitral valve regurgitation? 1. Allowed S1, S2 split, and a mitral opening snap 2. Holosystolic murmur heard best at the cardiac Apex 3. A midsystolic ejection click or murmur heard at the base 4. A high-pitched sound heard at the third intercostal space

2. Holosystolic murmur heard best at the cardiac Apex The murmur associated with mitral valve regurgitation is loud, high pitched, blowing, and holosystolic, which means occurring throughout systole. It is heard best at the cardiac Apex

The 56-year-old client diagnosed with tuberculosis is being discharged. Which statement made by the client indicates an understanding of the discharge instructions? 1. I will take my medication for the full three weeks prescribed. 2. I must stay on the medication for months if I am to get well. 3. I can be around my friends because I have started taking antibiotics. 4. I should get a TB skin test every three months to determine if I am well.

2. I'm a stay on the medication for months if I am to get well. Compliance with treatment plans for TB includes multi drug therapy for six months to one year for the client to be free of of the TB bacteria

The client diagnosed with chronic heart failure is reporting leg cramps at night. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day 2. Monitor the clients potassium level and assess the client intake of bananas and orange juice 3. Determine if the client has gained weight and instruct the client to keep the legs elevated 4. Instruct the client to ambulate frequently and perform calf muscle stretching exercises daily

2. Monitor the clients potassium level and assess the client intake of bananas an orange juice The most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium

The client diagnosed with infective endocarditis is admitted to the medical department. Which HCP order should be implemented first? 1. Administer intravenous antibiotics. 2. Obtain blood cultures times two. 3. Schedule an echocardiogram. 4. Encourage bedrest with bathroom privileges.

2. Obtain blood cultures times two. Blood cultures must be done before administering antibiotics, so that an adequate number of organisms can be obtained to culture and identify

The client diagnosed with pericarditis is reporting increased pain. Which intervention should the nurse implement first? 1. Administer oxygen via nasal cannula 2. Evaluate the clients urinary output. 3. Assess the client for cardiac complications 4. Encourage the client to use the incentives spirometer.

3. Assess the client for cardiac complications. The nurse must assess the client to determine if the pain is expected, secondary to pericarditis, or if the pain is indicative of a complication that requires intervention from the HCP

The client diagnosed with pericarditis is prescribed an NSAID. which teaching instruction should the nurse discuss with the client? 1. Explain the importance of tapering off the medication. 2. Discuss that the medication will make the client drowsy. 3. Instruct the client to take the medication with food. 4. Tell the client to take the medication when the pain level is around 8

3. Instruct the client to take the medication with food. NSAIDs must be taken with food, milk, or antacids to help decrease, gastric distress. NSAIDs reduce fever, inflammation, and pericardial pain

The client diagnosed with community acquired pneumonia is being admitted to the medical unit. Which priority nursing intervention has the highest priority? 1. Administer the oral antibiotic immediately. 2. Order the meal try to be delivered as soon as possible. 3. Obtain a sputum specimen for culture and sensitivity. 4. Have the UAP the client.

3. Obtain a sputum specimen for culture and sensitivity. specimens for culture are taken before beginning the medication to determine the antibiotic that will affectively treat an infection. Administering antibiotics before culture may make it impossible to determine the actual agent causing the pneumonia.

The nurse is assessing the client diagnosed with heart failure. Which clinical manifestations would indicate that the medical treatment has been effective? 1. The clients peripheral pitting edema has gone from a 3+ to 4+ 2. The client is able to take the radial pulse accurately 3. The client is able to perform activities of daily living without dyspnea 4. The client has minimal jugular vein distention

3. The client is able to perform activities of daily living without dyspnea Being able to perform ADLs without shortness of breath would indicate the clients condition is improving. The clients heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs.

The client has just received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching? 1. The client takes prophylactic antibiotics 2. The client uses a soft bristle toothbrush 3. The client takes an enteric coated acetylsalicylic acid daily 4. The client alternates rest with activity

3. The client takes an enteric-coated acetylsalicylic acid daily ASA and NSAIDs interfere with clotting and may potentiate the effects of anticoagulant therapy, which the client with a mechanical valve will be prescribed. Therefore the client should not take aspirin daily

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with chronic heart failure being discharged in the morning 2. The client having frequent incontinent liquid bowel movements and vomiting 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62 4. The client reporting chest pain on inspiration and a nonproductive cough

3. The client with an apical pulse rate of 116, RR of 26, BP of 94/62 This client is exhibiting clinical manifestations of shock, which makes this client the most unstable. An experienced nurse should care for this client

The employee health nurse is administering tuberculin skin testing to employees exposed to a client diagnosed with active tuberculosis. Which statement indicates the need for radiological evaluation instead of skin testing? 1. The first skin test indicates a flat purple area at the site of injection. 2. The client skin test indicates a red area measuring 4 mm 3. The clients previous skin test was read as positive. 4. The client has never shown a reaction to the tuberculin medication

3. The clients previous skin test was read as positive. if the client has ever reacted positively, then the client should have a CXR to look for causation and inflammation

Which nursing diagnosis would be a priority for the client diagnosed with myocarditis? 1. Anxiety related to possible long-term complications. 2. High risk for injury related to antibiotic therapy. 3. Increased cardiac output related to valve regurgitation. 4. Activity intolerance related to impaired cardiac muscle function

4. Activity intolerance related to impaired cardiac muscle function. Activity intolerance is the priority for the client diagnosed with myocarditis, and inflammation of the heart muscle. Nursing care is aimed at decreasing myocardial work and maintaining cardiac output.

The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of impaired gas exchange. Which is an expected outcome for this problem? 1. Performs chest physiotherapy three times a day. 2. Able to complete activities of daily living. 3. Ambulates in the hall several times during each shift. 4. Alert and oriented to person, place, time, and events.

4. Alert and oriented to person, place, time, and events. Impaired gas exchange results in hypoxia, the earliest clinical manifestation of which is a change in the level of consciousness

The nurse enters the room of the client diagnosed with heart failure. The client is lying in bed gasping for breath, is cooling clammy, and has buccal cyanosis. Which intervention with the nurse implement first? 1. Sponge the clients forehead 2. Obtain a pulse oximetry reading 3. Take the clients vital signs 4. Assist the client to a sitting position

4. Assist the client to a sitting position The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse will take vital signs and check the pulse oximeter and then sponge the clients forehead.

The nurse and the UAP are caring for four clients on a telemetry unit. Which nursing task would be best for the RN to delegate to the UAP? 1. Assist the client to go down to the smoking area for a cigarette 2. transport the client to the ICU via a stretcher 3. provide the client going home discharge teaching instructions 4. help position the client having a portable x-ray done

4. Help position the client having a portable x-ray done The UAP can assist the x-ray technician and positioning the client for the portable x-ray. This does not require judgment

The client just had a percutaneous transluminal balloon valvuloplasty, PTBV, and is in the recovery room. Which interventions to the post anesthesia care nurse implement? 1. Assess the client chest tube output 2. Monitor the client chest dressing 3. Evaluate the clients endotracheal lip line 4. Keep the clients affected leg straight

4. Keep the clients affected leg straight PTBV, an invasive procedure, is performed in a cardiac catheterization laboratory, and the client has a catheter inserted into the femoral artery. Therefore the client must keep the leg straight to prevent hemorrhaging at the insertion site

The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with heart failure. Which intervention should the nurse implement to assist the client in achieving this outcome? 1. Measure the intake and output 2. Provide 2G sodium diet 3. Weigh the client daily 4. Plan for frequent rest periods

4. Plan for frequent rest periods scheduling activities and rest. Allows the client to participate in the care and address the desired outcome

The nurse is teaching a class on valve replacements. Which statement identifies the disadvantage of having a biological tissue valve replacement? 1. The client must take a life long anticoagulant therapy 2. The clients infections are easier to treat 3. There is a low incidence of thromboembolism 4. The valve Has to be replaced frequently

4. The valve Has to be replaced frequently biological valves deteriorate and need to be replaced frequently; this is a disadvantage of them. Mechanical valves do not deteriorate and do not have to be replaced often

A nurse is admitting a client who is experiencing an exacerbation of HF. At which of the following times should the nurse initiate d/c planning? A. During admission process B. As soon as client's condition is stable C. During initial team conference D. On the day prior to d/c

A. During the admission process this is intended to ensure continuity of care and meet client's care needs. This process should include each member of clients health care team.

A nurse is assessing a client who has heart failure and is taking daily furosemide. The client 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. The Manifestations of hypokalemia include shallow respirations, muscle weakness, lethargy, and ectopic heartbeats

A nurse is caring for a client with HF whose telemetry reading displays a flattening T wave. Which of the following lab results should the nurse anticipate as the cause of this ECG change? A. Potassium 2.8 B. Digoxin 0.7 C. Hemoglobin 9.8 D. Calcium 8.0

A. Potassium 2.8 a flattened t wave or the development of U waves is indicative of a low potassium level

A nurse is providing teaching to a client with HF about reducing his daily sodium intake. Which of the following factors is the most important in determining the clients ability to learn new dietary habits? A. The involvement of the client in planning the change B. The emphasis the provider places on the dietary changes C. The learning theory the nurse uses to teach the dietary changes D. The extent of dietary changes planned for the client

A. The involvement of the client in planning the change Rationale According to evidence based practice, client involvement in planning dietary changes is the most important factor in the clients ability to learn new habits

A nurse is reviewing the menu selections of a client who has HF and anticipates to d/c home the following day. Which of the following lunch choices should the nurse identify as an indication that the client understands his dietary instructions? A. Turkey on whole wheat bread B. Hamburger and French fries C. Frankfurter on a white roll D. Macaroni and cheese

A. Turkey on whole wheat the primary dietary alteration for a client with HF is sodium restriction. A turkey sandwich on whole wheat is relatively low sodium content.

A nurse is completing dietary teaching with a client who has heart failure and is prescribed a 2G sodium diet. Which of the following statements by the client indicates an understanding of the teaching? A. "I should use salt sparingly while cooking" B. " I can have yogurt as a dessert" C. " I should use baking soda when I bake" D. " I should use canned vegetables instead of frozen"

B. " I can have yogurt as a dessert" The client understands the teaching when he selects yogurt as a dessert. Yogurt is low in fat and sodium and has a good source of calcium and protein

A nurse is assessing a client who has left sided HF. Which of the following findings should the nurse expect? A. Pitting peripheral edema B. Crackles in the lung bases C. JVD D. Hepatomegaly

B. Crackles in the lung bases L sided HF precipitates pulmonary congestion and edema, causing crackles in the lungs

A nurse is caring for an older adult client who has aspiration pneumonia. Which of the following age related changes contributes to the development of aspiration pneumonia? A. Decreased gastric secretions B. Diminished cough reflex C. Decreased sense of smell D. Degenerative joint changes

B. Diminished cough reflex could lead to possible aspiration, which can lead to pneumonia.

A nurse is providing discharge, teaching to an adult female client who has infective endocarditis about how to prevent reoccurrence. Which of the following statements by the client indicates an understanding of the teaching? 1. I will ask my provider to change my contraception to an intrauterine device. 2. I will notify my doctor before I have dental procedures. 3. I will avoid using antiseptic mouthwash for oral care. 4. I will wear a mask when I go out in public.

B. I will notify my doctor before I have dental procedures. The nurse should inform the client of ways to decrease the risk of reoccurrence of infective endocarditis. The client should notify the provider prior to invasive or dental procedures due to the need for prophylactic antibiotic therapy to reduce the risk of a streptococcal infection

A nurse is monitoring a client who has HF related to mitral stenosis. The client reports SOB on exertion. Which of the following conditions should the nurse expect? A. Increased CO B. Increased pulmonary congestion C. Decreased left atrial pressure D. Decreased pulmonary artery pressure

B. Increased pulmonary congestion pulmonary congestion is a manifestation of mitral valve stenosis. B/c of the defect in the mitral valve, the L atrial pressure rises and the left atrium dilates. The increased pressure results on a back-flow of blood from the L atrium through the pulmonary vein and into the lungs resulting in pulmonary congestion

A nurse is providing teaching to a client with a new prescription for furosemide. Which of the following statements should the nurse include in the teaching? A. "You can take ibuprofen for headaches while taking this medication" B. "You may experience increased swelling in your lower extremities while taking this medication" C. "You should eat foods high in K+ while taking this medication" D. "You should take this medication at bedtime"

C furosemide is a high ceiling loop diuretic that depletes K+, chloride, magnesium, and water.

A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following action should the nurse take first? A. Provide chest physiotherapy B. Perform oropharyngeal suction C. Encourage deep breathing and coughing D. Assist the client with ambulation

C clears secretions from airways

A nurse is admitting an older adult client with pneumonia. The clients daughter, who says to the nurse,"I'm so glad he is here. You can take much better care of him than I can." Which of the following responses should the nurse make? A. I am sure you have been taking good care of your father B. We have the equipment to take care of sick clients C. Caring for an older parent isn't easy D. Are you feeling guilty because your father has pneumonia?

C the nurse is offering empathy by letting the daughter know that she understands her situation and will offer help.

A nurse is caring for an older adult client who has pneumonia. Which of the following physiological changes associated with aging places the client at risk of pneumonia? A. Decreased anterior-posterior diameter B. Increased diameter of small airways C. Decreased number of cilia D. Increased alveolar surface area

C this along with less effective cough, reduces efficiency of normal defense mechanisms for clearing airway, putting client at increased risk of infection like pneumonia

Using high-quality monitoring tools, a facility committee identifies that clients who have congestive heart failure have an average length of stay of 5 days instead of the established standard of 3 days. Which step should the nurse implement next in the quality-improvement process? A. Educate staff members on shortening the length of stay for these clients B. Collect data regarding the length of stay for these clients C. Determine which actions can be instituted to address this problem D. Research the accuracy of the standard of care that has been accepted

C. Determine which actions can be instituted to address this problem Further analysis of data will identify factors that contribute to longer lengths of stay. Identifying actions to shorten the client's lengths of stay is the next step in the process.

A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? 1. Bradycardia with ST segment depression. 2. Relief of chest pain with deep inspiration. 3. Dyspnea with hiccups 4. Chest pain that increases when sitting upright.

C. Dyspnea with hiccups. A client who has pericarditis will experience, dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade.

A nurse is assessing an older adult client who has R sided HF. Which of the following findings is the nurses priority? A. The clients SpO2 is 92% on room air B. The client consumes 20% of her meals C. The client's weight increased by 0.91kg (2lbs) in 24 hrs D. The client has 1+ edema in the lower extremeties

C. The clients weight increased by 0.91 lbs in 24 hrs indictaion of worsening HF

A nurse is caring for a client who has HF and is taking oral furosemide 40mg daily. For which of the following side effects should the client be taught to monitor and notify provider if it occurs A. Nasal congestion B. Tremors C. Tinnitus D. Frontal headache

C. Tinnitus loop diuretics like furosemide can cause ototoxicity. Client should be taught to notify HCP if tinnitus, a full feeling in the ears, or hearing loss occurs

A nurse is assessing a client who has HF 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 nurse should recognize that N/V, abd discomfort, fatigue, and visual disturbances are common manifestation that can indicate client is experiencing digoxin toxicity

A nurse is providing discharge teaching to a client who has HF and a prescription for digoxin 0.125 mg PO daily and furosemide 20mg 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 in my diary" C. "I will skip a dose of my digoxin if my resting HR is below 72 bpm" D. "I will eat fruits and vegetables that have high potassium content every day"

D. "I will eat fruits and vegetables that have high potassium content every day" Hypokalemia is an adverse effect of diuretic therapy. B/c the client is taking digoxin it is important to maintain K+ levels between 3.5-5 to avoid digoxin toxicity.

A nurse in a providers office is assessing a client who has HF. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess? A. Sunken eyeballs B. Hypotension C. Poor skin turgor D. Bounding pulses

D. Bounding pulse a bounding pulse is an expected finding of fluid volume excess

A nurse is teaching a 70-year-old client about risk factors for heart failure. The client has mild asthma, diabetes, 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. 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 hyper thyroidism

A nurse is assessing a client who has right sided heart failure. Which of the following findings should the nurse expect? A. Decreased capillary refill B. Dyspnea C. Orthopnea D. Dependent edema

D. Dependent edema Rationale Blood return from the venous system to the R atrium is impaired by a weakened R heart. The subsequent systemic venous backup leads to the development of dependent edema

The nurse is providing teaching to a client who has heart failure and is taking spironolactone. Which of the following statements by the client indicates an understanding of the teaching? A. " I will increase my intake of citrus fruits, bananas, and potatoes." B. "I will use salt substitutes on my food" C. " I will drink as much water as I can while taking this medication" D. " I will watch for increased breast tissue growth while taking this medication"

D. I will watch for increased breast tissue growth while taking this medication spironolactone, which is derived from steroids, can cause adverse endocrine effects such as gynecomastia, impotence in men, and irregular menses and hirsutism in women

A nurse is caring for a client who has HF and is prescribed dobutamine hydrochloride by continuous IV infusion. The nurse should identify that which of the following is the theraputic effect of this medication? A. Improves O2 saturation rate B. Decreases elevated BP C. Reduces HR D. Improves CO

D. Improves CO dobutamine is a vasopressin that improves CO and hemodialysis status in clients.

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? 1. Fifth intercostal space just medial to the midclavicular line 2. Second intercostal space to the left of the sternum. 3. Fifth intercostal space to the left of the sternum. 4. Second intercostal space to the right of the stern.

D. Second intercostal space to the right of the sternum. The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a mid systolic injection murmur that can be clearly heard at the aortic area with the client. Client leaning forward.

A nurse is showing a client who has right sided HF an illustration of the heart. Which of the following blood vessels carry deoxygenated blood to the right atrium? A. Right coronary artery B. Left carotid artery C. Aorta D. Superior vena cava

D. Superior vena cava the nurse should identify that the superior and inferior vena cava carry deoxygenated blood to the right atrium

The nurse observes the UAP entering an airborne isolation room and leaving the door open. Which action is the RN's best response? 1. Close the door and discuss the UAP's action after coming out of the room 2. Make UAP come back outside the room and then reenter, closing the door 3. Say nothing to UAP but report incident to nursing supervisor 4. Enter the client's room and discuss the matter with UAP immediately

1 closing door reestablishes neg air pressure preventing air from entering hall and contaminating environment. It is also good to handle matters in private.

The client with a mechanical valve replacement ask the nurse, "why do I have to take antibiotics before getting my teeth cleaned?" Which response by the nurse is most appropriate? 1. You are at risk of developing an infection in your heart 2. Your teeth will not bleed as much if you have antibiotics 3. The procedure may cause your valve to malfunction 4. Antibiotics will prevent vegetative growth on your valves

1. you are at risk of developing an infection in your heart The client is at risk for developing endocarditis and should take prophylactic antibiotics before any invasive procedure

The RN charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate just having completed orientation to the medical floor? 1. The client admitted for diagnostic tests to rule out valvular heart disease 2. The client three days post MI being discharged tomorrow 3. The client exhibiting supraventricular tachycardia on telemetry 4. The client diagnosed with atrial fibrillation with an INR of five

2. The client three days post MI being discharged tomorrow because this client is being discharged, it would be an appropriate assignment for the new graduate

The nurse is developing a nursing care plan for a client diagnosed with left-sided heart failure. A nursing diagnosis of "decreased cardiac output related to the inability of the heart to pump effectively" is written. Which short term goal would be the best for the client? 1. The client will be able to ambulate in the hall by the date of discharge 2. The client will have an audible S1 and S2 with no S3 heard by the end of shift 3. The client will turn, cough, and deep breathe every two hours 4. The client will have an SPO2 reading of 98% by day two of care

2. The client will have an audible S1 and S2 with no S3 heard by the end of shift Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure, which could be life-threatening.

The nurse is feeding a client diagnosed with aspiration pneumonia. The client becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention, should the nurse implement first? 1. Suction the client nares 2. Turn the client to the side. 3. The client in the Trendelenburg position. 4. Notify the healthcare provider.

2. Turn the client to the side. Turning the client to the side allows for the food to be coughed up or come out of the mouth, rather than be aspirated into the lungs

The day shift nurse on a medical unit is making rounds after shift report. Which client should be seen first? 1. 65 yo client with diagnosed with tuberculosis has a sputum specimen to be sent to the lab 2. 76 yo client diagnosed with aspiration pneumonia has a clogged feeding tube 3. 45 yo client diagnosed with pneumonia who has a pulse ox reading of 92% 4. 39 yo client diagnosed with bronchitis has an arterial oxygenation level of 89%

3 pulse ox reading of 92% means arterial blood oxygen saturation is somewhere around 60-70%

The client is admitted with a diagnosis of rule out tuberculosis. Which type of isolation procedures should the nurse implement? 1. Standard 2. Contact 3. Droplet 4. Airborne

4. Airborne Tuberculosis bacteria are capable of disseminating over long distances on air currents. Clients diagnosed with tuberculosis are placed in negative air pressure rooms where the air in the rooms where the air in the room is not allowed to cross contaminate the air in the hallway

The client is diagnosed with pericarditis. Which are the most common clinical manifestations the nurse would expect to find when assessing the client? 1. Pulsus paradoxes. 2. Reports of fatigue and arthralgias 3. Petechiae and splinter hemorrhages. 4. Increased chest pain with inspiration.

4. Increased chest pain with inspiration. Chest pain is the most common symptom of pericarditis, usually has an abrupt onset, and is aggravated by respiratory movements, like deep inspiration, and coughing changes and body position, and swallowing

The client is being evaluated for valvular heart disease. Which information would be most significant? 1. The client has a history of CAD 2. There is a family history of valvular heart disease 3. The client has a history of smoking for 10 years 4. The client has a history of rheumatic heart disease

4. The client has a history of rheumatic heart disease Rheumatic heart disease is the most common cause of valvular heart disease

A nurse is assessing a client who has late-stage HF and is experiencing fluid volume overload. Which of the following findings should the nurse expect? A. Weight gain of 1kg (2.2 lbs) in 1 day B. Pitting edema +1 C. Client report of nocturnal cough D. B-type natriuretic peptide (BNP) level of 100 pg/mL

A. Weight gain of 1kg in 1 day indicates that the client is retaining fluid and is at risk of fluid volume overload. This suggests that the clients HF is worsening.

A nurse is reviewing the progress notes for a client who has HF. The provider noted some improvement in the client's CO. The nurse should understand that CO reflects which of the following physiologic parameters? A. Percentage of blood the ventricles pump during each beat B. Amount of blood the left ventricle pumps during each beat C. Amount of blood in the left ventricle at the end of diastole D. The HR x SV

D. The HR x SV CO is the product of client's heart rate and stroke volume (the amount of blood the left ventricle pumps with each contraction). In systolic HF, the heart cannot pump enough oxygenated blood into the circulation, causing CO to decrease.

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 anti-emetic C. Inform the clients provider D. Check the clients apical pulse

D. Check the clients apical pulse nausea, anorexia, fatigue, visual effects, and cardiac dysrhythmias (often caused by a slow pulse rate) are possible findings of 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 build 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 status, the nurse must first collect adequate data from the client. Assessing will provide the nurse with a knowledge to make an appropriate decision.