Exam 3 Review

A patient is admitted for an exacerbation of emphysema (COPD). The client has a fever, chills, and difficulty breathing on exertion. What is the priority nursing action based on the client's history and present status? A. Checking for capillary refill B. Encouraging increased fluid intake C. Suctioning secretions from the airway D. Administering a high concentration of oxygen

B. Encouraging increased fluid intake - replace fluid loss from fever & decrease the viscosity of secretions - nothing indicates secretions in airway presently, no high O2

The nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take? A. Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula. B. Place the client in a side-lying position and perform chest physiotherapy using clapping and vibration. C. Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. D. Assist the client in assuming a position of comfort and perform postural drainage.

C. Raise the HOB and give 2LO2 - 5L may cause further resp depression, physiotherapy can be done once stable

What is the most important information the nurse can share with a client who is just diagnosed with hypertension? A. "Continue with long-term follow-up care." B. "Monitor yourself for signs of hypertension." C. "Perform occasional blood pressure measurements." D. "Adjust your antihypertensive dose based on daily blood pressure results."

A. Hypertension can affect other body tissues, such as the kidneys and eyes; follow-up care and adherence to the therapeutic regimen (e.g., medications, diet, and exercise) are imperative. Hypertension often is asymptomatic, not symptomatic, and the client is already with hypertension. The client should maintain routine (e.g., daily, wediagnosedekly) records of blood pressure results as advised. The medication regimen should be followed exactly as prescribed; doses are adjusted by the healthcare provider.

You are completing an admission assessment on your patient, he has a known history of Parkinson's. His caregiver reports a new onset kicking of his left leg, what do you suspect? A. His disease process has progressed B. He is exhibiting normal s/s of Parkinson's C. He may have a toxic build up of his medication D. He is experiencing pain in the leg

C. He may be experiencing a toxic build up of medication - monitoring for new muscle twitch must both be as assessment and a teaching point for caregivers.

A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? A. "I am unable to run a mile (1.6 kilometers) now." B. "I wake up at night short of breath." C. "My wife says I snore very loudly." D. "My shoes seem larger lately."

C. Increased shortness of breath is often an indicator of fluid overload in the heart failure client. Being unable to run a mile (1.6 kilometers), snoring loudly, and shoes seeming larger are not as related to heart failure as waking up at night with shortness of breath.

During an assessment, the nurse shines a light into the client's eyes and observes that the pupil remains dilated. Which cranial nerve (CN) does the nurse suspect to be affected? A. CN III B. CN V C. CN VII D. CN VIII

CN III is the oculomotor nerve, which is responsible for pupillary constriction and accommodation. Damage to this nerve may result in failure of the pupils to constrict; thus the pupils will remain dilated even upon exposure to a light source. CN V is the trigeminal nerve, which is responsible for chewing. CN VII is the facial nerve; asymmetrical facial movements indicate damage to this nerve. CN VIII is the vestibulocochlear nerve; decreased hearing acuity or hearing impairment or equilibrium impairment may indicate damage to CN VIII.

A patient is being discharged with a high risk for blood clot formation, they are prescribed Warfarin. What should not be included in the discharge teaching? A. "this medication will increase your risk for bleeding" B. "you will need to avoid bananas and oranges" C. "you need to confirm with your provider before taking any medication OTC" D. "you will need to have labs drawn frequently to monitor for effective therapy"

B. "you will need to avoid bananas and oranges" - the patient needs to avoid foods high in Vitamin K - Kale, Spinach, Broccoli, Pickles, cabbage, asparagus. Bananas and oranges are avoided in patients at risk for hyperkalemia

A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient's wishes with them. The nurse is acting as the patient's: A. Educator B. Advocate C. Caregiver D. Case manager

B. Advocate

The nurse and the patient who is diagnosed with hypertension develop this goal: "The patient will select a 2-gram sodium diet from the hospital menu for the next 3 days." Which evaluation method will be best for the nurse to use when determining whether teaching was effective? A. Have the patient list substitutes for favorite foods that are high in sodium. B. Check the sodium content of the patient's menu choices over the next 3 days. C. Ask the patient to identify which foods on the hospital menus are high in sodium. D. Compare the patient's sodium intake before and after the teaching was implemented.

B. All of the answers address the patient's sodium intake, but the desired patient behaviors in the learning objective are most clearly addressed by evaluating the sodium content of the patient's menu choices.

Your patient has just returned from surgery, he reports shortness of breath and chest pain, which is the best initial action? A. Perform an ECG B. Allow him to rest C. Provide supplemental O2 D. Administer sublingual nitrogen

C. Provide supplemental O2

A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? A. "My ankles are swollen." B. "I am tired at the end of the day." C. "When I eat a large meal, I feel bloated." D. "I have trouble breathing when I walk rapidly."

D - Dyspnea on exertion often occurs with left ventricular heart failure because the heart is unable to pump enough oxygenated blood to meet the energy requirements for muscle contractions related to the activity

Which of the following should be included in the teaching plan for a patient about to begin taking Lisinopril(ACE-I)? SATA. A. Changing positions slowly B. Reporting episodes of lightheadedness to provider C. How to monitor BP & HR at home D. Eating foods high in potassium E. Reporting coughing to provider

A, B, C & E - ACE-I actually increase the risk for hyperkalemia, so an increase in potassium rich foods is not necessary

Which actions by the new RN demonstrate an understanding of delirium prevention in hospitalized patients? A. Offering a sleep mask and ear plugs B. Completing a thorough medication review C. Performing consistent pain assessments D. Administering Benadryl to promote sleep E. Performing a daily CAM-ICU assessment

A, B, C, E - administering additional medication may precipitate delirium development

A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply. A. Dependent edema B. Swollen hands and fingers C. Collapsed neck veins D. Right upper quadrant discomfort E. Oliguria

A. B. D. With right-sided heart failure, signs of systemic congestion occur as the right ventricle fails; key features include dependent edema and swollen hands and fingers. Upper right quadrant discomfort is expected with right ventricular failure because venous congestion in the systemic circulation results in hepatomegaly. Jugular venous collapse and oliguria are key features of left-sided heart failure. Left-sided heart failure is associated with decreased cardiac output.

A nurse finds that an older adult has reduced consciousness and fatigue and imagines something that is unreal. Which condition does the nurse suspect in the client? A. Delirium B. Dementia C. Depression D. Alzheimer's disease

A. Delirium is an acute confusion state where the client has reduced or disturbed consciousness, fatigue, and distorted perceptions accompanied by delusions, hallucinations, and misperceptions. Clear consciousness exists and misconceptions are usually absent in clients with dementia. Clear consciousness exists and distortions and hallucinations are only observed in severe cases of depression. Alzheimer's disease is a progressive cerebral deterioration that can occur in middle-aged or advanced age adults.

A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient? A. Risk for injury: Check on patient every 15 minutes. B. Risk for suffocation: Place "Oxygen in Use" sign on door. C. Disturbed body image: Encourage patient to express concerns about body. D. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.

A. Risk for injury: Check on patient every 15 minutes. The priority nursing diagnosis is Risk for injury. This patient could cause harm to self by interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out. Before restraining a patient, it is important to implement and exhaust alternatives to restraint.

When educating a patient, which is the best description of a TIA? A. Temporary episodes of neurologic dysfunction B. Intermittent attacks caused by multiple small clots C. Ischemic attacks that result in progressive neurologic deterioration D. Exacerbations of neurologic dysfunction alternating with remissions

A. Temporary episodes of neurologic dysfunction Narrowing of arteries supplying the brain causes temporary neurologic deficits that last for a short period. Between attacks, neurologic functioning is normal

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears a course wheeze. Which type of lung sounds will the nurse hear? A. Snorting sounds during the inspiratory phase B. Moist rumbling sounds that clear after coughing C. Musical sounds more pronounced during expiration D. Crackling inspiratory sounds unchanged with coughing

C. Musical sounds more pronounced during expiration

You enter a patients room for the AM assessment, you find the oxygen regulator set to 4L, which device should the patient be wearing? A. Non-rebreather B. Simple Mask C. Nasal Cannula D. Partial Mask

C. Nasal Cannula

Your patient has a history of hypertension, his family reports he was talking funny then became unconscious. His vitals are 98*, HR78, RR16, BP120/80. Which complication is the nurses priority? A. Injury B. Constipation C. Respiratory distress D. Decreased fluid volume

C. Respiratory Distress - the others are not life threatening

Your patient has a history of hypertension, his family reports he was talking funny then became unconscious. His vitals are 98*, HR78, RR16, BP120/80. Which below is the nurses priority? A. Injury B. Consitpation C. Respriatory distress D. Decreased fluid volume

C. Respriatory distress

The patient is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication? A. Cataracts B. Esophagitis C. Kidney failure D. Diabetes mellitus

C. Some renal impairment usually is present even with mild hypertension and is attributed to the ischemia resulting from narrowed renal blood vessels and increased intravascular pressure; decreased blood flow causes atrophy of renal structures, such as tubules, glomeruli, and nephrons, leading to kidney failure.

Which equipment is needed to assess cranial nerve X (Vagus)? A. Tuning Fork B. Ophthalmoscope C. Tongue depressor D. Cotton and Pin

C. Tongue depressor - to assess soft palate symmetry and the presence of the gag reflex. A tuning fork is used to assess cranial nerve VIII (auditory). An ophthalmoscope is used to assess cranial nerve II (optic). Cotton and a straight pin are used to assess sensory function: light touch and pain.

Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing? A. Spinal shock B. Hypovolemic shock C. Transtentorial herniation D. Increasing intracranial pressure

D. Increasing intracranial pressure

An older patient experiences a CVA and has right-sided hemiplegia and expressive aphasia. His children ask the nurse which functions will be impaired. Which abilities does the nurse explain will be affected? A. Stating wishes verbally B. Recognizing familiar objects C. Comprehending written words D. Understanding verbal communication

D. Stating wishes verbally - not recognizing familiar objects is agnosia, not comprehending written words is alexia, not understanding verbal communication is receptive aphasia

What patient response indicates to the nurse that a vasodilator medication is effective? A. Absence of adventitious breath sounds B. Increase in the daily amount of urine produced C. Pulse rate decreases from 110 to 75 beats/min D. Blood pressure changes from 154/90 to 126/72 mm Hg

D. Vasodilation will lower the blood pressure. The pulse rate is not decreased and may increase. Breath sounds are not directly affected by vasodilation, although vasodilator medications can decrease preload and afterload, which could indirectly affect breath sounds in heart failure. The urine output is not affected immediately, although control of blood pressure can help preserve renal function over time.