HIM Exam 3

A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this clients teaching?

Gather everything you need for a chore before you begin.

A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority?

Assess distal pulses and skin color.

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next?

Assess for symptoms of left-sided heart failure.

A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?

Assess the clients respiratory rate, rhythm, and depth.

A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?

Assess the clients respiratory status.

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best?

Assist in finding one change the client can control.

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess?

Atrial fibrillation

A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this clients discharge teaching?

Avoid large crowds and people who are sick.

A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this clients teaching?

Avoid using salt substitutes.

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the clients understanding. Which food choice for lunch indicates the client correctly understood the teaching?

Grilled chicken breast with glazed carrots

A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply.)

Hematocrit: 32.8% Serum sodium: 130 mEq/L Proteinuria Microalbuminuria

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.)

Hypokalemia Flaccid paralysis with respiratory depression Hyponatremia Decreased level of consciousness

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left- sided heart failure?

I must stop halfway up the stairs to catch my breath.

After providing discharge teaching, a nurse assesses the clients understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching?

I take sodium bicarbonate after every meal to prevent heartburn.

After teaching a client who was malnourished and is being discharged, a nurse assesses the clients understanding. Which statement indicates the client correctly understood teaching to decrease risk for the development of metabolic acidosis?

I will eat three well-balanced meals and a snack daily.

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the clients understanding. Which client statement indicates a need for additional teaching?

I will have my teeth cleaned by my dentist in 2 weeks.

After teaching a client who is being treated for dehydration, a nurse assesses the clients understanding. Which statement indicates the client correctly understood the teaching?

I will weigh myself each morning before I eat or drink.

After teaching a client with congestive heart failure (CHF), the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.)

Ill read the nutritional labels on food items for salt content. I will eat oatmeal for breakfast instead of ham and eggs. Substituting fresh vegetables for canned ones will lower my salt intake.

A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism?

Increased rate and depth of respirations

After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client?

Instruct the client to ask for assistance when rising from bed.

A nurse is planning care for a client who is anxious and irritable. The clients arterial blood gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L. Which questions should the nurse ask the client and spouse when developing the plan of care? (Select all that apply.)

Is your spouses current behavior typical? Do you drink any alcoholic beverages?

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best?

Measure for new compression stockings.

A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid-base imbalance? (Select all that apply.)

Metabolic acidosis Older adult who is following a carbohydrate-free diet Respiratory alkalosis Client on mechanical ventilation at a rate of 28 breaths/min Metabolic alkalosis Older client prescribed antacids for gastroesophageal reflux disease

A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy?

Metabolic alkalosis

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?

Most people with hypertension do not have symptoms.

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care?

My hands shake when I try to do things requiring coordination.

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure?

My shoes fit really tight lately.

A client is taking warfarin (Coumadin) and asks the nurse if taking St. Johns wort is acceptable. What response by the nurse is best?

No, it may interfere with the warfarin.

A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best?

No, women should only have one beer a day as a general rule.

A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority?

Notify the Rapid Response Team.

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met?

Oxygen saturation of 98%

A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene?

Palpating both carotid arteries at the same time

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal?

Participate in blood pressure screenings at the mall.

A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects related to an acid-base imbalance should the nurse assess? (Select all that apply.)

Positive Chvosteks sign Anxiety and irritability

A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first?

Prepare to administer dextrose 20% and 10 units of regular insulin IV push.

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.)

Pulmonary crackles Confusion, restlessness Cough that worsens at night

A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this clients teaching?

Read food labels to determine sodium content.

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply.)

Reposition the client every 2 hours. Accurately record intake and output. Use the same scale to weigh the client each morning.

After teaching a client to increase dietary potassium intake, a nurse assesses the clients understanding. Which dietary meal selection indicates the client correctly understands the teaching?

Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)

Serum potassium level of 5.4 mEq/L Blood osmolality of 250 mOsm/L

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.)

Shortness of breath Abdominal bloating New-onset bradycardia

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement?

Sit the client up with a pillow to lean forward on.

A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive?

Sodium bicarbonate 100 mEq diluted in 1 L of D5W

After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all that apply.)

Strong productive cough Active bowel sounds

A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.)

Teach the client about dietary restrictions. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. Confirm that an echocardiogram has been completed.

The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning?

Triglycerides: 198 mg/dL

A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.)

Use a draw sheet to reposition the client in bed. Provide nonslip footwear for the client to use when out of bed.

A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this clients discharge teaching?

Weigh yourself daily while wearing the same amount of clothing.

A nurse cares for a client with right-sided heart failure. The client asks, Why do I need to weigh myself every day? How should the nurse respond?

Weight is the best indication that you are gaining or losing fluid.

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, I know a transplant is my last chance, but I dont want to become a vegetable. How should the nurse respond?

Would you like information about advance directives?

A nurse cares for an older adult client with heart failure. The client states, I dont know what to do. I dont want to be a burden to my daughter, but I cant do it alone. Maybe I should die. How should the nurse respond?

Would you like to talk more about this?

A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing this clients plan of care?

You appear anxious. What is causing your distress?

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, Why is this important? How should the nurse respond?

Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes.

A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?

A 34-year-old on NPO status who is receiving intravenous D5W

A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.)

A 36-year-old who is malnourished A 42-year-old with uncontrolled diabetes A 76-year-old who is prescribed antacids

A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure?

A 36-year-old woman with aortic stenosis

A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.)

A 36-year-old woman with systemic lupus erythematosus (SLE) A 42-year-old man recovering from coronary artery bypass graft surgery An 80-year-old man with a bacterial infection of the respiratory tract

A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration?

A 76-year-old who is cognitively impaired

A nurse is working with a client who takes atorvastatin (Lipitor). The clients recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?

Ask if the client eats grapefruit.

A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next?

Assess clients rate, rhythm, and depth of respiration.

A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take?

Administer PRN acetaminophen.

A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results?

Anxiety-induced hyperventilation

A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss?

Anxious client who has tachypnea

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?

Apply a warm moist pack.

A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?

Apply oxygen by mask or nasal cannula.

A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection?

Appropriate hand hygiene before giving care

A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the clients heart failure?

Are you able to walk upstairs without fatigue?

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this clients safety prior to discharging home? (Select all that apply.)

Are your bedroom and bathroom on the first floor? What social support do you have at home? What spiritual beliefs may impact your recovery?

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?

Baked chicken breast, broccoli, tomatoes

A client at risk for developing hyperkalemia states, I love fruit and usually eat it every day, but now I cant because of my high potassium level. How should the nurse respond?

Berries, cherries, apples, and peaches are low in potassium.

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, Why will I need to take anticoagulants for the rest of my life? How should the nurse respond?

Blood clots form more easily in artificial replacement valves.

A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess?

Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg

A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these values?

Bronchial obstruction related to aspiration of a hot dog

A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met?

Distal pulse on affected extremity 2+/4+

A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first?

Cardiac rate and rhythm

A nurse is caring for four clients. Which one should the nurse see first?

Client who had a first dose of captopril (Capoten) and needs to use the bathroom

A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia?

Client with pancreatitis who has continuous nasogastric suctioning

A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information?

Could you walk further than that a few months ago?

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this clients teaching?

Do not take this medication within 1 hour of taking an antacid.

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.)

Electrocardiogram changes Paralytic ileus Skeletal muscle weakness

A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find?

Friction rub at the left lower sternal border

The nurse is caring for four hypertensive clients. Which druglaboratory value combination should the nurse report immediately to the health care provider?

Furosemide (Lasix)/potassium: 2.1 mEq/L

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?

Dangle the client on the bedside before ambulating.

A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan?

Decreased orthostatic light-headedness and dizziness

A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?

Depth of respirations

A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first?

administer oxygen by mask or nasal cannula

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service?

african american churches

A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?

assess the airway

A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the clients stenosis has progressed?

dyspnea on exertion

A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?

encourage oral fluid intake

A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.)

increased pulse rate distended neck veins skeletal muscle weakness

A student nurse asks what essential hypertension is. What response by the registered nurse is best?

it is hypertension with no specific cause

A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess?

kussmaul respirations

A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.)

night sweats cardiac murmur Olser's nodes

A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene?

palpates the abdomen in four quadrants

A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L. For which clinical manifestations should the nurse assess? (Select all that apply.)

reduced deep tendon reflexes drowsiness increased respiratory rate

A nurse is planning interventions that regulate acid-base balance to ensure the pH of a clients blood remains within the normal range. Which abnormal physiologic functions may occur if the client experiences an acid- base imbalance? (Select all that apply.)

reduction in the function of hormones fluid and electrolyte imbalances increase in the effectiveness of many drugs

A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use?

standard precautions

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?

teach the client fall prevention measures