med surg 308 test 2

The nurse is assessing the dark-skinned client who has a perfusion problem. Which findings support the nurse's conclusion of cyanosis? Select all that apply. 1. Bluish appearing nailbeds 2. Grayish-green skin tone 3. Blue color in the soles of the feet 4. Whitish color around the mouth 5. Yellow-colored oral mucous membranes 6. Grayish-colored conjunctivae

1. Bluish appearing nailbeds 3. Blue color in the soles of the feet 4. Whitish color around the mouth 6. Grayish-colored conjunctivae

The nurse is assessing the client receiving brimonidine eye drops. Which assessment findings will the nurse recognize as known side effects of brimonidine? Select all that apply. 1. Blurred vision 2. Ocular itching 3. Ocular stinging 4. Hearing loss 5. Conjunctivitis

1. Blurred vision 2. Ocular itching 3. Ocular stinging 5. Conjunctivitis

At 0745 hours, the nurse is informed by the HCP that a cardiac catheterization is to be completed on the client at 1400 hours. Which intervention should be the nurse's priority? 1. Place the client on NPO status. 2. Teach about the cardiac catheterization. 3. Start an IV infusion of 0.9% NaCl. 4. Witness the client's signature on the consent.

1. Place the client on NPO status.

The client has Buck's traction to temporarily immobilize a fracture of the proximal femur before surgery. Which assessment finding requires the nurse to intervene immediately? 1. Reddened area at the client's coccygeal area 2. Voiding concentrated urine at 50 mL/hr 3. Capillary refill 3 seconds, pedal pulses palpable 4. Ropes, pulleys intact; 5-lb weight hangs freely

1. Reddened area at the client's coccygeal area

The client asks the nurse about symptoms associated with retinal detachment. Which symptoms should the nurse identify? Select all that apply. 1. Seeing bright flashes of light 2. Shooting, throbbing eye pain 3. Severe frontal headache 4. Diminished visual acuity 5. Seeing floating dark spots in the vision field

1. Seeing bright flashes of light 4. Diminished visual acuity 5. Seeing floating dark spots in the vision field

The client is admitted with acute infective endocarditis (IE). Which assessment findings should the nurse associate with IE? Select all that apply. 1. Skin petechiae 2. Crackles in lung bases 3. Peripheral edema 4. Murmur 5. Arthralgia 6. Hemangioma

1. Skin petechiae 2. Crackles in lung bases 3. Peripheral edema 4. Murmur 5. Arthralgia

The nurse is caring for the client with varicose veins. Which action should indicate to the nurse that an expected outcome has been met? 1. States will walk daily to promote venous return 2. Reports decreased need for compression stockings 3. States can finally stand for prolonged periods of time 4. Chooses diet high in potassium and low in magnesium

1. States will walk daily to promote venous return

The client newly diagnosed with HF has an ejection fraction (EF) of 20%. Which criteria should the nurse use to evaluate the client's readiness for discharge to home? Select all that apply. 1. There is a scale in the client's home. 2. The client is stable after starting to walk 24 hrs ago. 3. The client is receiving furosemide IV 20 mg bid. 4. A smoking cessation consult is scheduled for 2 days after discharge. 5. A home-care nurse is scheduled to see the client 3 days after

1. There is a scale in the client's home. 2. The client is stable after starting to walk 24 hrs ago. 5. A home-care nurse is scheduled to see the client 3 days after

The nurse receives serum laboratory results for six clients who were admitted with chest pain and have no other comorbidities. Place the clients' laboratory result findings in the order of priority that the nurse should address these. 1. Troponin T 42 ng/mL (0.0-0.4 ng/mL) 2. WBC 11,000/mm3 3. Hgb 7.2 g/dL 4. SCr 2.2 mg/dL 5. K 2.2 mEq/L 6. Total cholesterol 430 mg/dL

1. Troponin T 42 ng/mL (0.0-0.4 ng/mL) 5. K 2.2 mEq/L 3. Hgb 7.2 g/dL 4. SCr 2.2 mg/dL 6. Total cholesterol 430 mg/dL 2. WBC 11,000/mm3

The nurse completes discharge teaching to the client who had an aortic valve replacement with a synthetic valve. The nurse evaluates that the client understands the teaching when the client states plans to take which action? Select all that apply. 1. Use a soft toothbrush for dental hygiene. 2. Floss teeth daily to prevent plaque. 3. Initially wear loose-fitting shirts. 4. Use an electric razor for shaving. 5. Consume foods high in vitamin K.

1. Use a soft toothbrush for dental hygiene. 3. Initially wear loose-fitting shirts. 4. Use an electric razor for shaving.

The client with interstitial pulmonary disease has dyspnea and fatigue. Which recommendation by the nurse will be most helpful to this client? 1. Use energy conservation measures. 2. Use oxygen therapy while at home. 3. Remain in an upright position. 4. Use controlled coughing to clear the airway

1. Use energy conservation measures.

The CXR results of the client who had cardiac surgery is WNL. The nurse plans to remove the client's chest tubes as prescribed. Which is the nurse's priority intervention? 1. Auscultate the client's lung sounds. 2. Administer 2 mg morphine sulfate IV. 3. Turn off the suction to the chest drainage system. 4. Put the needed supplies at the client's bedside.

2. Administer 2 mg morphine sulfate IV.

The nurse notes the wound illustrated when assessing the client who has distal foot pain due to vascular insufficiency. Which notation is the nurse likely to find in the client's medical record? 1. Venous ulcer on left foot 2. Arterial ulcer on right foot 3. Diabetic ulcer on left foot 4. Stress ulcer on right foot

2. Arterial ulcer on right foot

A resident of a long-term care facility tells the nurse, "I'm having a hard time hearing people talk and can't understand the voices on TV." Which action is most appropriate? 1. Teach the client about eliminating background noises in the room. 2. Assess the client's hearing and use an otoscope for examination. 3. Schedule an appointment with the HCP for bilateral ear irrigations. 4. Instruct the client to look at the speaker's lips to decipher words.

2. Assess the client's hearing and use an otoscope for examination.

The client newly diagnosed with asthma is preparing for discharge. Which point should the nurse emphasize during the client's teaching? 1. Wheezing at night is common; call the HCP if worsening. 2. Avoid exposure to mold, which might trigger an attack. 3. Use the peak flow meter only if symptoms are worsening. 4. Use the inhaled steroid medication as your rescue inhaler.

2. Avoid exposure to mold, which might trigger an attack.

1031. The clinic nurse is teaching the client at risk for arteriosclerosis. The nurse should teach the client that the dietary therapy to decrease homocysteine levels includes eating foods rich in which nutrient? 1. Monosaturated fats 2. B-complex vitamins 3. Vitamin C 4. Calcium

2. B-complex vitamins

The nurse increases activity for the client diagnosed with ACS. Which finding best supports that the client is not tolerating the activity? 1. HR increased by 15 bpm during activity 2. BP 130/86 down to 108/66 after walking 25 feet 3. Dyspneic and diaphoretic; relieved when sitting 4. MAP is 80 after walking 100 feet.

2. BP 130/86 down to 108/66 after walking 25 feet

The home health nurse is visiting the client whose chronic bronchitis has recently worsened due to not following previous instructions. Which instruction should the nurse reinforce? 1. Increase amount of bedrest. 2. Increase fluid intake to 3 L daily. 3. Decrease carbohydrate intake. 4. Decrease use of home oxygen.

2. Increase fluid intake to 3 L daily.

The client states to the clinic nurse, "I had pain in the left calf for a few days earlier in the week, but I am pain-free now." The nurse's assessment findings include the following: dorsalis pedis pulses palpable, no pain upon dorsiflexion bilaterally, a few visible varicose veins in each leg, and slight swelling in only the left leg. Which is the nurse's best action? or 4 4. Explain to the client that there are no significant findings.

2. Inform the HCP of the assessment findings.

The nurse is planning care of the client with Ménière's disease. Which interdisciplinary team member should the nurse expect to consult regarding client care? 1. Rheumatologist 2. Otolaryngologist 3. Physical therapist 4. Oncologist

2. Otolaryngologist

The nurse is taking the client's BP at a screening clinic. Which statement demonstrates the client's awareness of having a risk factor for hypertension? 1. "My doctor told me my BMI is 23 and my BP is 118/70." 2. "I usually have a glass of wine daily to unwind." 3. "I plan to get my BP checked more often, as I am African American." 4. "I have colds during the winter, so I get the influenza vaccine yearly."

3. "I plan to get my BP checked more often, as I am African American."

The nurse completes discharge teaching for the client with chronic stage 2 hypertension. Which statement by the client indicates that teaching was effective? 1. "I will limit my intake of potassium." 2. "I will start a rigorous exercise program now." 3. "I will call my provider if my vision blurs." 4. "I will strive to maintain my BMI at 32."

3. "I will call my provider if my vision blurs."

The client, who is a 15-pack-year cigarette smoker, has painful fingers and toes and is diagnosed with Buerger's disease (thromboangiitis obliterans). Which measure to prevent disease progression should be the nurse's initial focus when teaching the client? 1. Avoid exposure to cold temperatures. 2. Maintain meticulous hygiene. 3. Abstain from all tobacco products. 4. Follow a low-saturated-fat diet.

3. Abstain from all tobacco products.

1044. The nurse observes sinus tachycardia with new-onset ST segment elevation on the ECG monitor of the client who has an SPO2 of 90% and reporting chest pain. Which should be the nurse's priority intervention? 1. Draw blood for cardiac enzymes STAT. 2. Call the cardiac catheterization laboratory. 3. Apply 1 inch of nitroglycerin paste topically. 4. Apply oxygen at 4 LPM via nasal cannula. 5. Amiodarone IV infusion 6. Diltiazem IV infusion

3. Apply 1 inch of nitroglycerin paste topically. 4. Apply oxygen at 4 LPM via nasal cannula. 5. Amiodarone IV infusion 6. Diltiazem IV infusion

The client has a hordeolum of the left eye, which is painful. Which intervention, if prescribed, should the nurse implement? 1. Apply an eye patch on the left eye. 2. Instill isopto carpine eye drops bid. 3. Apply a warm compress qid. 4. Apply OTC neomycin-polymyx ointment.

3. Apply a warm compress qid.

The new nurse is experiencing difficulty auscultating the client's heart sounds and consults an experienced nurse. Which techniques should the experienced nurse recommend? Select all that apply. 1. Auscultate over the client's gown. 2. Auscultate standing on the client's left side. 3. Ask the client to sit and lean forward. 4. Feel the radial pulse while listening to heart sounds. 5. Turn the client to the left side-lying position.

3. Ask the client to sit and lean forward. 4. Feel the radial pulse while listening to heart sounds. 5. Turn the client to the left side-lying position.

The client has open-angle glaucoma. Which instruction should the nurse include when teaching the client? 1. Limit oral fluid intake to 1000 mL daily. 2. Eat foods that are high in omega-3 fatty acids. 3. Have annual eye exams with an eye specialist. 4. Use timolol maleate eye drops when feeling eye pressure.

3. Have annual eye exams with an eye specialist.

The client with class II HF according to the New York Heart Association Functional Classification has been taught about the initial treatment plan for HF. The nurse determines that the client needs additional teaching when stating that the treatment plan includes which component? 1. Diuretics 2. A low-sodium diet 3. Home oxygen therapy 4. Angiotensin-converting enzyme (ACE) inhibitors

3. Home oxygen therapy

The client with glaucoma is prescribed pilocarpine hydrochloride 1% eye drops to both eyes qid. The nurse knows that this medication has which expected action? 1. Increases the outflow of aqueous humor 2. Improves vision in dimly lit environments 3. Increases production of aqueous humor 4. Increases ability of both pupils to dilate

3. Increases production of aqueous humor

The nurse is helping the client newly diagnosed with obstructive sleep apnea to apply a CPAP mask at bedtime. When asked by the client about the purpose of CPAP, what should be the nurse's best response? 1. "The CPAP machine will breathe for you during sleep." 2. "Use of the CPAP will reduce intrathoracic pressure." 3. "The CPAP machine delivers higher levels of oxygen." 4. "Use of the CPAP prevents collapse of small air sacs."

4. "Use of the CPAP prevents collapse of small air sacs."

The 60-year-old client notices a gradual decline in visual acuity and asks if it could be from a cataract. Which question will help determine whether a cataract is developing? 1. "Has your ability to perceive colors changed?" 2. "Does your vision appear distorted or wavy?" 3. "Does the center of your visual field appear dark?" 4. "Do you see random flashes of bright light?"

1. "Has your ability to perceive colors changed?"

The client with symptoms of intermittent claudication receives treatment with a peripheral percutaneous transluminal angioplasty with placement of an endovascular stent. Which statements, if made by the client, support the home-care nurse's conclusion that the client is making lifestyle changes to decrease the likelihood of restenosis and arterial occlusion? or 4. "I see a podiatrist tomorrow for foot care." 5. "I'm following a low-saturated-fat diet." 6. "I now take rosu

1. "I have been doing exercises twice daily." 2. "All nicotine products were thrown away." 5. "I'm following a low-saturated-fat diet." 6. "I now take rosuvastatin calcium."

The nurse is completing a home visit with the client who has an arterial ulcer secondary to PAD. Which statement by the client warrants immediate intervention by the nurse? 1. "I soak my feet daily for warmth and to keep them soft." 2. "I cover the sore on my foot with sterile gauze to protect it." 3. "I use a pillow under my calves to keep my heels off the bed." 4. "I lubricate my feet daily to prevent them from cracking."

1. "I soak my feet daily for warmth and to keep them soft."

The client tells the nurse, "My optometrist told me that cataracts are beginning to develop in both of my eyes." Which follow-up statement made by the client should the nurse correct? 1. "It is important that I schedule cataract surgery as soon as possible." 2. "Usually surgery is performed on each eye at different times." 3. "My own lens will be removed when I have cataract surgery." 4. "An intraocular lens may be inserted with the surgical procedure."

1. "It is important that I schedule cataract surgery as soon as possible."

A family member of the client undergoing cataract surgery asks the nurse if there are ways to prevent cataracts. Which recommendations should the nurse suggest? Select all that apply. 1. "Wear sunglasses that limit ultraviolet light penetration." 2. "Wear sunscreen with a high protection factor number." 3. "Wear eye protection if there is any risk for eye injury." 4. "Avoid activities and reading in dimly lit environments." 5. "Eat foods that are high in vitamin

1. "Wear sunglasses that limit ultraviolet light penetration." 3. "Wear eye protection if there is any risk for eye injury."

The client who had a synthetic valve replacement a year ago is hospitalized with unstable angina. Heparin and nitroglycerin IV infusions were started, but then nitroglycerin was discontinued after the client's pain resolved. The HCP prescribes oral warfarin 5 mg to start at 1700 hrs. Which is the nurse's best action? 1. Administer the warfarin as prescribed. 2. Call the HCP to question starting warfarin. 3. Discontinue heparin and then give warfarin. 4. Hold warfarin until heparin is discontinue

1. Administer the warfarin as prescribed.

The nurse is admitting the client with a thoracic aortic aneurysm. Which intervention should the nurse plan to include? 1. Administering antihypertensive medications 2. Palpating the thorax to determine the aneurysm's size 3. Inserting an NG tube set to moderate suction 4. Teaching about a low-fat and low-sodium diet

1. Administering antihypertensive medications

The nurse is teaching the client about using the illustrated attachment to the meter-dosed inhaler. The nurse should explain that this attachment is used for what purpose? 1. Allows for a greater amount of medication to be delivered 2. Permits visualization of the medication as it is delivered 3. Maintains the sterility of the mouthpiece and medication 4. Used to activate the medication canister by simply inhaling

1. Allows for a greater amount of medication to be delivered

The nurse is caring for the client who had a cardiac valve replacement. To decrease the risk of DVT and PE, which interventions should the nurse plan to include? Select all that apply. 1. Apply a pneumatic compression device. 2. Administer an IV heparin infusion. 3. Encourage coughing and deep breathing hourly. 4. Teach about doing isometric leg exercises. 5. Avoid using graded compression elastic stockings.

1. Apply a pneumatic compression device. 4. Teach about doing isometric leg exercises.

The nurse is assessing the client following a coronary artery bypass graft. Which finding in the immediate postoperative period should be most concerning to the nurse? 1. Copious chest tube output; now none for 1 hr 2. Current core temperature of 101.3°F (38.5°C) 3. pH 7.32; PaCO2 48; HCO3 28; PaO2 80 4. Urine output 160 mL in the last 4 hrs

1. Copious chest tube output; now none for 1 hr

The nurse and client are updating the client's asthma action plan. Which information should be updated on the action plan? 1. Drug adjustments for peak flows less than 50% of normal 2. Timeline for allergy skin testing to verify known triggers 3. The route the client may drive to the hospital during an attack 4. The best methods for performing chest physiotherapy (CPT)

1. Drug adjustments for peak flows less than 50% of normal

The nurse is caring for the client following a left knee arthroscopy. What information should the nurse teach? Select all that apply. 1. Elevate the left leg on pillows for 24 to 48 hrs. 2. Have an ice pack continually on the left knee for 24 hrs. 3. Report severe joint pain immediately to the HCP. 4. Resume usual activities to minimize joint stiffness. 5. Treat mild pain with an analgesic such as acetaminophen.

1. Elevate the left leg on pillows for 24 to 48 hrs. 3. Report severe joint pain immediately to the HCP. 5. Treat mild pain with an analgesic such as acetaminophen.

The nurse is assessing the client following cardiac surgery. Which assessment findings should be of the greatest concern to the nurse? 1. Jugular vein distention, muffled heart sounds, BP 84/48 2. Temperature 96.4°F (35.8°C), HR 58 bpm, shivering 3. HR 110 bpm, audible S1 and S2, pain rated at a 5 4. Central venous pressure (CVP) 4 mm Hg, urine output 30 mL/hr, sinus rhythm with PVCs

1. Jugular vein distention, muffled heart sounds, BP 84/48

The nurse is reviewing the medication list of the client with Ménière's disease. Which medication should the nurse give to treat the client's vertigo? 1. Meclizine 2. Megestrol 3. Meropenem 4. Metoprolol

1. Meclizine

The nurse is preparing the client for a thoracic aneurysm repair. Which assessment findings should prompt the nurse to conclude that a rupture may have occurred? Select all that apply. 1. Oliguria 2. Dyspnea 3. Hypotension 4. Abdominal distention 5. Severe chest pain radiating to the back

1. Oliguria 2. Dyspnea 3. Hypotension 5. Severe chest pain radiating to the back

The nurse enters the room of the client with COPD and finds the client seated as illustrated. How should the nurse document the client's position? 1. Orthopneic position 2. Abdominal breathing position 3. Pursed-lip breathing position 4. Diaphragmatic breathing position

1. Orthopneic position

The client is admitted with an ACS. Which should be the nurse's priority assessment? 1. Pain 2. Blood pressure 3. Heart rate 4. Respiratory rate

1. Pain

The client is scheduled for a coronary artery bypass graft in 1 week. Which presurgical instructions should the nurse provide to the client? Select all that apply. 1. Stop taking aspirin and products containing aspirin. 2. Continue aerobic exercises 30 minutes daily. 3. Use the antimicrobial soap as prescribed. 4. Shave your chest and legs and then shower. 5. Resume normal activities when discharged.

1. Stop taking aspirin and products containing aspirin. 3. Use the antimicrobial soap as prescribed.

The nurse completes teaching the client with a newly inserted ICD. Which statement, if made by the client, indicates that further teaching is needed? 1. "The ICD will give me a shock if my heart goes into ventricular fibrillation again." 2. "When I feel the first shock, my family should start CPR immediately and call 911." 3. "I'm afraid of my first shock; my friend stated his shock felt like a blow to the chest. 4. "Some states do not allow driving until there is a 6-m

2. "When I feel the first shock, my family should start CPR immediately and call 911."

The nurse is taking the BP on multiple clients. Which reading warrants the nurse notifying the HCP because the client's MAP is abnormal? 1. 94/60 mm Hg 2. 98/36 mm Hg 3. 110/50 mm Hg 4. 140/78 mm Hg

2. 98/36 mm Hg

The nurse collects the following assessment data on the client who has no known health problems: BP 135/89 mm Hg; BMI 23; waist circumference 34 inches; serum creatinine 0.9 mg/dL; serum potassium 4.0 mEq/L; LDL cholesterol 200 mg/dL; HDL cholesterol 25 mg/dL; and triglycerides 180 mg/dL. Which intervention should the nurse anticipate? 1. A low-calorie regular diet 2. A statin antilipidemic medication 3. A thiazide diuretic medication 4. Low-salt, low-saturated-fat, low-potassium die

2. A statin antilipidemic medication

The nurse, caring for the client following an anterior MI, obtains the assessment findings illustrated. Based on these findings, the nurse should immediately notify the HCP and plan which intervention? 1. Administer an IV fluid bolus of 0.9% NaCl; the client is in right heart failure. 2. Initiate an IV infusion of dopamine; the client is in cardiogenic shock. 3. Prepare the client for pericardiocentesis; the findings support cardiac tamponade. 4. Notify radiology for a STAT chest x-r

2. Initiate an IV infusion of dopamine; the client is in cardiogenic shock.

The client is discovered to have a popliteal aneurysm. Because of the aneurysm, the nurse should closely monitor the client for which most closely associated problem? 1. Thoracic outlet syndrome 2. Ischemia in the lower limb 3. Pulmonary embolism 4. Raynaud's phenomenon

2. Ischemia in the lower limb

The nurse is teaching the client with COPD about the purpose of pursed-lip breathing. Which explanation is most appropriate? 1. It reduces upper airway inflammation. 2. It strengthens the respiratory muscles. 3. It improves inhaled drug effectiveness. 4. It reduces anxiety by slowing the HR.

2. It strengthens the respiratory muscles.

The nurse is reviewing home management strategies with the client who has dry macular degeneration. The nurse should review using which objects with the client? Select all that apply. 1. Protective goggles 2. Lighting that is bright 3. An Amsler grid 4. A soft eye patch 5. Magnification device

2. Lighting that is bright 3. An Amsler grid 5. Magnification device

The client is having sharp chest pains that radiate to the left shoulder and calls for the nurse. Which prescribed intervention should the nurse implement first? 1. STAT 12-lead electrocardiogram (ECG) 2. Obtain VS and oxygen saturation level 3. Nitroglycerin 0.4 mg sublingual 4. Morphine sulfate 2-4 mg IV prn

2. Obtain VS and oxygen saturation level

The client arrives to the unit following insertion of a permanent pacemaker via the right subclavian vein approach. Which intervention should the nurse include in the client's plan of care to best prevent pacemaker lead dislodgement? 1. Inspect the incision for approximation and bleeding. 2. Prevent the right arm from going above shoulder level. 3. Assist the client with using a walker when out of bed. 4. Request a STAT chest x-ray upon return from the procedure.

2. Prevent the right arm from going above shoulder level.

The nurse is discussing healthy lifestyle practices with the client who has chronic venous insufficiency. Which practices should be emphasized with this client? Select all that apply. 1. Avoid eating an excess of dark green vegetables. 2. Take rests and elevate the legs while sitting. 3. Wear graduated compression stockings during the day 4. Increase standing time and shift weight when upright. 5. Sleep with legs elevated above the level of the heart.

2. Take rests and elevate the legs while sitting. 3. Wear graduated compression stockings during the day 5. Sleep with legs elevated above the level of the heart.

The RN and the NA are caring for four clients, all in need of immediate attention. The NA is a senior nursing student who has been giving medications and performing procedures on clients as a student nurse. The unit charge nurse determines that care is appropriate when the RN working with the NA delegates which actions? Select all that apply. or 4. Change this client's chest tube dressing because it got wet. 5. Provide a sponge bath for the client with the increased temperature.

2. Take vital signs on the client newly admitted with heart failure. 5. Provide a sponge bath for the client with the increased temperature.

The nurse is caring for multiple clients. Which client should the nurse identify as having the greatest risk for developing a DVT? or 4. The client with dependent rubor, pallor upon lower-extremity elevation, and absent peripheral pulses; platelet count of 350,000/mm3

2. The client postop THR who has venous insufficiency and is immobile; platelet count = 550,000/mm3

The client with severely diminished vision has difficulty with visual discrimination. Which interventions should the nurse recommend to improve the client's sight in the home environment? 1. Ensure that all room walls are painted with colors that blend. 2. Use a white board and a black marker when writing out lists. 3. Place Velcro tabs on wall light switches to ease locating them. 4. Ensure that doorknobs on the doors are a bright contrasting color. 5. Match the color of dishe

2. Use a white board and a black marker when writing out lists. 3. Place Velcro tabs on wall light switches to ease locating them. 4. Ensure that doorknobs on the doors are a bright contrasting color.

The nurse is teaching the client newly diagnosed with asthma. Which instructions should the nurse include to reduce allergic triggers? Select all that apply. 1. Wash bedclothes and linens in cold water. 2. Use dust covers on mattresses and pillows. 3. Keep house fresh with a scented deodorizer. 4. Vacuum carpets daily in the bedrooms. 5. Clean the albuterol MDI daily under hot running water.

2. Use dust covers on mattresses and pillows. 4. Vacuum carpets daily in the bedrooms.

The nurse is teaching the client newly diagnosed with chronic stable angina. Which instructions on measures to prevent future angina should the nurse incorporate? Select all that apply. 1. Increase isometric arm exercises to build endurance. 2. Wear a facemask when outdoors in cold weather. 3. Take nitroglycerin before a stressful event even if pain-free. 4. Perform most exertional activities in the morning. 5. Take a daily laxative to avoid straining. 6. Discontinue use of tobacco

2. Wear a facemask when outdoors in cold weather. 3. Take nitroglycerin before a stressful event even if pain-free. 6. Discontinue use of tobacco

The client with diminished sight has problems with the glare from light. Which recommendation should the nurse make? 1. Install fluorescent lighting throughout the home. 2. Wear sunglasses and hats with brims when outdoors. 3. Avoid going outdoors on days that are sunny. 4. Use direct sunlight from windows rather than lights.

2. Wear sunglasses and hats with brims when outdoors.

The nurse receives shift report for four clients on a cardiac step-down unit. Prioritize the order, from most urgent to least urgent, that the nurse should assess the clients. or 4. The 38-year-old who had an aortic valve replacement 2 days ago, BP 114/72 mm Hg, HR 100 bpm, RR 28 breaths/min, and temperature 101.2°F (38.4°C)

3,4,1,2

The client, hospitalized with a lower respiratory tract infection, has a history of mild liver disease and asthma. Which prescription by an HCP should the nurse question? 1. Albuterol 2.5 mg nebulized q4h 2. Methylprednisolone 60 mg IV q6h 3. Aspirin 325 mg 2 tabs PO q4h prn pain or fever 4. Oxygen to maintain SaO2 greater than 95%

3. Aspirin 325 mg 2 tabs PO q4h prn pain or fever

The client who had a femoral-popliteal bypass graft 3 days ago summons the nurse because of throbbing pain in the surgical extremity. Which action should the nurse take first? 1. Explain that the throbbing pain is from the increased blood flow. 2. Check the dressings for an increase in the amount of drainage. 3. Assess the dorsalis pedis and posterior tibial pulses in that extremity. 4. Ask the client to rate the level of pain on a 0-to-10 scale.

3. Assess the dorsalis pedis and posterior tibial pulses in that extremity.

The nurse is assessing the client with chronic bronchitis. Which finding should the nurse expect? 1. Minimal sputum with cough 2. Copious pink, frothy sputum 3. Barrel chest appearance 4. Stridor on expiration

3. Barrel chest appearance

The nurse is assessing the client who is to have a closed reduction for a right elbow dislocation. Which should be the nurse's priority assessment? 1. Presence of bruising to the right elbow 2. Pain level rating on a 0 to 10 scale 3. CMS of the right forearm 4. Left-handed or right-handed

3. CMS of the right forearm

The client with COPD is in the third postoperative day following right-sided thoracotomy. Just before shift change, the client's SaO2 dropped to 84% and the only action the day shift nurse took was to increase the client's oxygen to 10 L per mask. Which action should be taken by the nurse? 1. Work to wean oxygen down to 3 L by mask. 2. Call respiratory therapy for a nebulizer treatment. 3. Check the respiratory status and notify the HCP. 4. Administer a dose of the prescribed ana

3. Check the respiratory status and notify the HCP.

The nurse is reviewing the new nurse's discharge instructions for the client who had outpatient cataract surgery. Which statement should the experienced nurse remove from the discharge instructions? 1. Avoid lifting, pushing, or pulling objects heavier than 15 pounds. 2. Clean eye with a clean tissue; wipe from inner to outer eye. 3. Cough and deep breathe every 2 to 3 hrs while you are awake. 4. Avoid lying on the side of the affected eye the night after surgery.

3. Cough and deep breathe every 2 to 3 hrs while you are awake.

The client with macular degeneration is told the condition is progressing to an advanced stage. Which findings should the nurse expect when completing the assessment? Select all that apply. 1. Curtain appearance over part of the visual field 2. Loss of peripheral vision in the affected eye 3. Difficulty seeing in dimly lit environments 4. Visual distortions in the central vision 5. Clouding of the lens in both eyes

3. Difficulty seeing in dimly lit environments 4. Visual distortions in the central vision

The nurse is preparing to admit the client who has been diagnosed with TB. Which interventions should the nurse plan to implement? 1. Ensure that the room assigned is a positive-pressure airflow room. 2. Wear gown and gloves when handling the client's stool or urine. 3. Don an N95 respirator mask before entering the client's room. 4. Keep the client in the room until antibiotics have been started. 5. Begin prescribed doses of isoniazid, rifampin, pyrazinamide, and ethambutol.

3. Don an N95 respirator mask before entering the client's room. 5. Begin prescribed doses of isoniazid, rifampin, pyrazinamide, and ethambutol.

The client is admitted with possible PE. In consulting with the HCP, the nurse learns that the V/Q scan shows a ventilation/perfusion quotient (V/Q) mismatch. Which intervention is appropriate? 1. Explain to the client that airborne precautions will be necessary. 2. Tell the client that the scan did not show a pulmonary embolus. 3. Explain to the client that further diagnostic testing will be needed. 4. Inform the client that the results of the V/Q scan were normal.

3. Explain to the client that further diagnostic testing will be needed.

The client with asthma has obvious wheezing and signs of a possible impending asthma attack. Which intervention should the nurse implement first? 1. Have the client cough and deep breathe. 2. Prepare the client for possible intubation. 3. Give an inhaled beta-2 adrenergic agonist. 4. Notify the client's HCP.

3. Give an inhaled beta-2 adrenergic agonist.

The client returns to a hospital unit after undergoing placement of a vena cava filter. Which intervention should the nurse implement? 1. Restart heparin therapy as soon as possible. 2. Reinforce the abdominal incision dressing. 3. Inspect the groin insertion site for bleeding. 4. Increase fluids to promote excretion of the dye.

3. Inspect the groin insertion site for bleeding.

The nurse reviews the chart of the client diagnosed with closed-angle glaucoma. Which documented finding should the nurse question with the HCP? 1. Sudden onset of eye pain 2. Reduced central visual acuity 3. Normal intraocular pressure 4. Nausea and vomiting

3. Normal intraocular pressure

The nurse is assessing the client who had an AAA repair with graft placement 30 minutes ago. The nurse is unable to palpate the posterior tibial pulse of one leg that was palpable 15 minutes earlier. What should be the nurse's priority? 1. Recheck the pulse in 5 minutes. 2. Reposition the affected leg. 3. Notify the surgeon of the finding. 4. Document that the pulse is absent.

3. Notify the surgeon of the finding.

The 20-year-old is diagnosed with hypertrophic cardiomyopathy. Knowing that the client was on the college soccer team, which information should be the nurse's priority when planning to teach? 1. Provide pamphlets on genetic testing to avoid passing on an inherited disease. 2. Reinforce the need to continue exercise with soccer to strengthen the heart. 3. Provide information about CPR to persons living with the client. 4. Counsel on foods for consuming on a low-fat, low-cholesterol

3. Provide information about CPR to persons living with the client.

The nurse is assessing the client who had an inferior-septal wall MI. Which potential complication should the nurse further explore when noting that the client has JVD and ascites? 1. Left-sided heart failure 2. Pulmonic valve malfunction 3. Right-sided heart failure 4. Ruptured septum

3. Right-sided heart failure

The client's eyes, tested with the use of a Snellen chart, show 20/40 vision in the right eye and 20/30 in the left eye. How should the nurse interpret these results? 1. The client has elevated intraocular pressure in both eyes. 2. The client needs testing for glaucoma with a tonometer. 3. The left eye is closer to normal vision than the right eye. 4. The client has errors of refraction indicating astigmatism.

3. The left eye is closer to normal vision than the right eye.

The nurse reviews symptoms of acute graft occlusion with the client who has had a revascularization graft procedure of the lower extremity. Which symptom of acute arterial occlusion stated by the client indicates the need for further teaching? 1. Severe pain 2. Paresthesia 3. Warm and red incisions 4. Inability to move the foot

3. Warm and red incisions

The nurse telephones the client 1-day post-cataract surgery. Which client statements necessitate an evaluation by an ophthalmologist? Select all that apply. 1. "My eye starts hurting about 4 hrs after a pain pill." 2. "My eye is still red but it is less than yesterday." 3. "I'm ready to have my other cataract now." 4. "I can't see as well as I could yesterday after surgery." 5. "The eye patch helps me from seeing floating shapes."

4. "I can't see as well as I could yesterday after surgery." 5. "The eye patch helps me from seeing floating shapes."

The nurse completed teaching the client with a corneal abrasion about proper care of the injury. Which statements indicate that the client understood the teaching? Select all that apply. 1. "I should promptly report a sudden absence of pain." 2. "I should keep my affected eye uncovered when up." 3. "I should insert two eye drops 5 to 10 seconds apart." 4. "I should leave the eye patch in place for 24 hrs." 5. "I will avoid rubbing my affected eye or the eye patch

4. "I should leave the eye patch in place for 24 hrs." 5. "I will avoid rubbing my affected eye or the eye patch."

The client asks the nurse what can be done to alleviate the pain and discomfort associated with varicose veins. Which response by the nurse is best? 1. "Dangle your legs off the side of the bed often." 2. "The only option is surgery to remove the veins." 3. "Wear long, tight pants to compress bulging veins" 4. "Wear elastic stockings to promote venous return."

4. "Wear elastic stockings to promote venous return."

The nurse is assessing the newly admitted client who has an 8-cm AAA. Which finding should the nurse expect? 1. Report of persistent nagging pain in the upper anterior chest 2. Systolic bruit palpated over the upper abdomen 3. Edema of the face and neck with distended neck veins 4. A pulsating mass in the mid to upper abdomen

4. A pulsating mass in the mid to upper abdomen

The nurse assesses the client returning from a coronary angiogram in which the femoral artery approach was used. The client's baseline BP during the procedure was 130/72 mm Hg, and the cardiac rhythm was sinus rhythm. Which finding should alert the nurse to a potential complication? 1. BP 154/78 mm Hg 2. Pedal pulses palpable at +1 3. Left groin soft to palpation; 1 cm ecchymotic area 4. Apical pulse 132 bpm; irregular-irregular rhythm

4. Apical pulse 132 bpm; irregular-irregular rhythm

The client's daughter tells the nurse of frustration while communicating with her elderly mother who wears hearing aids. Which intervention should the nurse suggest to the client's daughter? 1. Minimize oral communication to essential matters. 2. Speak directly into her mother's better ear. 3. Use exaggerated mouth expressions while speaking. 4. Attract her mother's attention before speaking.

4. Attract her mother's attention before speaking.

The nurse, assessing the client hospitalized following an MI, obtains these VS: BP 78/38 mm Hg, HR 128, RR 32. The nurse notifies the HCP concerned that the client may be experiencing which most life-threatening complication? 1. Pulmonary embolism 2. Cardiac tamponade 3. Cardiomyopathy 4. Cardiogenic shock

4. Cardiogenic shock

The client had a femoral-popliteal artery bypass graft surgery 1 day ago. What should be the nurse's priority at this time? 1. Monitor I&O q4h. 2. Report edema in the operative leg. 3. Have the client at 90-degrees when sitting in bed. 4. Check pedal and post-tibial pulses bilaterally q4h.

4. Check pedal and post-tibial pulses bilaterally q4h.

The client, returning from a coronary catheterization in which the femoral artery approach was used, sneezes. Which should be the nurse's priority intervention? 1. Palpate pedal pulses. 2. Measure vital signs. 3. Assess for an allergic reaction. 4. Check the insertion site.

4. Check the insertion site.

The nurse observes that the client, 3 days post-MI, seems unusually fatigued. Upon assessment, the client is dyspneic with activity, has sinus tachycardia (ST), and has generalized edema. Which action by the nurse is most appropriate? 1. Administer high-flow oxygen. 2. Encourage the client to rest more. 3. Continue to monitor the client's heart rhythm. 4. Compare the admission and current weight.

4. Compare the admission and current weight.

The client with a pelvic fracture developed a fat embolism. The nurse should assess the client for which specific sign? 1. Dyspnea 2. Chest pain 3. Delirium 4. Petechiae

4. Petechiae

The nurse is assessing the lung sounds of the client with pneumonia who is having pain during inspiration and expiration. Which information about lung sounds should the nurse document when hearing loud grating sounds over the lung fields? 1. Bronchial 2. Wheezing 3. Coarse crackles 4. Pleural friction rub

4. Pleural friction rub

The client with a left anterior descending (LAD) 90% blockage has crushing chest pain, unrelieved by taking sublingual nitroglycerin. Which most concerning ECG finding should be reported to the HCP STAT? 1. Q waves 2. Flipped T waves 3. Peaked T waves 4. ST segment elevation

4. ST segment elevation

The nurse assesses the client at a vascular clinic after being treated with pentoxifylline for 6 weeks. The nurse determines that pentoxifylline has been effective when noting that the client has which finding? 1. A decrease in lower-extremity edema 2. No symptoms of withdrawal after quitting smoking 3. A venous ulcer on the ankle that has decreased in size 4. The ability to walk a longer distance without claudication

4. The ability to walk a longer distance without claudication