Med-Surg Exam 1

The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement? 1. Prepare ice packs and mix dantrolene sodium. 2. Request the defibrillator be brought into the OR. 3. Draw a PTT and prepare a heparin drip. 4. Obtain finger stick blood glucose immediately.

1. 1. Unexplained tachycardia, hypotension, and elevated temperature are signs of malignant hyperthermia, which is treated with ice packs and dantrolene sodium. 2. A defibrillator would be needed if the client were in ventricular tachycardia or ventricular fibrillation. 3. These interventions would not be appro- priate for malignant hyperthermia. 4. This would be important if the client had diabetes, but it does not address malignant hyperthermia.

Which nursing intervention has the highest priority when preparing the client for a surgical procedure?1. Pad the client's elbows and knees. 2. Apply soft restraint straps to the extremities. 3. Prepare the client's incision site. 4. Document the temperature of the room.

2. 1. This intervention prevents nerve damage from positioning, but it is not a higher priority than preventing the client from falling off the OR table. 2. This action would prevent the client from falling off the table, which is the highest priority. 3. Preparing the incision site is not a higher priority than preventing the client from falling off the OR table. 4. The temperature of the room does not have a higher priority than safety.

The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a surgery unit. Which task would be most appropriate to delegate to the UAP? 1. Explain to the client how to cough and deep breathe. 2. Discuss preoperative plans with the client and family. 3. Determine the ability of the caregivers to provide postoperative care. 4. Assist the client to take a povidone-iodine (Betadine) shower.

4

Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Complete the preoperative checklist. 2. Assess the client's preoperative vital signs. 3. Teach the client about coughing and deep breathing. 4. Assist the client to remove clothing and jewelry.

4. 1. The nurse should complete this form because it requires analysis, which cannot be delegated to the UAP. 2. Nurses cannot delegate assessment. 3. The nurse cannot delegate teaching to a UAP. 4. The UAP can remove clothing and jewelry.

The nurse determines that the patient has stage 2 hypertension when the patient's average blood pressure is (select all that apply)? a. 150/96 mm Hg b. 155/88 mm Hg c. 172/92 mm Hg d. 160/110 mm Hg e. 182/106 mm Hg

A B C D E

Which subjective data related to the cardiovascular system should be obtained from the patient (select all that apply)? A. annual income B. smoking history C. religious preference D. number of pillows used to sleep E. blood for basic laboratory studies

B C D

A 56-year-old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that? a. a BP recheck should be scheduled in a few weeks b. dietary sodium and fat content should be decreased c. there is an immediate danger of a stroke and hospitalization will be required d. diagnosis of a possible cause, treatment, and ongoing monitoring will be needed

D - this scenario of hypertension may mean that it is secondary to some other problem.

The circulating nurse notes a discrepancy in the needle count. What intervention should the nurse implement first? 1. Inform the other members of the surgical team about the problem. 2. Assume the original count was wrong and change the record. 3. Call the radiology department to perform a portable x-ray. 4. Complete an occurrence report and notify the risk manager.

1

The client one (1) day postoperative develops an elevated temperature. Which intervention would have priority for the client? 1. Encourage the client to deep breathe and cough every hour. 2. Encourage the client to drink 200 mL of water every shift. 3. Monitor the client's wound for drainage every eight (8) hours. 4. Assess the urine output for color and clarity every four (4) hours.

1

The nurse received a male client from the post-anesthesia care unit. Which assessment data would warrant immediate intervention? 1. The client's vital signs are T 97 ̊F, P 108, R 24, and BP 80/40. 2. The client is sleepy but opens the eyes to his name. 3. The client is complaining of pain at a "5" on a 1-to-10 pain scale. 4. The client has 20 mL of urine in the urinary drainage bag.

1

The nurse received a report the elderly postoperative client became confused during the previous shift. Which client problem would the nurse include in the plan of care? 1. Risk for injury. 2. Altered comfort level. 3. Impaired circulation. 4. Impaired skin integrity.

1

Which action by the client indicates to the nurse preoperative teaching has been effective? 1. The client demonstrates how to use the incentive spirometer device. 2. The client demonstrates the use of the patient-controlled analgesia pump. 3. The client can name two (2) anesthesia agents used during surgery. 4. The client ambulates down the hall to the nurse's station each hour.

1

Which client would the nurse identify as having the highest risk for developing postoperative complications? 1. The 67-year-old client who is obese, has diabetes, and takes insulin. 2. The 50-year-old client with arthritis taking nonsteroidal anti-inflammatory drugs. 3. The 45-year-old client having abdominal surgery to remove the gallbladder. 4. The 60-year-old client with anemia who smokes one (1) pack of cigarettes per day.

1

Which intervention has priority for the nurse in the surgical holding area? 1. Verify the surgical checklist. 2. Prepare the client's surgical site. 3. Assist the client to the bathroom. 4. Restrain the client on the surgery table.

1

The client in the surgery holding area identifies the left arm as the correct surgical site, but the operative permit designates surgery to be performed on the right arm. Which interventions should the nurse implement? (Select all that apply) 1. Review the client's chart. 2. Notify the surgeon. 3. Immediately call a "time-out." 4. Correct the surgical permit. 5. Request the client mark the left arm.

1 2 3 5

The client diagnosed with appendicitis has undergone an appendectomy. At two (2) hours postoperative, the nurse takes the vital signs and notes T 102.6 ̊F, P 132, R 26, and BP 92/46. Which interventions should the nurse implement? List in order of priority. 1. Increase the IV rate. 2. Notify the health-care provider. 3. Elevate the foot of the bed. 4. Check the abdominal dressing. 5. Determine if the IV antibiotics have been administered.

1 3 4 5 2

Which problem should the nurse identify as priority for client who is one (1) day postoperative? 1. Potential for hemorrhaging. 2. Potential for injury. 3. Potential for fluid volume excess. 4. Potential for infection.

1. 1. All clients who undergo surgery are at risk for hemorrhaging, which is the priority problem. 2. The client is at risk for injury, but the priority problem the first day postoperative is hemorrhaging. 3. A potential fluid imbalance would be for less fluid as a result of blood loss and decreased oral intake; it would not be for fluid volume excess. 4. Infection would be a potential problem but not priority over hemorrhaging on the first postoperative day.

The nurse is planning the care of the surgical client having conscious sedation. Which intervention has highest priority? 1. Assess the client's respiratory status. 2. Monitor the client's urinary output. 3. Take a 12-lead ECG prior to injection. 4. Attempt to keep the client focused.

1. 1. Assessing the respiratory rate, rhythm, and depth is the most important action. 2. The nurse needs to monitor all systems, but monitoring the urine output would not be priority over monitoring breathing. 3. Monitoring the client's ECG is appropri- ate, but it is not priority. 4. The client needs to be relaxed, not focused, but this is not priority over respiratory status.

The nurse and the unlicensed assistive personnel (UAP) are working on the surgical unit. Which task can the nurse delegate to the UAP? 1. Take routine vital signs on clients. 2. Check the Jackson Pratt insertion site. 3. Hang the client's next IV bag. 4. Ensure the client obtains pain relief.

1. 1. Taking the vital signs of the stable client may be delegated to the UAP. 2. Assessments cannot be delegated; "check" is a word which means to assess. 3. IVs cannot be hung by the UAP; this is considered administering a medication. 4. Evaluating the client's pain relief is a responsibility of the RN.

The PACU nurse is receiving the client from the OR. Which intervention should the nurse implement first? 1. Assess the client's breath sounds. 2. Apply oxygen via nasal cannula. 3. Take the client's blood pressure. 4. Monitor the pulse oximeter reading.

1. 1. The airway should be assessed first. When caring for a client, the nurse should follow the ABCs: airway, breathing, and circulation. 2. After assessing the client's airway and breathing, the nurse can apply oxygen via a nasal cannula if it is necessary. 3. The blood pressure is taken automatically by the monitor, but this is not priority over airway. 4. The pulse oximeter is applied to the client's finger to obtain the peripheral oxygenation status, but the nurse should assess the client's breathing first.

Which activities are the circulating nurse's responsibilities in the operating room? 1. Monitor the position of the client, prepare the surgical site, and ensure the client's safety. 2. Give preoperative medication in the holding area and monitor the client's response to anesthesia. 3. Prepare sutures; set up the sterile field; and count all needles, sponges, and instruments. 4. Prepare the medications to be administered by the anesthesiologist and change the tubing for the anesthesia machine.

1. 1. The circulating nurse has many responsibilities in the OR, including coordinating the activities in the OR; keeping the OR clean; ensuring the safety of the client; and maintaining the humidity, lighting, and safety of the equipment. 2. This is the role of the nurse anesthetist or anesthesiologist. 3. This is the role of the scrub nurse or technologist. 4. If there is an anesthesia technologist, this would be his or her role or the nurse anes- thetist and the anesthesiologist would as- sume the role

The nurse requests the client to sign a surgical informed consent form for an emergency appendectomy. Which statement by the client indicates further teaching is needed? 1. "I will be glad when this is over so I can go home today." 2. "I will not be able to eat or drink anything prior to my surgery." 3. "I can practice relaxing by listening to my favorite music." 4. "I will need to get up and walk as soon as possible."

1. 1. The client will be in the hospital for a few days. This is not a day-surgery pro- cedure. The client needs more teaching. 2. Clients are NPO (nothing by mouth) prior to surgery to prevent aspiration during and after anesthesia. The client understands the teaching. 3. Listening to music and other relaxing tech- niques can be used to alleviate anxiety and pain. This statement indicates the client understands the teaching. 4. Clients are encouraged to get out of bed as soon as possible and progress until a return to daily activity is achieved. The client understands the teaching.

The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after three (3) tap water enemas. Which intervention should the nurse implement first? 1. Notify the surgeon of the client's status. 2. Continue giving enemas until clear. 3. Increase the client's IV fluid rate. 4. Obtain STAT serum electrolytes.

1. 1. The nurse should contact the surgeon because the client is at risk for fluid and electrolyte imbalance after three (3) enemas. Clients who are NPO, elderly clients, and pediatric clients are more likely to have these imbalances. 2. Administering more enemas will put the client at further risk for fluid volume deficit and electrolyte imbalance. 3. The IV may need to be increased, but the nurse would need an order for this intervention. 4. The electrolyte status may need to be assessed, but the nurse would need an order for this intervention.

The circulating nurse is planning the care for an intraoperative client. Which statement is the expected outcome? 1. The client has no injuries from the OR equipment. 2. The client has no postoperative infection. 3. The client has stable vital signs during surgery. 4. The client recovers from anesthesia.

1. 1. This expected outcome addresses the safety of the client while in the OR. 2. This would be an expected outcome in the postoperative period. 3. The anesthesiologist or nurse anesthetist would monitor the client's vital signs during surgery. 4. This would be an expected outcome for the anesthesiologist or nurse anesthetist.

The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? (Select all that apply.) 1. The client has loose, decayed teeth. 2. The client is experiencing anxiety. 3. The client smokes two (2) packs of cigarettes a day. 4. The client has had a chest x-ray which does not show infiltrates. 5. The client reports using herbs.

1. 3. 5. 1. Loose teeth or caries need to be re- ported to the anesthesiologist so he or she can make provisions to prevent breaking the teeth and causing the client to possibly aspirate pieces. 2. The nurse should report any client who is extremely anxious, but the nurse can address the needs of a client experiencing expected surgical anxiety. 3. Smokers are at a higher risk for complications from anesthesia. 4. No infiltrates on a chest x-ray is a normal finding and does not be reported. 5. Herbs—for example, St. John's wort, licorice, and ginkgo—have serious inter- actions with anesthesia and with bodily functions such as coagulation.

The client is in the lithotomy position during surgery. Which nursing intervention should be implemented to decrease a complication from the positioning? 1. Increase the intravenous fluids. 2. Lower one leg at a time. 3. Raise the foot of the stretcher. 4. Administer epinephrine, a vasopressor.

2

The nurse is completing the preoperative checklist. Which laboratory value should be reported to the health care provider immediately? 1. Hemoglobin 13.1 g/dL. 2. Glucose 60 mg/dL. 3 3 3. White blood cells 6.0 (× 10 )/mm . 4. Potassium 3.8 mEq/L.

2

The unlicensed assistive personnel (UAP) can be overheard talking loudly to the scrub technologist discussing a problem which occurred during one (1) of the surgeries. Which intervention should the nurse in the surgical holding area with a female client implement? 1. Close the curtains around the client's stretcher. 2. Instruct the UAP and scrub tech to stop the discussion. 3. Tell the surgeon on the case what the nurse overheard. 4. Inform the client the discussion was not about her surgeon.

2

Which client assessment data are priority for the post-anesthesia care nurse? 1. Bowel sounds. 2. Vital signs. 3. IV fluid rate. 4. Surgical site.

2

Which problem would be appropriate for the nurse to identify for the preoperative client having an open reduction and internal fixation of the right ankle? 1. Alteration in skin integrity. 2. Knowledge deficit of postoperative care. 3. Alteration in gas exchange and pattern. 4. Alteration in urinary elimination.

2

The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication? 1. Alteration in comfort. 2. Risk for depressed respiratory pattern. 3. Potential for infection. 4. Fluid and electrolyte imbalance.

2. 1. Narcan does not cause pain for the client. 2. A client with respiratory depression treated with Narcan can have another episode within 15 minutes after receiv- ing the drug as a result of the short half-life of the medication. 3. Infection would not be a concern immediately after surgery. 4. Although the client may experience an imbalance in fluid or electrolytes, this problem would not be of concern as a result of the administration of Narcan.

The nursing manager is making assignments for the OR. Which case should the manager assign to the inexperienced nurse? 1. The client having open-heart surgery. 2. The client having a biopsy of the breast. 3. The client having laser eye surgery. 4. The client having a laparoscopic knee repair.

2. 1. Open-heart surgery is complex, and the care of the client should be assigned to an experienced nurse with special training. 2. The case of a client having a biopsy of the breast would be a good case for an inexperienced nurse because it is simple. 3. Laser eye surgery requires the nurse in the OR to have additional training to operate the equipment. 4. Additional training to be in the OR would be required for this case because special care to prevent infection is needed in orthopedic cases.

Which statement would be an expected outcome for the postoperative client who had general anesthesia? 1. The client will be able to sit in the chair for 30 minutes. 2. The client will have a pulse oximetry reading of 97% on room air. 3. The client will have a urine output of 30 mL per hour. 4. The client will be able to distinguish sharp from dull sensations.

2. 1. The postoperative client is expected to be out of bed as soon as possible, but this goal is not specific to having general anesthesia. 2. The anesthesia machine takes over the function of the lungs during surgery, so the expected outcome should directly reflect the client's respiratory status; the alveoli can collapse, causing atelectasis. 3. Urine output should be 30 mL/hr, but the expected outcome is not specific to general anesthesia. 4. Sensation would be an outcome assessed after use of a spinal anesthesia or block, but it is not specific to general anesthesia.

The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement? 1. Notify the surgeon about the client's request to wear the medal. 2. Tape the medal to the client and allow the client to wear the medal. 3. Request the family member take the medal prior to surgery. 4. Explain taking the medal to surgery is against the policy.

2. 1. The surgeon does not need to be notified of the client's request; this can be addressed by the nursing staff. 2. The medal should be taped and the client should be allowed to wear the medal because meeting spiritual needs is essential to this client's care. 3. The client should be allowed to bring the medal to surgery if the medal is taped to the client. 4. Hospital policies should be established for the well-being of clients, and spiritual needs should be addressed.

The circulating nurse is positioning clients for surgery. Which client has the greatest potential for nerve damage? 1. The 16-year-old client in the dorsal recumbent position having an appendectomy. 2. The 68-year-old client in the Trendelenburg position having a cholecystectomy. 3. The 45-year-old client in the reverse Trendelenburg position having a biopsy. 4. The 22-year-old client in the lateral position having a nephrectomy.

2. 1. The young client is not a high risk for nerve damage secondary to positioning. 2. The client's age, along with positioning with increased weight and pressure on the shoulders, puts this client at higher risk 3. This client is sitting in an upright position, which would not put this client at risk for nerve damage. 4. A younger client would not be at a high risk for nerve damage when lying on the side.

The nurse identifies the nursing diagnosis "risk for injury related to positioning" for the client in the operating room. Which nursing intervention should the nurse implement? 1. Avoid using the cautery unit which does not have a biomedical tag on it. 2. Carefully pad the client's elbows before covering the client with a blanket. 3. Apply a warming pad on the OR table before placing the client on the table. 4. Check the chart for any prescription or over-the-counter medication use.

2. 1. This would prevent an electrical injury, but the interventions must address positioning, which is the etiology of the nursing diagnosis. 2. Padding the elbows decreases pressure so nerve damage and pressure ulcers are prevented. This addresses the etiology of the nursing diagnosis. 3. This would help to decrease hypothermia, but it does not address the etiology of the nursing diagnosis. 4. Checking the chart for medication use would help prevent interactions between anesthesia and routine medications, but it does not address the etiology of the nursing diagnosis.

The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature, and complains of muscle stiffness. Which interventions should the nurse implement? (Select all apply.) 1. Give a back rub to the client to relieve stiffness. 2. Apply ice packs to the axillary and groin areas. 3. Prepare an ice slush for the client to drink. 4. Prepare to administer dantrolene, a smooth-muscle relaxant. 5. Reposition the client on a warming blanket.

2. 4. 1. A back rub is a therapeutic intervention, but it is not appropriate for a life-threatening complication of surgery. 2. Ice packs should be applied to the axillary and groin areas for a client experiencing malignant hyperthermia. 3. The client would be NPO to prepare for intubation, but an ice slush would be used to irrigate the bladder and stomach per nasogastric tube. 4. Dantrolene is the drug of choice for treatment. 5. Cooling blankets, not a warming blanket, are used to decrease the fast-rising temperature.

The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? (Select all that apply.) 1. Perform passive range-of-motion exercises. 2. Discuss how to cough and deep breathe effectively. 3. Tell the client he can have a meal in the PACU. 4. Teach ways to manage postoperative pain. 5. Discuss events which occur in the post-anesthesia care unit.

2. 4. 5. 1. Passive means the nurse performs the range-of-motion exercises. The client in the PACU should do active range-of-motion exercises. 2. Coughing effectively aids in the removal of pooled secretions which can cause pneumonia. Deep-breathing exercises keep the alveoli inflated and prevent atelectasis. 3. The client having abdominal surgery will be NPO until bowel sounds return, which will not occur in the PACU; therefore, the client is not given a meal. 4. The client's postoperative pain should be kept within a tolerable range. 5. These interventions help decrease the client's anxiety.

The circulating nurse observes the surgeon tossing a bloody gauze sponge onto the sterile field. Which action should the circulating nurse implement first? 1. Include the sponge in the sponge count. 2. Obtain a new sterile instrument pack. 3. Tell the surgical technologist about the sponge. 4. Throw the sponge in the sterile trashcan.

3

The male client in the day surgery unit complains of difficulty urinating postoperatively. Which intervention should the nurse implement? 1. Insert an indwelling catheter. 2. Increase the intravenous fluid rate. 3. Assist the client to stand to void. 4. Encourage the client to increase fluids.

3

The nurse is completing the preoperative checklist on a client going to surgery. Which information should the nurse report to the surgeon? 1. The client understands the purpose of the surgery. 2. The client stopped taking aspirin three (3) weeks ago. 3. The client uses the oral supplements licorice and garlic. 4. The client has mild levels of preoperative anxiety.

3

The postoperative client complains of hearing a "popping sound" and feeling "something opening" when ambulating in the room. Which intervention should the nurse implement first? 1. Notify the surgeon the client has had an evisceration. 2. Contact the surgery department to prepare for emergency surgery. 3. Assess the operative site and cover the site with a moistened dressing. 4. Explain this is a common feeling and tell the client to continue with activity.

3

Theclientinthesurgicalholdingareatellsthenurse"Iamsoscared.Ihaveneverhad surgery before." Which statement would be the nurse's most appropriate response? 1. "Why are you afraid of the surgery?" 2. "This is the best hospital in the city." 3. "Does having surgery make you afraid?" 4. "There is no reason to be afraid."

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Which client outcome would the nurse identify for the preoperative client? 1. The client's abnormal laboratory data will be reported to the anesthesiologist. 2. The client will not have any postoperative complications for the first 24 hours. 3. The client will demonstrate the use of a pillow to splint while deep breathing. 4. The client will complete an advance directive before having the surgery.

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Which nursing task would be most appropriate to delegate to the unlicensed assistive personnel (UAP) on a postoperative unit? 1. Change the dressing over the surgical site. 2. Teach the client how to perform incentive spirometry. 3. Empty and record the amount of drainage in the JP drain. 4. Auscultate the bowel sounds in all four (4) quadrants.

3

Which problem is appropriate for the nurse to identify for a client in the intraoperative phase of surgery? 1. Alteration in comfort. 2. Disuse syndrome. 3. Risk for injury. 4. Altered gas exchange.

3

Which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective? 1. "I will take my temperature each week and report any elevation." 2. "I will not need any pain medication when I go home." 3. "I will take all of my antibiotics until they are gone." 4. "I will not take a shower until my three (3)-month checkup."

3

The unlicensed assistive personnel (UAP) reports the vital signs for a first-day postoperative client as T 100.8 ̊F, P 80, R 24, and BP 148/80. Which intervention would be most appropriate for the nurse to implement? 1. Administer the antibiotic earlier than scheduled. 2. Change the dressing over the wound. 3. Have the client turn, cough, and deep breathe every two (2) hours. 4. Encourage the client to ambulate in the hall.

3. 1. Antibiotics need to be administered at the scheduled time. 2. These data would not support the need to change the dressing, and surgeons usually want to change the surgical dressing for the first time. 3. Having the client turn, cough, and deep breathe is the best intervention for the nurse to implement because, if a client has a fever within the first day, it is usually caused by a respiratory problem. 4. The client is first-day postoperative, and ambulating in the hall would not be appropriate.

The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first? 1. Apply antiembolism hose to the client. 2. Attach the drain to 20 cm suction. 3. Assess the client's vital signs. 4. Listen to the report from the anesthesiologist.

3. 1. Applying antiembolism hose may be appro- priate, but it is not the first intervention.2. Attaching a drain would be appropriate but not before assessing the client. 3. Assessing the client's status after transfer from the PACU should be the nurse's first intervention. 4. Receiving reports is not the nurse's first intervention.

The circulating nurse observes the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement? 1. Place the sponge back where it was. 2. Tell the technician not to waste supplies. 3. Do nothing because this is the correct procedure. 4. Take the sponge out of the room immediately.

3. 1. Items which are on the edge of the sterile field are considered contaminated and should be removed from the field. 2. The technician is not wasting supplies; the technician is following principles of asepsis. 3. The technician followed the correct procedure. Sponges are counted to maintain client safety, so all sponges must be kept together to repeat the count before the incision site is su- tured. The sponge must be removed, not used, and placed in a designated area to be counted later. 4. Taking the contaminated sponge out of the room would cause a discrepancy in the sponge count.

Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia? 1. Loss of sensation at the lumbar (L5) dermatome. 2. Absence of the client's posterior tibial pulse. 3. The client has a respiratory rate of eight (8). 4. The blood pressure is within 20% of client's baseline.

3. 1. Loss of sensation in the L5 dermatome is expected from spinal anesthesia. 2. Absence of a posterior tibial pulse is indicative of a block in the blood supply, but it is not a complication of spinal anesthesia. 3. If the effects of the spinal anesthesia move up rather than down the spinal cord, respirations can be depressed and even blocked. 4. This is an expected outcome and does not indicate a complication.

The nurse must obtain surgical consent forms for the scheduled surgery. Which client would not be able to consent legally to surgery? 1. The 65-year-old client who cannot read or write. 2. The 30-year-old client who does not understand English. 3. The 16-year-old client who has a fractured ankle. 4. The 80-year-old client who is not oriented to the day.

3. 1. The 65-year-old client who cannot read can mark an "X" on the form and is legally able to sign a surgical permit as long as the client understands the benefits, alternatives, and all potential complications of the surgery. 2. The client who does not speak English can and should have information given and questions answered in the client's native language. 3. A 16-year-old client is not legally able to give permission for surgery unless the adolescent has been given an emancipated status by a judge. This information was not given in the stem. 4. A client is able to give permission unless determined incompetent. Not knowing the day of the week is not significant.

Which situation demonstrates the circulating nurse acting as the client's advocate? 1. Plays the client's favorite audio book during surgery. 2. Keeps the family informed of the findings of the surgery. 3. Keeps the operating room door closed at all times. 4. Calls the client by the first name when the client is recovering.

3. 1. The client is not awake during surgery, so playing a favorite audio book would not be an example of client advocacy. 2. This would be a nice action to take, but it is not an example of client advocacy. 3. This would keep the client's dignity by maintaining privacy. With this action, the nurse is speaking for the client while the client cannot speak as a re- sult of anesthesia; this is an example of client advocacy. 4. Clients should be referred to by their last name, rather than first, unless the client requests the staff to use his or her first name. This is not an example of client advocacy.

The surgical client's vital signs are T 98 ̊F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3) and the skin is pale and damp. Which intervention should the nurse implement first? 1. Call the surgeon and report the vital signs. 2. Start an IV of D5RL with 20 mEq KCl at 125 mL/hr. 3. Elevate the feet and lower the head. 4. Monitor the vital signs every 15 minutes.

3. 1. The surgeon should be notified, but this is not the first action; the client must be cared for. 2. The postoperative client had lactated Ringer's infused during surgery. The rate should be increased during hemorrhage— which the vital signs indicate is occurring— but potassium should not be added. 3. By lowering the head of the bed and raising the feet, the blood is shunted to the brain until volume-expanding fluids can be administered, which is the first intervention for a client who is hemorrhaging. 4. When signs and symptoms of shock are observed, the nurse will monitor the vital signs more frequently than every 15 minutes.

The nurse is completing a preoperative assessment on a male client who states, "I am allergic to codeine." Which intervention should the nurse implement first? 1. Apply an allergy bracelet on the client's wrist. 2. Label the client's allergies on the front of the chart. 3. Ask the client what happens when he takes the codeine. 4. Document the allergy on the medication administration record.

3. 1. This is an important step for the nurse to implement, but it is not the first intervention. 2. This must be done, but it is not the first intervention. 3. The nurse should first assess the events which occurred when the client took this medication because many clients think a side effect, such as nausea, is an allergic reaction. 4. This information must be put on the med- ication administration record (MAR), but it is not the first intervention.

The nurse is assessing a client in the day surgery unit who states, "I am really afraid of having this surgery. I'm afraid of what they will find." Which statement would be the best therapeutic response by the nurse? 1. "Don't worry about your surgery. It is safe." 2. "Tell me why you're worried about your surgery." 3. "Tell me about your fears of having this surgery." 4. "I understand how you feel. Surgery is frightening."

3. 1. This statement is giving false reassurance. 2. "Why" is never therapeutic. The client does not owe the nurse an explanation. 3. This statement focuses on the emotion which the client identified and is therapeutic. 4. This statement belittles the client's fear, and no person understands how another person feels.

The client received naloxone (Narcan), an opioid antagonist, in the post-anesthesia care unit. Which nursing intervention should the nurse include in the care plan? 1. Measure the client's intake and output hourly. 2. Administer sleep medications at night. 3. Encourage the client to verbalize feelings. 4. Monitor respirations every 15 to 30 minutes.

4

Which statement explains the nurse's responsibility when obtaining informed consent for the client undergoing a surgical procedure? 1. The nurse should provide detailed information about the procedure. 2. The nurse should inform the client of any legal consultation needed. 3. The nurse should write a list of the risks for postoperative complications. 4. The nurse should ensure the client is voluntarily giving consent.

4

Which data indicate to the nurse the client who is one (1) day postoperative right total hip replacement is progressing as expected? 1. Urine output was 160 mL in the past eight (8) hours. 2. Paralysis and parasthesia of the right leg. 3. T 99.0 ̊F, P 98, R 20, and BP 100/60. 4. Lungs are clear bilaterally in all lobes.

4. 1. Adequate urine output should be 30 mL/hr or at least 240 mL in an eight (8)-hour period. 2. Paralysis (inability to move) and paresthesia (numbness and tingling) indicate neurovascular compromise to the right leg, which indicates a complication and is not an expected outcome. 3. The client's temperature and pulse are slightly elevated and the BP is low, which does not indicate effective nursing care. 4. Lung sounds which are clear bilaterally in all lobes indicate the client has adequate gas exchange, which prevents postoperative complications and indicates effective nursing care.

The charge nurse is making shift assignments. Which postoperative client should be assigned to the most experienced nurse? 1. The 4-year-old client who had a tonsillectomy and is able to swallow fluids. 2. The 74-year-old client with a repair of the left hip who is unable to ambulate. 3. The 24-year-old client who had an uncomplicated appendectomy the previous day. 4. The 80-year-old client with small bowel obstruction and congestive heart failure.

4. 1. The client appears stable; pediatric clients can become unstable quickly, but the most experienced nurse would not need to care for this client. 2. A client with a fractured hip will be ambu- lated by the physical therapist and this client is stable, so the most experienced nurse does not need to care for this client. 3. A young client who had an appendectomy would require routine postoperative care. 4. An older client with a chronic disease would be a complicated case, requiring the care of a more experienced nurse.

The nurse is preparing a client for surgery. Which intervention should the nurse implement first? 1. Check the permit for the spouse's signature. 2. Take and document intake and output. 3. Administer the "on call" sedative. 4. Complete the preoperative checklist.

4. 1. The client's signature, not the spouse's, should be on the surgical permit. 2. This would be important information if ab- normal, but it is not the first intervention. 3. "On call" sedatives should be administered after the surgical checklist is completed. 4. Completing the preoperative checklist has the highest priority to ensure all details are completed without omissions.

Which violation of surgical asepsis would require immediate intervention by the circulating nurse? 1. Surgical supplies were cleaned and sterilized prior to the case. 2. The circulating nurse is wearing a long-sleeved sterile gown. 3. Masks covering the mouth and nose are being worn by the surgical team. 4. The scrub nurse setting up the sterile field is wearing artificial nails.

4. 1. These are appropriate activities in a surgery department; therefore, no intervention is required. 2. This is required to maintain surgical asepsis. 3. This follows the principles of surgical asepsis. 4. According to the Centers for Disease Control and Prevention (CDC),the Association of Operating Room Nurses (AORN), and the Association for Practitioners in Infection Control, artificial nails harbor microorganisms, which increase the risk for infection.

The nurse is caring for a client scheduled for total hip replacement. Which behavior indicates the need for further preoperative teaching? 1. The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth. 2. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves the feet in a circular motion. 3. The client uses the incentive spirometer and inhales slowly and deeply so the piston rises to the preset volume. 4. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.

4. 1. This is the correct way to perform deep-breathing exercises; therefore, no further teaching is needed. 2. This is the correct way to perform range- of-motion exercises; therefore, no further teaching is needed. 3. This is the way to use a volume incentive spirometer; therefore, no further teaching is needed. 4. The correct way to get out of bed postoperatively is to roll onto the side, grasp the side rail to maneuver to the side, and then push up with one hand while swinging the legs over the side. The client needs further teaching.

Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery? 1. Calcium 9.2 mg/dL. 2. Bleeding time 2 minutes. 3. Hemoglobin 15 g/dL. 4. Potassium 2.4 mEq/L.

4. 1. This laboratory value is within normal limits. 2. This laboratory value is within normal limits. 3. This laboratory value is within normal limits. 4. This potassium level is low and should be reported to the health-care provider because potassium is important for muscle function, including the cardiac muscle.

The circulating nurse and the scrub technician find a discrepancy in the sponge count. Which action should the circulating nurse take first? 1. Notify the client's surgeon. 2. Complete an occurrence report. 3. Contact the surgical manager. 4. Re-count all sponges.

4. 1. When discrepancies occur in the count, it is usually a simple mistake discovered with a re-count. The surgeon will be notified if the count is wrong after a re-count. 2. If an error is found to have been made, an occurrence report will be completed, but it is not the first intervention. 3. This would be done if a correct count is not maintained, but it is not the first intervention. 4. A re-count of sponges may lead to the discovery of the cause of the presumed error. Usually it is just a miscount or a result of a sponge being placed in a location other than the sterile field, such as the floor or a lower shelf.

When a person's blood pressure rises, the homeostatic mechanism to compensate for an elevation involves stimulation of? A. baroreceptors that inhibit the sympathetic nervous system, causing vasodilation B. chemoreceptors that inhibit the sympathetic nervous system causing vasodilation C. baroreceptors that inhibit the parasympathetic nervous system, causing vasodilation D. chemoreceptors that stimulate the sympathetic nervous system, causing an increased heart rate

A

When assessing a patient, you note a pulse deficit of 23 beats. This finding may be caused by? a. dysrhythmias b. heart murmurs c. gallop rhythms d. pericardial friction rubs

A

Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? a. collect a detailed diet history b. provide a list of low-sodium foods c. help the patient make an appointment with a dietitian d. teach the patient about foods that are high in potassium

A

The nurse has just finished teaching a hypertensive patient about the newly prescribed ramipril (Altace). Which patient statement indicates that more teaching is needed? a. a little swelling around my lips and face is okay b. the medication may not work as well if i take any aspirin c. the doctor may order a blood potassium level occasionally d. i will call the doctor if i notice that I have a frequent couch

A - ACE inhibitor therapy should be discontinued if angioedema occurs

The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (vasotec). The charge nurse will need to intervene if the new RN tells the patient to? a. increase the dietary intake of high-potassium foods b. make an appointment with the dietitian for teaching c. check the blood pressure (BP) with a home BP monitor at least once a day d. move slowly when moving from lying to sitting to standing

A - ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect.

The nurse hears a murmur between the S1 and S2 heart sounds at the patient's left fifth intercostal space and midclavicular line. How will the nurse record this information? a. Systolic murmur heard at mitral area b. Systolic murmur heard at Erb's point c. Diastolic murmur heard at aortic area d. Diastolic murmur heard at the point of maximal impulse

A - S1 signifies the onset of ventricular systole. - S2 signifies the onset of diastole. - A murmur occurring between these two sounds is a systolic murmur

The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a. 43-year-old with a (blood pressure (BP) of 160/92 who is complaining of chest pain b. 52-year-old with a BP of 212/90 who has intermittent claudication c. 50-year-old with a BP of 190/104 who has a creatinine of 1.7 mg/dL d. 48-year-old with a BP of 172/98 whose urine shows microalbuminuria

A - pt A may be experiencing acute MI

The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg." The nurse will need to call the health care provider about the a. postoperative patient with a BP of 116/42. b. newly admitted patient with a BP of 150/87. c. patient with left ventricular failure who has a BP of 110/70. d. patient with a myocardial infarction who has a BP of 140/86.

A - the MAP is calculated using the formula MAP=(systolic BP + 2(diastolic BP) / 3

To auscultate for S3 and S4 gallops in the mitral area, the nurse listens with the? a. bell of the stethoscope with the patient in the left lateral position b. diaphragm of the stethoscope with patient in a supine position c. bell of the stethoscope with the patient sitting and leaning forward d. diaphragm of the stethoscope with the patient lying flat on the left side

A -Gallop rhythms generate low-pitched sounds are are mostly easily heard with the bell of the stethoscope -Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall -The diaphragm of the stethoscope is best to use for the higher-pitched sounds such as S1 and S2

Which nursing responsibilities are priorities when caring for a patient returning from a cardiac catheterization (select all that apply)? a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses c. Assisting the patient to ambulate to the bathroom to void d. Informing the patient that he will be sleepy from the general anesthesia e. Instructing the patient about the risks of the radioactive isotope injection

A B

A patient has a severe blockage in his right coronary artery. Which heart structures are most likely to be affected by this blockage (select all that apply)? A. AV node B. Left ventricle C. Coronary sinus D. Right ventricle E. Pulmonic valve

A B D

The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? a. serum creatine of 2.8 mg/dL b. serum potassium of 4.5 mEq/L c. serum hemoglobin of 14.7 g/dL d. blood glucose level of 96 mg/dL

A - indicates renal damage

Propranolol (infernal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this medication when the patient reveals a history of? a. asthma b. daily alcohol use c. peptic ulcer disease d. myocardial infarction (MI)

A - nonselective B-blockers block B1 and B2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma - B-blocker therapy is recommended after MI

A P wave on an ECG represents an impulse arising at the? A. SA node and repolarizing the atria B. SA node and depolarizing the atria C. AV node and depolarizing the atria D. AV node and spreading the bindle of HIS

B

A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask first? a. did you take any acetaminophen (tylenol) today? b. Have you been consistently taking your medications? c. have there been any recent stressful events in your life? d. have you recently taken any antihistamine medications?

B

A patient with hypertension who has just started taking atenolol (tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should the nurse take first? a. inform the patient about the reasons for a possible change in drug dosage b. question the patient about whether the medication is actually being taken c. inform the patient that multiple drugs are often needed to treat hypertension d. question the patient regarding any lifestyle changes made to help control BP

B

A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse? a. presses on the skin over the tibia for 10 seconds to check for edema b. palpates both carotid arteries simultaneously to compare pulse quality c. documents a murmur heard along the right sternal border as a pulmonic murmur d. places the patient in the left lateral position to check for the point of maximal impulse

B

The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP? a. Teaching a patient scheduled for exercise electrocardiography about the procedure b. Placing electrodes in the correct position for a patient who is to receive ECG monitoring c. Checking the catheter insertion site for a patient who is recovering from a coronary angiogram d. Monitoring a patient who has just returned to the unit after a transesophageal echocardiogram

B

The part of the vascular system that is responsible for hemostasis is the? A. thin capillary vessels B. endothelial layer of the arteries C. elastic middle layer of the veins D. smooth muscle of the arterial wall

B

Which heart valve sound is heard best at the left midclavicular line at the level of the fifth ICS? a. aortic b. mitral c. tricuspid d. pulmonic

B

When auscultating over the patient abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a? a. thrill b. bruit c. murmur d. normal finding

B - A bruit is the sound created by turbulent blood flow in an artery - Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel - A murmur is the sound caused by turbulent blood flow through the heart

Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider? a. blood glucose level of 175 mg/dL b. blood potassium level of 3.0 mEq/L c. Most recent blood pressure (BP) reading of 168/94 mm Hg d. orthostatic systolic BP decrease of 12 mm HG

B - Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life threatening dysrhythmias. - B and C will also require intervention but not as immediate - d is common and will require intervention is pt is symptomatic

A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first? a. start an IV line b. place the patient on NPO status c. administer O2 per nasal cannula d. give lorazepam (Ativan) 1 mg IV

B - NPO for 6 hours preceding the TEE - the other actions will need to be accomplished as well

Earn assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To document more information about the murmur, which action will the nurse take next? a. find the point of maximal impulse b. determine the timing of the murmur c. compare the apical and radial pulse rates d. palpate the quality of the peripheral pulses

B - Relevant information: position heard best (sitting, lying, leaning forward), timing of the murmur in relation to the cardiac cycle (systole, diastole), and where on the thorax the murmur is heard best

A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that? a. it will be important to lie completely still during the procedure b. a flushed feeling may be noted when the contrast dye is injected c. monitored anesthesia care will be provided during the procedure d. arterial pressure monitoring will be required for 24 hours after the test

B - a sedative drug may be used

When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is most important for the nurse to communicate to the health care provider? a. the patients pedal pulses are +1 b. the patient is allergic to shellfish c. the patient had a heart attack a year ago d. the patient has not eaten anything today

B - contrast dye is iodine based

Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient? a. deflate the BP cuff at a rate of 5 to 10 mm Hg per second b. have the patient sit in a chair with the feet flat on the floor c. assist the patient to the supine position for BP measurements d. obtain two BP readings in the dominant arm and average the results

B - cuff should be deflated 2-3 mm Hg per second

Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of diabetes mellitus? a. 102/60 mm Hg b. 128/76 mm Hg c. 139/90 mm Hg d. 136/82 mm Hg

B - goal for a patient with hypertension and diabetes mellitus is a BP <130/80

The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? a. urine output over 8 hours is 250 mL less than the fluid intake b. the patient cannot move the left arm and leg when asked to do so c. tremors are noted in the fingers when the patient extends the arms d. the patient complains of a headache with pain at level 8/10 (o to 10 scale)

B - indicates that a hemorrhagic stroke may be occurring

The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient? a. low dietary fiber intake b. no regular aerobic exercise c. weight 5 pounds above ideal weight d. drinks a beer with dinner on most nights

B - prevention includes exercising aerobically for 30 mins most days of the week - DASH diet might help which increases fiber but only fiber will not help - one drink a day will not increase the risk

A patient with a tricuspid valve disorder will have impaired blood flow between the A. vena cava and right atrium. B. left atrium and left ventricle. C. right atrium and right ventricle. D. right ventricle and pulmonary artery.

C

An expected finding in the assessment of an 81-year-old patient is? a. a narrowed pulse pressure b. diminished carotid artery pulses c. difficulty isolating the apical pulse d. an increased heart rate in response to stress

C

An older patient has been diagnosed with possible white coat hypertension. Which action will the nurse plan to take next? a. schedule the patient for regular blood pressure BP checks in the clinic b. instruct the patient about the need to decrease stress levels c. tell the patient how to self monitor and record BPs at home d. inform the patient that ambulatory blood pressure monitoring will be needed

C

The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside (Nipride). Which nursing action can the nurse delegate to an experienced licensed practical / vocational nurse (LPN/LVN)? a. titrate nitoprusside to decrease mean arterial pressure (MAP) to 115 mm Hg b. evaluate effectiveness of nitroprusside therapy on blood pressure (BP) c. set up the automatic blood pressure machine to take BP every 15 minutes d. assess the patients environment for adverse stimuli that might increase BP

C

Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan? a. insert an IV catheter b. administer oral sedative medications c. teach the patient about the procedure d. confirm that the patient has been fasting

C

Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be most important to report to the health care provider before the MRI? a. the patient has an allergy to shellfish b. the patient has a history of atherosclerosis c. the patient has a permanent ventricular pacemaker d. the patient took all the prescribed cardiac medications today

C

Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes? a. give the patient a list o low sodium, low cholesterol foods that should be included in the diet b. emphasize the increased risk or heart problems unless the patient makes the dietary changes c. help the patient modify favorite high fat recipes by using monounsaturated oils when possible d. inform the patient that a diet containing no saturated fat and minimal salt will be necessary

C - highest percentage of of calories from fat should come from monounsaturated fats

Which action should the nurse take when administering the initial dose of oral labetalol (Normodyne) to a patient with hypertension? a. encourage the use of hard candy to prevent dry mouth b. instruct the patient to ask for help if heart palpitations occur c. ask the patient to request assistance when getting out of bed d. teach the patient that headaches may occur with this medication

C - labetalol decreases sympathetic nervous system activity by blocking both and B-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension.

During change-of-shift report, the nurse obtains the following information about a hypertensive patient who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention? a. the patients most recent blood pressure (BP) reading is 158/91 mm Hg b. the patients pulse has dropped from 68 to 57 beats/minute c. the patient has developed wheezes throughout the lung fields d. the patient complains that the fingers and toes feel quite cold

C - wheezes indicate bronchospasm

The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be? a. myoglobin b. low-density lipoprotein (LDL) cholesterol c. troponin T and I d. creatine kinase-MB (CK-MB)

C - Cardiac troponin start to elevate 4 to 6 hours after myocardial injury - Myoglobin rises in response to myocardial injury with 30 to 60 minutes - Creatine kinase (CK-MB) is specific to myocardial injury and infarction and increases 4 to 6 hours after the infarction occurs

The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which patient laboratory result is most important to communicate as soon as possible to the health care provider? a. patient whose triglyceride level is high b. patient who has very low homocysteine level c. patient with increase in troponin T and troponin I level d. patient with elevated high-sensitivity C-reactive protein level

C - Elevation of troponin T and I indicates that the patient has had an acute myocardial infarction - Other labs are associated with risk

Which information should the nurse include when teaching a patient with newly diagnosed hypertension? a. increasing physical activity will control blood pressure (BP) for most patients b. most patients are able to control BP through dietary changes c. annual BP checks are needed to monitor treatment effectiveness d. hypertension is usually asymptomatic until target organ damage occurs

D

While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Which action should the nurse take next? a. document this finding in the patients record b. obtain vital signs, including oxygen saturation c. have the patient perform the valsalva maneuver d. observe for JVD with the patient upright at 45 degrees

D

After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective? a. The patient avoids eating nuts or nut butters. b. The patient restricts intake of chicken and fish. c. The patient has two cups of coffee in the morning. d. The patient has a glass of low-fat milk with each meal.

D - DASH diet includes increase intake of calcium rich foods. and nuts are high in nutrients and 4 to 5 servings weekly are recommended

When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse? a. Patient complaint of feeling tired b. Pulse change from 87 to 101 beats/minute c. Blood pressure (BP) increase from 134/68 to 150/80 mm Hg d. Newly inverted T waves on the electrocardiogram

D - ECG changes associated with coronary ischemia (such as T-wave inversions and ST segment depression) indicate that the myocardium is not getting adequate oxygen delivery and that the exercise test should be terminated immediately

When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the? a. family history of coronary artery disease b. increased risk associated with the patients gender c. increased risk of cardiovascular disease as people age d. elevation of the patients low-density lipoprotein (LDL) level

D - decreases in LDL will help reduce the pt risk for developing CAD

Which action will be included in the plan of care when the nurse is caring for a patient who is receiving nicardipine (cardene) to treat a hypertensive emergency? a. keep the patient NPO to prevent aspiration caused by nausea and possible vomiting b. organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night c. assist the patient up in the chair for meals to avoid complications associated with immobility d. use an automated noninvasive blood pressure machine to obtain frequent blood pressure (BP) measurements

D - frequent monitoring of BP is needed when the pt is receiving rapid-acting IV antihypertensive medications - maintain bedrest to prevent decreased cerebral perfusion and fainting

The nurse teaches the patient being evaluated for rhythm disturbances with a halter monitor to? a. connect the recorder to a computer once daily b. exercise more than usual while the monitor is in place c. remove the electrodes when taking a shower or tub bath d. keep a diary of daily activities while the monitor is worn

D - patients should not shower - should continue with their usual daily activities - it stores information about the patients rhythm until the end of testing when removed then the data us analyzed

While doing the admission assessment for a thin 76-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take? a. Teach the patient about aneurysms. b. Notify the hospital rapid response team. c. Instruct the patient to remain on bed rest. d. Document the finding in the patient chart.

D - this is common in thin individuals unless there is a bruit, pain, or hyper/hypotension associated with the pulsation

When reviewing the 12-lead electrocardiograph (ECG) for a healthy 79-year-old patient who is having an annual physical examination, what will be of most concern to the nurse? a. the PR interval is 0.21 sec b. the QRS duration is 0.13 sec c. there is a right bundle branch block d. there heart rate is 42 beats/min

D A-C are common changes in older adults but the HR should not change with age

During a physical examination of a 74-year-old patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The most appropriate action for the nurse to take next will be to? a. ask the patient about risk facts for atherosclerosis b. document that the psi is in the normal anatomic location c. auscultate both the carotid arteries for the presence of a bruit d. asses the patient for symptoms of left ventricular hypertrophy (cardiac enlargement)

D PMI should be at the intersection of the 5th intercostal space and left midclavicular line.

To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory results will the nurse plan to review? a. troponin b. homocysteine (Hcy) c. low-density lipoprotein (LDL) d. B-type natruiretic peptide (BNP)

D - BNP risk for heart failure - A-C assess for myocardial infarction (troponin) or risk for coronary artery disease

A patient has just been diagnosed with hypertension and has been started on captopril (Capoten). Which information is important to include when teaching the patient about this medication? a. check blood pressure (BP) in both arms before taking the medication b. increase fluid intake if dryness of the mouth is a problem c. include high-potassium foods such as bananas in the diet d. change position slowly to help prevent dizziness and falls

D - angiotensin-converting enzyme (ACE) inhibitors frequency cause orthostatic hypotension - increasing fluids may counteract the medication and patient is taught to use gum or hard candy to relieve dry mouth - BP should be taken in the non dominant arm in the morning for newly diagnosed before the medication and in the evening - ACE inhibitors cause potassium retention so increase intake of potassium would be inappropriate

The nurse is caring for a 70-year-old who uses hydrochlorothiazide (hydrodiuril) and enalalrip (norvasc), but whose self-monitored blood pressure (BP) continues to be elevated. Which patient information may indicate a need for a change? a. patient takes a daily multivitamin tablet b. patient checks BP daily just after getting up c. patient drinks wine three or four times a week d. patient uses ibuprofen (motrin) daily to treat osteoarthritis

D -NSAIDs can prevent adequate BP control, the pt may need to avoid the use if ibuprofen. - multivitamin will help supply vitamin D, which may help lower BP

After noting a pulse deficit when assessing a 74-year-old patient who has just arrived in the emergency department, the nurse will anticipate[ate that the patient may require? a. emergent cardioversion b. a cardiac catheterization c. hourly blood pressure (BP) checks d. electrocardiographic (ECG) monitoring

D Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would best be detected with ECG monitoring.