Med Surg II Exam

About which laboratory values should the nurse be immediately concerned because they could cause cardiac arrest? Select all that apply. 1.Calcium 7.9 mg/L 2.Potassium 5.9 mEq/L 3.Sodium 138 mEq/L 4.Chloride 104 mEq/L 5.Magnesium 1.7 mg/dL

1.Calcium 7.9 mg/L 2.Potassium 5.9 mEq/L

You are reviewing the lab results of a male client recently admitted to your coronary care unit. Which of the following lab results are abnormal? K 3.2 Plts 90,000 BUN 15 Cr 1.9 Na 141

K Plts Cr

An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that—my dad takes that for his heart. There's nothing wrong with my heart." Which description best describes the client's response? 1.Angry 2.Denial 3.Phobic 4.Obsessive-compulsive

2.Denial

The nurse is assisting in developing a plan of care for a client who will be returning to the nursing unit following a cardiac catheterization via the femoral approach. Which nursing intervention should be included in the postprocedure plan of care? 1.Place the client's bed in the Fowler's position. 2.Encourage the client to increase fluid intake. 3.Instruct the client to perform range-of-motion exercises of the extremities. 4.Hold regularly scheduled medications for 24 hours following the procedure.

2.Encourage the client to increase fluid intake

a provider orders 2.0mg/kg of a drug for a pt weighing 97 lbs. the drug is available as 175mg/ 2ml. how many ml must the nurse administer?

1 ml

The nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse should do which intervention to effectively accomplish this goal? 1.Provide a quiet and low-stimulus environment. 2.Encourage the family to come visit very frequently. 3.Encourage the client to call friends and relatives each day. 4.Recommend that the client watch TV as a constant diversion.

1. Provide a quiet and low-stimulus environment

A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action? 1.Assist the client to get back into bed. 2.Report the chest pain episode to the health care provider. 3.Tell the client to stand still, and take the client's blood pressure. 4.Give a nitroglycerin tablet, and assist the client to the bathroom.

1. assist the client to get back to bed

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse (RN) and expects which interventions to be prescribed? Select all that apply. 1.Administering oxygen 2.Inserting a Foley catheter 3.Administering furosemide 4.Administering morphine sulfate intravenously 5.Transporting the client to the coronary care unit 6.Placing the client in a low-Fowler's side-lying position

1.Administering oxygen 2.Inserting a Foley catheter 3.Administering furosemide 4.Administering morphine sulfate intravenously

The nurse is preparing for a health fair about tobacco use and the development of coronary heart disease. Which information should the nurse include? Select all that apply. 1.Nicotine decreases oxygen to the heart. 2.Hypnosis may be helpful to stop smoking. 3.Avoid exposure to environmental tobacco smoke. 4.Cigars or pipes are healthier than cigarette smoking. 5.Tobacco smoking increases a female's level of estrogen.

1.Nicotine decreases oxygen to the heart. 2.Hypnosis may be helpful to stop smoking. 3.Avoid exposure to environmental tobacco smoke

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. Next, the nurse should check the client's medical history for which item? 1.Smoking history 2.Recent exposure to allergens 3.History of recent insect bites 4.Familial tendency toward peripheral vascular disease

1.Smoking history

The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use? 1.Surgical tourniquet 2.Dry sterile dressings 3.Incentive spirometer 4.Over-the-bed trapeze

1.Surgical tourniquet

The nurse is assisting a client admitted to the hospital with pulmonary edema to prepare for discharge. The nurse should reinforce with the client the importance of complying with which measure to prevent a recurrence? 1.Weigh self every morning before breakfast. 2.Sleep with the head elevated on only one pillow. 3.Take additional digoxin if respiratory distress occurs. 4.Adjust diuretic dose based on severity of peripheral edema.

1.Weigh self every morning before breakfast.

The nurse is reinforcing instructions to a client with angina pectoris about measures to reduce recurrence of chest pain. The nurse should stress to the client the importance of taking which measure? 1. Saving all chores for the end of the day 2. Avoiding exposure to either very hot or very cold weather 3. Eating large meals to reduce the work of the gastrointestinal tract 4. Keeping items stored above shoulder level to encourage exercise

2. Avoiding exposure to either very hot or very cold weather

A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. The nurse should take which action? 1. Get a prescription for pain medication. 2. Have the client stop and lie back down in bed. 3. Report the complaint to the health care provider. 4. Have the client continue to get out of bed and into a chair.

2. Have the client stop and lie back down in bed.

A provider orders 10000mcg of a drug for a patient. The drug is available at 4mg/tablet. How many tablets should the nurse administer?

2.5 tablets

A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL (16.2 mmol/L) and a serum creatinine level of 2.2 mg/dL (193.6 mcmol/L) has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for which condition? 1.Hypovolemia 2.Acute kidney injury 3.Glomerulonephritis 4.Urinary tract infection

2.Acute kidney injury

A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The nurse should take which action first? 1.Check the client's vital signs. 2.Assist the client to sit or lie down. 3.Administer sublingual nitroglycerin. 4.Apply nasal oxygen at a rate of 2 L/min.

2.Assist the client to sit or lie down.

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed? 1.Strict bed rest for 24 hours 2.Bathroom privileges and self-care activities 3.Unrestricted activities because the client is monitored 4.Unsupervised hallway ambulation with distances less than 200 feet

2.Bathroom privileges and self-care activities

A client is wearing a continuous cardiac monitor which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which action first? 1.Call a code blue. 2.Check the client status and lead placement. 3.Call the primary health care provider (PHCP). 4.Press the recorder button on the ECG console.

2.Check the client status and lead placement.

The nurse is assisting with caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? 1.Limiting movement and abduction of the left arm 2.Limiting movement and abduction of the right arm 3.Assisting the client to get out of bed and ambulate with a walker 4.Having the physical therapist do active range of motion to the right arm

2.Limiting movement and abduction of the right arm

The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse? 1.Blood pressure 2.Status of airway 3.Oxygen flow rate 4.Level of consciousness

2.Status of airway

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving if which breath sounds are noted? 1.Rhonchi 2.Wheezes 3.Crackles in the lung bases 4.Crackles throughout the lung fields

3. Crackles in the lung bases

The nurse has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? "1. I need to substitute eggs and milk for meat." 2."I will eliminate all cholesterol and fat from my diet." 3."I should routinely use polyunsaturated oils in my diet." 4."I need to seriously consider becoming a strict vegetarian."

3."I should routinely use polyunsaturated oils in my diet."

The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse should expect to note which specific characteristic of this condition? 1.Dyspnea 2.Hacking cough 3.Dependent edema 4.Crackles on lung auscultation

3.Dependent edema

The nurse monitors the laboratory data on a client at risk for coronary artery disease. A fasting blood glucose reading of 200 mg/dL is recorded on the chart. The nurse analyzes this result as indicative of which finding? 1.Decreased, indicating a decreased risk of coronary artery disease 2.Elevated, but would not present a risk for coronary artery disease 3.Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease 4.Normal, indicating adequate blood glucose control with no risk for coronary artery disease

3.Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. Which is a life-threatening complication that could be occurring? 1.Pneumonia 2.Pulmonary edema 3.Pulmonary embolism 4.Myocardial infarction

3.Pulmonary embolism

A client is admitted to the hospital with possible rheumatic endocarditis. The nurse should check for a history of which type of infection? 1.Viral infection 2.Yeast infection 3.Streptococcal infection 4.Staphylococcal infection

3.Streptococcal infection

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and conducting an initial assessment, the nurse assisting in caring for the client expects the cardiologist to write a prescription for the client to remain on bed rest. In which position should the bed be positioned? 1.In the high-Fowler's position 2.With the head of bed elevated at least 60 degrees 3.With the head of bed elevated no more than 30 degrees 4.With the foot of bed elevated as much as tolerated by the client

3.With the head of bed elevated no more than 30 degrees

A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions? 1."I am considering cutting my workload." 2."I need to cut down on cigarette smoking." 3."I am so relieved that my heart is repaired." 4."I need to adhere to my dietary restrictions."

4. "I need to adhere to my dietary restrictions."

The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse should plan to maintain bed rest for this client in which position? 1.High-Fowler's position 2.Supine with no head elevation 3.Left lateral (side-lying) position 4.Supine with head elevation no greater than 30 degrees

4. Supine with head elevation no greater than 30 degrees

A client in a long-term care facility who has a history of angina pectoris wants to go for a short walk outside with a family member. It is a sunny but chilly December day. The nurse should perform which intervention to care for this client in a holistic manner? 1.Tell the client that this is not allowed. 2.Tell the family member not to take the client outdoors. 3.Give the client a cup of hot coffee before going outside. 4.Instruct the family member to dress the client warmly before going outside.

4.Instruct the family member to dress the client warmly before going outside.

The nurse is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation? 1.Provide the client with a walker. 2.Remove the telemetry equipment. 3.Encourage the client to cough and deep breathe. 4.Premedicate the client with an analgesic before ambulating.

4.Premedicate the client with an analgesic before ambulating.

A client is scheduled for a cardiac catheterization using a radiopaque dye. The nurse checks which most critical item before the procedure? 1.Intake and output 2.Height and weight 3.Peripheral pulse rates 4.Prior reaction to contrast media

4.Prior reaction to contrast media

When preparing a client for a pericardiocentesis, in which position does the nurse place the client? 1.Supine with slight lowering of the head 2.Lying on the right side with a pillow under the head 3.Lying on the left side with a pillow under the chest wall 4.Supine with the head of bed elevated at a 45- to 60-degree angle

4.Supine with the head of bed elevated at a 45- to 60-degree angle

The nurse's assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should consequently identify what nursing diagnosis in the patient's plan of care? A) Risk for ineffective breathing pattern related to hypotension B) Risk for falls related to orthostatic hypotension C) Risk for ineffective role performance related to hypotension D) Risk for imbalanced fluid balance related to hemodynamic variability

B) Risk for falls related to orthostatic hypotension

a long term care facility is the site of an outbreak of infectious diarrhea. the nurse educator has emphasized the importance of hand hygiene to staff members. the use of alcohol based cleansers may be ineffective if the causative agent is identified as what? a. Clostridium difficile b. e coli c. shigella d. Staphylococcus aureus

a. Clostridium difficile

the nurse cares for a patient who is scheduled for a cardiac cath. prior to the procedure what is the most important question to ask when screening? a. are you allergic to shellfish? b.do you have a hx of CP? c. what have your BS readings been this week? d. what did you eat for bfast?

a. are you allergic to shellfish?

a client on the medical unit is found to have TB. what is the most appropriate precaution for the staff to take to prevent the transmission? a.standard & airborne precautions b. standard and contact c. droplet d. standard only

a.standard & airborne precautions

SNS stimulation to the heart results in: a. increased HR and warm dry skin b. increased HR and cool moist skin c. decreased HR and slower conduction d. decreased HR and slower automaticity

b. increased HR and cool moist skin

while assessing a bed ridden client the nurse notes the presence of sacral edema. which is most likely to contribute to edema? a.L sided HF b.R sided HF c. PE d. diabetes

b.R sided HF

a medical nurse is careful to adhere to infection control protocols, incl handwashing. which statement about handwashing supports the nurse's practice? a. wearing gloves is known to be an adequate substitute for handwashing b. waterless products should be avoided in situations where running water is unavailable c.freq handwashing reduces transmission of pathogens from one client to another d. bar soap is preferable to liquid soap

c.freq handwashing reduces transmission of pathogens from one client to another

you are teaching a client about coronary blood flow. which statement below would be correct? a.coronary arteries receive most of the blood flow during systole b. blood flow to coronary arteries is related only to breathing patterns c.most of the blood flow to the coronary arteries is supplied during diastole d. most of the blood flow to the coronary arteries in supplied during inspiration

c.most of the blood flow to the coronary arteries is supplied during diastole

A client diagnoses with this form of angina presents with predictable level of pain that occurs during physical or emotional stress. What is: a.crescendo angina b.unstable angina c.stable angina d. microvascular angina

c.stable angina

you are caring for a patient who is post right groin entry cardiac catheterization. which of the following would be a priority concern when caring for this patient? a. BP 100/56, HR 88 b. O2 sat of 94%, RR 16 c.patient complaint of pain at R femoral insertion site d. patient complaint of numbness of right foot

d. patient complaint of numbness of right foot

The nurse determines that a client with coronary artery disease (CAD) understands disease management if the client makes which statement? 1."I will walk for one-half hour daily." 2."As long as I exercise I can eat anything I wish." 3."My weight has nothing to do with this disease." 4."It doesn't matter if my father had high cholesterol."

1."I will walk for one-half hour daily."

The primary health care provider (PHCP) is going to perform carotid massage on a client with rapid rate atrial fibrillation. Which interventions should the nurse anticipate? Select all that apply. 1.The client should be placed on a cardiac monitor. 2.The PHCP massages the carotid artery for a full minute. 3.The head should be turned toward the side to be massaged. 4.Rhythm strips should be obtained before, during, and after the procedure. 5.Monitor the vital signs, cardiac rhythm, and level of consciousness after the procedure.

1.The client should be placed on a cardiac monitor. 4.Rhythm strips should be obtained before, during, and after the procedure. 5.Monitor the vital signs, cardiac rhythm, and level of consciousness after the procedure.

The nurse is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply. 1.Wear elastic stockings. 2.Be careful not to injure the legs or feet. 3.Use a heating pad on the legs to aid vasodilation. 4.Walk each day to increase circulation to the legs. 5.Cut down on the amount of fats consumed in the diet.

2.Be careful not to injure the legs or feet. 4.Walk each day to increase circulation to the legs. 5.Cut down on the amount of fats consumed in the diet.

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds expecting to hear which breath sounds bilaterally? 1.Rhonchi 2.Crackles 3.Wheezes 4.Diminished breath sounds

2.Crackles

The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage does the nurse instruct the client to select from the menu? 1.Tea 2.Cola 3.Coffee 4.Lemonade

4. lemonade

The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to the client to try to motivate the client to quit smoking? 1."Since the damage has already been done, it will be all right to cut down a little at a time." 2."None of the cardiovascular effects are reversible, but quitting might prevent lung cancer." 3."If you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year." 4."If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."

4."If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."

A resident of a long term care facility has reported chest pain to a nurse. What aspect of the resident's pain would be most suggestive of angina as the cause? a. the pain occurs immediately upon physical exertion b. the pain is worse when the resident inhales deeply c. the pain is worse when the resident coughs d. the pain most severe when the resident moves his upper body

a. the pain occurs immediately upon physical exertion

which of the following practices is most consistent with standard precautions? a. washing hands immediately after removing gloves b. double gloving when working with a client who has a blood-borne illness c. wearing a masking and gown when starting an IV line d. recapping all needles promptly after use to prevent needlestick injuries

a. washing hands immediately after removing gloves

the nurse is providing discharge teaching to a pt diagnosed with HF and angina. which of the following should be included in this gentleman's discharge teaching regarding self-care? SATA a.monitor weight monthly until weight stabilizes b. follow a low fat, low sodium diet c. increase the intensity of daily exercise until you develop chest plan d.if nitro is required for chest pain, sit down prior to taking it e. nitro should be replaced every 6 months once opened

b. follow a low fat, low sodium diet d.if nitro is required for chest pain, sit down prior to taking it e. nitro should be replaced every 6 months once opened

which assessment finding would alert the nurse that the patient may be experiencing a MI? a.4+ swelling of feet and ankles b. pain radiating to the neck and jaw c. pink, foamy sputum d.hoarseness

b. pain radiating to the neck and jaw

A patient is receiving furosemide (lasix) for therapeutic diuresis. When administering lasix, which level will require priority monitoring, and possible replacement d/t this diuresis? a. sodium b.potassium c. mag d. chloride

b. potassium

you are ambulating a pt in the hall when she suddenly complains of CP. which of the following would you do FIRST? a. draw isoenzymes b.administer sublingual nitro c. assist the pt to a sitting position d. have the pt ambulate back to her bed

c. assist the pt to a sitting position

a cardiac stress test is contra-indicated: a.in the client who requires an assessment of chest pain b, in the client who requires a functional assessment of current cardiac status c. in the client who is experiencing aortic stenosis d.in the client who is 6-8 week post MI to assess status

c. in the client who is experiencing aortic stenosis