Med Surge - Exam 4
The nurse is assessing a female patient with a family history of coronary artery disease (CAD). Which report is most concerning to the nurse?
"I stay tired all of the time, and it feels like my bra is too tight."
The nurse is caring for a patient who is scheduled to undergo a stress echocardiogram. Which statement indicates that the nurse's teaching about preparation for the test has been successful?
"I will have to move extremely quickly from the treadmill to the table."
The home health nurse assesses the patient taking ferrous sulfate (Feosol). Which patient statement alerts the nurse that teaching is necessary regarding this medication?
"It tastes better when I take my medicine with milk."
The nurse is providing patient teaching to a pregnant patient who works as a cashier in a grocery store. Which suggestion by the nurse will help most in preventing varicose veins?
"March in place" while standing at the counter.
The nurse is teaching a patient about the purpose of his telemetry. Which statement indicates that the nurse's teaching has been successful?
"The nurses will be able to monitor my heart rate and rhythm."
An 86-year-old patient asks why her ankles have a brownish discoloration and the skin looks so thick. Which is the most accurate response by the nurse?
"The valves in the vessels in your legs aren't working as well as they used to, which causes the discoloration and thickening of your skin."
The nurse is caring for a patient on lisinopril (Zestril). The patient asks how this medication affects blood pressure. Which response best explains the medication's effects?
"This medication lowers blood pressure by blocking an enzyme that causes blood vessels to constrict."
The nurse is caring for a patient with pernicious anemia. The patient asks the nurse why she experiences constant fatigue. Which response most accurately answers the patient's question?
"Your anemia causes inadequate oxygen delivery to your cells, which causes you to feel fatigue."
Which disorder(s) is/are examples of congenital heart defects? (Select all that apply.)
-Coarctation of the aorta -Septal defects -Valvular defects
Which age-related changes occur in the hematologic system? (Select all that apply.)
-Decreased blood volume -Decreased bone marrow production -Decreased rate of blood cell production -Increased clotting time
Which preventative measure(s) may protect against development of cardiovascular disease? (Select all that apply.)
-Exercising regularly for at least 30 minutes -Maintaining high-density lipoprotein (HDL) greater than 50 mg/dL -Refraining from smoking -Obtaining and maintaining a healthy weight
The nurse is assessing a patient with a dark complexion for cyanosis. To ensure the most accurate assessment, which locations should the nurse inspect? (Select all that apply.)
-Gums -Roof of the mouth
Which factors may affect the volume of cardiac output? (Select all that apply.)
-Heart rate -Preload -Contraction strength -Afterload
Which actions should the nurse take to help the severely anemic patient conserve energy? (Select all that apply.)
-Manage care to include frequent rest periods. -Assist with activities of daily living (ADLs). -Place personal care items close at hand. -Arrange for small meals with between-meal snacks.
The patient with AML has a platelet count of 95,000. What interventions should be included in the plan of care for this patient? (Select all that apply.)
-Observe for melena and hematuria. -Measure abdominal girth daily. -Apply ice and pressure to puncture sites. -Use electric razor.
Which assessment technique assures accuracy in daily abdominal girth measurement? (Select all that apply.)
-Place marks on the lateral sides of the abdomen where the tape is placed. -Use the same tape every day. -Measure the same area every day. -Measure girth at the same time every day.
Which modifiable risk factors increase a patient's risk for heart disease? (Select all that apply.)
-Smoking -Obesity -Sedentary lifestyle
Which organ(s) compose the lymphatic system? (Select all that apply.)
-Thymus -Lymph nodes -Spleen
Which statement(s) describe functions of blood? (Select all that apply.)
-To transport blood gases -To regulate pH by buffering -To regulate fluid distribution -To regulate body temperature
The nurse is caring for a patient with Raynaud's disease who is employed as a construction worker, has hypertension, and smokes 1/2 to 1 pack of cigarettes per day. What teaching points should the nurse include in discharge instructions? (Select all that apply.)
-Wear gloves during cool weather -Insulated socks are advisable when working in cool weather. -Attend a smoking program. -Wear gloves when handling hot objects at work.
The nurse monitoring a patient who is receiving a transfusion will stop the transfusion in the event of the patient complaining of: (Select all that apply.)
-a headache. -back pain. -a rash. -urticaria.
Aplastic anemia has its etiology in a variety of drugs, such as: (Select all that apply.)
-antimetabolite cancer drugs. -phenylbutazone (Butazolidin) -chloramphenicol (Chloromycetin). -sulfonamides.
The nurse anticipates that the patient with venous insufficiency will need an intervention for: (Select all that apply.)
-assessment for phlebitis. -elevating feet to reduce edema. -strategies to decrease itching. -approach to regular exercise.
Some of the causes of leukemia are thought to be: (Select all that apply.)
-exposure to radiation. -exposure to pesticides. -exposure to benzene.
The nurse recommends to a patient with iron deficiency anemia to include foods high in iron, such as: (Select all that apply.)
-liver. -lima beans. -prune juice. -dried apricots.
The nurse in a long-term care facility designs a teaching program for the residents to help prevent peripheral vascular disease (PVD) caused by age-related changes, which include: (Select all that apply.)
-loss of elasticity in vessel walls. -atherosclerotic vessels. -sedentary practices. -weakened leg muscles.
Peripheral vascular disease (PVD) is characterized by: (Select all that apply.)
-narrowing of arteries. -obstruction of veins -defective valve function. -production of thrombophlebitis.
The nurse instructs that the "6 Ps" of arterial disease include: (Select all that apply.)
-pain. -paresthesia -pallor
The nurse makes a visual aid differentiating between mild, moderate, and severe anemia. The signs and symptoms of mild anemia include: (Select all that apply.)
-palpitations. -dyspnea on exertion.
The nurse is aware that the patient with a nutritional anemia is lacking the nutrients: (Select all that apply.)
-proteins. -folic acid. -iron
The nurse outlines methods of prevention of peripheral vascular disease (PVD), which include: (Select all that apply.)
-relieving stress. -controlling diabetes. -maintaining appropriate weight. -routinely exercising. -stopping smoking.
The nurse cautions the patient with uncontrolled hypertension that the consequences of the disease will include: (Select all that apply.)
-threat of a stroke. -possible kidney failure. -risk for heart attack. -probability of congestive heart failure.
The nurse plans to enhance blood flow in the 80-year-old long-term care facility resident by interventions such as: (Select all that apply.)
-using lap throws or light blankets over legs while sitting -encouraging walking. -coaching isometric exercises. -keeping environment warm.
What is the average life span of a platelet cell?
10 Days
What is the average life span of a RBC
120 Days
Hypertension is diagnosed by the finding of a blood pressure reading greater than:
140/90 twice, 2 weeks apart.
When using a 0 to 4+ scale to grade pulse quality, how should the nurse record a normal volume pulse?
3+
Blood must be started within _____ minutes of its arrival on the unit.
30
The nurse is caring for a patient with a blood pressure of 140/90, an apical pulse of 82, and a radial pulse of 76. Which value indicates that the nurse accurately calculated the patient's pulse pressure?
50
If melena appears, a minimum of what amount of blood has been deposited into the gastrointestinal (GI) tract?
50 mL
The student nurse is planning a presentation on hypertension to present in a community setting. Which group of individuals should the student identify as having the highest incidence of hypertension?
African Americans
When the nurse notes a rise in the eosinophil count, which problem does she suspect?
Allergy
The nurse is caring for a patient whose complete blood count reports an abnormal amount of "bands," or immature granulocytes. Based on this finding, which problem does the nurse suspect?
An ongoing bacterial infection
The nurse is caring for a patient with pernicious anemia immediately following a bone marrow biopsy of the left posterior iliac crest. Which action should the nurse perform first?
Apply pressure to the site for 5 minutes with an ice pack.
Which statement about the hematologic system is accurate?
"African Americans have the highest incidence of sickle cell disease."
The nurse is planning the care for a patient who is to have a saphenous vein stripping. What will be the priority intervention?
Bed rest and leg elevation for the first 12 to 24 hours
Jaundice results from excessive release of which substance into the bloodstream?
Bilirubin
The patient asks if it is harmful for him to drink a glass of wine with dinner on a daily basis. Which is the nurse's best response?
"As long as it is okay with your physician, moderate alcohol intake can be beneficial to your cardiovascular health."
The nurse is caring for an older adult patient. A family member of the patient seems to frequently catch colds. Which response is best?
"Bone marrow activity decreases by about 50% with aging, which lowers the immune response to infection."
The nurse is caring for a patient with a history of hypertension. Which information is most important for the nurse to obtain?
"Do you use over-the-counter decongestants or diet pills?"
The nurse evaluates a need for further instruction to the patient with sickle cell anemia when he says:
"I am looking forward to my annual ski trip to Colorado."
The 65-year-old patient complains of leg pain that disappears at rest after having walked a short distance. The nurse recognizes that the patient's symptoms are consistent with which problem?
Claudication
The nurse is caring for a patient diagnosed with an abdominal aortic aneurysm. The patient is complaining of intense abdominal pain and lightheadedness. The patient's blood pressure has dropped and pulse is rising. What is the priority nursing intervention?
Contact the physician immediately.
The 75-year-old diabetic patient has an inflamed area at the shin caused by scratching. Which intervention should the nurse perform first?
Cover with clear occlusive dressing.
The nurse is reviewing laboratory reports for multiple patients. Which patient's laboratory values require the nurse's immediate attention?
Hemoglobin (Hgb) of 7.1 g/dL; white blood cell (WBC) count of 4500 mL/mm3
The nurse assessing a patient with a deep venous thrombosis (DVT) becomes concerned when the patient demonstrates which sign or symptom?
Hemoptysis
The patient has been prescribed a low-sodium diet. Which food omissions from the diet will indicate the patient has an adequate understanding of the recommended diet?
Hot dogs
The nurse is caring for an older adult patient who is confused and irritable. The nurse reviews the patient's history and notes that it is negative for dementia. Which potential underlying problem should the nurse suspect?
Hypoxia
The patient who is on daily doses of warfarin is instructed in the use of a coagulation monitoring device. The patient is taught that the device will monitor which blood clotting time?
INR
The nurse is initiating the care plan for a patient with peripheral arterial disease, who complains of pain in the lower extremities at a 3/10, has a 0.5 cm 1 cm ulcer on the left lower leg, and the lower legs are shiny and hairless bilaterally. What is the priority nursing diagnosis?
Impaired skin integrity related to ulcer on lower extremity
The 85-year-old patient with a newly diagnosed heart murmur expresses concern that he has never been notified of this finding before. What is the most likely cause of this patient's heart murmur?
Insufficient valves
The nurse is outlining a teaching program for diabetic patients. Which teaching point about heart disease prevention should the nurse emphasize most?
Keep blood sugar below 100 mg/dL.
Which organ releases the erythropoietin-stimulating factor that directs stem cells in the bone marrow to make blood cells?
Kidney
The nurse is caring for an older adult patient. While auscultating the patient's apical pulse, the nurse notices an irregular rhythm. The nurse suspects which causative factor for the patient's dysrhythmia?
Loss of cells in the sinoatrial (SA) nodes
Which layer of the heart contains muscle fibers that contract to pump blood?
Myocardium
The nurse is reviewing a patient's assessment data upon admission to the acute care facility. Which finding best indicates iron deficiency anemia?
Pale conjunctiva
In a blood pressure of 120/80, what does the "80" indicate?
Pressure in the relaxed ventricles
The nurse is caring for a patient who is taking radiation treatments. The patient has a platelet count of 100,000/mm3. Which action is most important for the nurse to add to the patient's care plan?
Remove the clutter from the patient's room
The nurse is caring for a 50-year-old patient who complains of tingling in his toes. Which other assessment finding would cause the nurse to suspect arterial insufficiency?
Shiny, hairless legs
Which organ can help the body compensate in the event of a massive hemorrhagic episode by contracting and adding blood to the circulating volume?
Spleen
The nurse is caring for an 80-year-old African American patient. On assessment, the nurse observes yellow sclera. Which other finding would support the nurse's suspicion that hemolysis is occurring?
Tea colored urine
The nurse is caring for a patient who just returned from a transradial heart catheterization. Which action indicates the priority care for the postprocedure period?
The nurse places the pulse oximeter on the thumb or first digit of the affected hand.
While performing a focused cardiac assessment, the nurse auscultates an abnormal swooshing sound. Which action is most appropriate to clarify the nurse's finding?
The nurse uses the bell of the stethoscope while asking the patient to lean forward.
Change question stem, answer options, rationale, and cognitive level as follows:
The student chooses a 1 1/2 inch needle.
Which statement accurately describes the purpose of a Doppler flow study?
To visualize obstructions in leg vessels
The nurse is educating a female patient with a family history of coronary artery disease (CAD) about risk factors and prevention of heart disease in women. Which information is most important for the nurse to include?
Women should incorporate stress reduction techniques into their daily lifestyle.
The patient with acute myelogenous leukemia (AML) asks why he is making more WBCs when he already has so many. The nurse clarifies that the large number of leukemic white cells he already has:
are not as effective as normal white cells would be.
The patient is instructed that the most common and effective antiplatelet aggregation agent is:
aspirin.
The patient with a deep venous thrombosis is on a protocol of IV urokinase. The nurse clarifies that this drug will:
dissolve the clot.
The Unna paste boot is wrapped in a variety of directions to make the most of muscular action. These dressings are usually changed:
every 2 to 3 days.
The nurse takes into consideration that the patient with polycythemia vera will have a phlebotomy to thin the blood:
every 2 to 3 months.
The nurse uses a visual aid to depict the several kinds of hemoglobin. Which hemoglobin changes the shape of the red blood cell RBC on which it resides?
hemoglobin S
Because of a deficiency of iron, the person with iron deficiency anemia is unable to make sufficient:
hemoglobin.
The nurse assessing a patient with polycythemia vera would anticipate:
high hemoglobin.
The nurse anticipates that the patient with iron deficiency anemia will have red cells that are:
hypochromic and microcytic.
The nurse adds an intervention to the care plan of a patient who has just been prescribed a thiazide diuretic, which is to increase:
intake of foods containing potassium.
The nurse explains that induction therapy for acute lymphocytic leukemia (ALL) is a(n):
intensive protocol of chemotherapy in high doses to achieve remission.
The nurse frequently assesses for signs of infection on the patient with aplastic anemia because the patient will not be able to produce an inflammatory response related to the low level of:
leukocytes.
The nurse stresses to the patient with sickle cell anemia that one of the most elementary home interventions to help prevent sickle cell crisis is to:
maintain adequate fluid intake.
The home health nurse caring for the patient with polycythemia vera will focus care on:
maintenance of high fluid intake.
The home health nurse is alarmed that the hypertensive patient's blood pressure has risen to 200/160, but he denies any discomfort. The nurse interprets these assessments as being indicative of:
malignant hypertension.
Extreme care is used by the nursing staff when repositioning or transporting a patient with advanced multiple myeloma to prevent:
pathologic fractures.
The nurse cautions the 79-year-old male who had a gastrectomy a month ago that he is at risk for _____ anemia.
pernicious
The nurse is aware that a common cause of reduced amounts of erythropoietin is:
renal failure.
Because of reduced sensitivity of the baroreceptors in the older adult who is also on a diuretic, the nurse instructs the patient to:
sit on the side of the bed before standing.
The nurse is conscientious in the care of the feet and legs of a patient with sickle cell anemia because:
stasis ulcers are a constant threat.
The patient scheduled for a percutaneous angioplasty (PTA) is instructed that a ________ is left in the artery to keep it patent.
stent
The nurse instructs the 20-year-old female patient with sickle cell trait that:
the trait can be passed on to all children.
