MS1 POST TEST

To determine the extent of the lesions

A client with a positive Mantoux test result will be sent for a chest x-ray. For which of the following reasons is this done?

Chills, fever, night sweats, and hemoptysis

SITUATION: A nurse is conducting an educational session with patients regarding tuberculosis. A dient has active TB. Which of the following symptoms will he exhibit?

Creatinine Kinase (CK-MB)

Which of the following blood test is most indicative of cardiac damage?

Stable angina

Which of the following condition is associated with a predictable level of pain that occurs as a result of physical or emotional stress?

The water-seal chamber doesn't fluctuate when no suction is applied.

Which of the following measures best determines that a patient who had a pneumothorax no longer needs a chest tube?

balancing activity and rest

Which of the following measures would a nurse include in the care plan of Mr. K who has chronic bronchitis?

Coronary artery spasm

A chent is admitted for treatment of Prinzmetal Angina. When developing the care plan, the nurse keeps in mind that this type of angina is triggered by:

skin test doesn't differentiate between active and dormant tuberculosis

A client asks the nurse the question regarding the Mantoux test for tuberculosis. The nurse should base her response on the fact that the:

Respiratory Acidosis

A client in the hospital with pulmonary edema has developed tachypnea, dyspnea, crackles, and hypoxemia which are not relieved by 02 therapy. This client will develop which of the following acid-base imbalances?

ST elevation

A client is being evaluated for possible myocardial infarction. The nurse performs a 12-lead ECG for an episode of new chest pain. The nurse will monitor for which sign of acute myocardial injury?

Institute Isolation precaution

A client suspected with severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?

Bathroom privileges and self-care activities

A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client activities?

Rising diastolic blood pressure

A client with myocardial infarction is going into cardiogenic shock. Because of the risk of myocardial ischemia, for which of the following should the nurse carefully assess the client

air pollution and secondhand cigarette smoke

A community health nurse visits Carlo who had exacerbation of asthma. The nurse would most likely assess for which one of the following in determining what exacerbates the Carlo's asthma?

"I make sure my oxygen mask is on tightly so it won't fall while I nap."

A home care nurse visits a client with chronkc obstructive pulmonary disease who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use?

Ineffective airway clearance

A nurse is assessing her with fatigue, tachycardia, crackles and pink frothy sputum. Which nursing diagnosis is of the most importance?

Wheezes

A nurse is auscultating the breath sounds of a client who has been diagnosed with asthma. On expiration, the nurse hears continuous high-pitched squeaking sounds. The nurse knows that this respiratory abnormality can be described as which of the following?

2L/min

A nurse is caring for Lindsay has emphysema. The client is receiving oxygen. The nurse assesses the oxygen now rate to ensure that it does exceed

Using a bed side commode

A nurse is developing a care plan for Hermie who has pulmonary edema. The nurse establishes a goal to have the dient participate in activities that reduce cardiac workload. The nurse identifies which client action as contributing to this goal?

I can perform my normal activities

A nurse is preparing a patient for discharge following coronary artery bypass graft (CABG). Which of the following statements, if made by the patient, would indicate the need for further teaching about the immediate postoperative period?

Negative

A nurse is reading a Mantoux skin test for a client with no documented health problems. The site has no indurations and a 1mm area of ecchymosis. The nurse Interprets that the result is:

"It is best to exercise once a week for 1 hour."

A nurse is teaching James with angina pectoris about disease management and lifestyle changes that are necessary to control disease progression. Which statement by the client indicates a need for further instruction?

Meats and citrus fruits

A nurse is teaching a client with TB about dietary elements that should be increased in the dit. The nurse suggests that the client increase intake of:

Luncheon meat sandwiches and dill pickles

A nurse reviews the dietary history of a patient with congestive heart failure. The nurse should instruct the patient to eliminate which of the following foods to comply with a sodium-restricted diet?

Air hunger

A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the Pollowing symptoms should the nurse expect the patient to exhibit?

The system is functioning properly

A patient has a chest tube to underwater drainage that is connected to suction. A nurse observes that continuous bubbling in the suction control chamber. This finding most likely indicates that

Cardiac arrhythmias

A primary goal of nursing care for Marlon is to recognize life-threatening complications of MI. As Marion's nurse, you have to anticipate occurrence of complications. Take note that the major cause of death after an MI is:

The client's sputum exam is negative for acid fast bacteria

Airborne precautions for a client with tuberculosis can be stopped when the nurse has confirmed that:

Suctioning if cough is ineffective

Which of the following nursing Interventions would promote effective respiratory distress?

Anginal pain usually lasts only 3-5 mins

An adult is admitted to the coronary care unit to rule out MI. The client states *I am not sure if this is just angina, and I cannot understand the difference angina & heart attack pain". Which response is most appropriate for the nurse to make?

myocardial necrosis

An increase in the creatinine kinase-MB isoenzyme (CK-MB) can be caused by:

You should have regular amount of exercise activities

An overweight client asks for information on losing weight. After instructing the patient to decrease her caloric intake, which of the following responses by the nurse would be the best?

High Fowler's position

Which of the following positions would best aid breathing for Hermie who has acute pulmonary edema?

Surfactant production is reduced in ARDS

Which of the following statements concerning ARDS is true?

Fumes

Breeja will be discharged in a few days. During a discharge teaching session, what should the nurse instruct this client to avold?

Administer bronchodilator by nebulizer

Carlo comes to the ER with acute asthmatic attack. RR is 46/min and he appears to be in acute respiratory distress. Which of the following nursing actions should be initiated first?

I sleep using two pillows

Which of the following statements, if made by Ken, a patient who Is suspected of having congestive heart fallure, would support the diagnosis?

SITUATION: A 45-year-old adult has a cholesterol blood test done at a screening clinic sponsored by local health club. The nurse volunteering at the screening teaches the client that diet and exercises should be used as health measures to keep the total cholesterol level below 200 mg/dL. The nurse records a client's history and discovers several risk factors for coronary artery disease. Which cardiac risk factors are considered controllable?

Diabetes, hypercholesterolemia, hypertension

Unexplained restiessness, iritabet y, and tachypnea

Early sions and syn notoms of inadequate oxygenation include which of the following?

3421

Following emergency endotracheat intubation, you must verify tube placement and secure the tube. Ust in order the steps that are required to perform this function? 1. Obtain an order for a chest x-ray to document tube placement. 2. Secure the tube in place. 3. Auscultate the chest during assisted ventilation. 4. Confirm that the breath sounds are equal and bilateral.

Patent tubes

Frequent assessment of the closed drainage system is important to ensure appropriate functioning. The observes that water level fluctuates with respiratory effort. The nurse considers this as a sign of:

"I will have to inform my dentist of my condition before treatment."

George has a diagnosis of valvular heart disease receives discharge instructions for a nurse, wrich of the following statements, If made by the patient would indicate a correct understanding of the discharge teaching?

pericardiocentesis

George has just arrived from the operating room after an open-heart surgery. While you are assessing him, you noted a pulsus paradoxus. You expect the physician to perform what emergency resuscitative procedure?

"Respiratory movement intensifies pericarditis pain"

George's mother asks why the client's breathing is shallow. The CORRECT response of the nurse would be:

Chest tube insertion

In addition to treatment of underlying cause, the nurse understands that management of Cardo who has acute respiratory distress syndrome (ARDS) will Include which medical intervention?

restricting IV fluids

Ken Is admitted with congestive heart failure. He has shortness of breath, and a +3-4 peripheral edema. The care plan to reduce the client's edema should include the nursing strategies for:

"I chose broiled chicken for dinner"

Ken Is placed on low sodium diet. Which client statement indicates the nurse nutrition teaching plan has been effective?

Bibasilar fine crackles

Ken is returning from the operating room after surgery. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign and symptom indicates left-sided heart failure?

cardiac output

Ken patient reports diminishing energy level. The nurse should recognize that this symptom is most likely a result of decreased

Fruit and vegetables

Ken was placed on a low sodium diet. The wife asks the nurse which foods to include in the client's diet while at home. The nurse would instruct to include the following:

Keep the zero point of the manometer in level with the client's right atrium

Ken's central venous pressure is monitored every hour. When you measure the VP, using a water manometer, you are expected to observe which of the following to ensure accuracy of CVP measurement?

Remove the dressing

Mang Sebastian experienced an open pneumothorax and a chest wound, which has been covered with an occlusive dressing. He begins to experience severe dyspnes, and blood pressure begins to fall. The nurse should first:

Inflamed lung tissue

Margarette is admitted to an acute care facility. The client in the next room is being treated by mycoplasmal pneumonia. Desolte the different causes of the various types of pneumonia, all of them share which feature?

place the client in respiratory isolation

Margarette is being admitted to the nursing unit with a diagnosis of pneumonia. She has a history of arrested TB. When planning care for this client the nurse's initial action should be to

"Splint your chest wall with a pillow for comfort."

Margarette is being treated for pneumonia. She has a persistent cough and complains of severe pain on coughing. What could you tell her to help her reduce her discomfort?

teach the client deep breathing and coughing techniques

Margarette is hospitalized with probable bacterial pneumonia. The physician has ordered a sputum specimen for culture and sensitivity. In order to obtain a good specimen, the nurse should

Obtain a sputum specimen

Margarette who has pneumonia is admitted to the hospital with a productive cough. Which of the following actions should a nurse carry out first?

High fever

Margarette, a client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

can climb 2 flights of stairs without dyspnea

Marlon who has myocardial infarction asks when his sex activity can be resumed. The nurse's response is accurate when she says sex activity maybe resumed if client:

Allow the use of bedside commode

Nursing care of the post-MI patient is directed towards reducing the workload of the heart and 02 consumption, Which nursing action best accomplishes this goal?

myocardial ischemia

On the cardiac monitor, ECG changes were observed such as, flattened T waves and depressed ST segments. Which of the following will you consider as the probable condition responsible for the ECG changes.

Middle-aged woman with aortic stenosis

SITUATION: A nurse is preparing for the admission of Ken, a client with heart fallure who is being sent directly to the hospital from the physician's office. Which client is at most risk of developing left-sided heart failure?

Increased anterior-posterior chest diameter

SITUATION: Breeja has a long history of emphysema and is admitted to the hospital because of a respiratory infection that has not improved with outpatient therapy. Which finding would the nurse expect to observe during the clients nursing assessment?

Acute respiratory distress syndrome (ARDS)

SITUATION: Cardo, a firefighter who was involved in extinguishing a house fire is being treated for smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. Which of the following conditions has the patient most likely developed?

Viral respiratory infections

SITUATION: Carlo, a client with a 10 year history of asthma presents with respiratory distress with labored breathing, using of accessory muscles and audible expiratory wheezes. Which of the following is one of the most common precipitating factors of an acute asthma attack?

Fever, chest discomfort, and elevated

SITUATION: George Clooney, age 45, is admitted to the medical-surgical floor with weakness and left-sided chest pain. The symptoms have been present for several weeks after a viral illness. Which signs and symptoms are present with diagnosis of pericarditis?

Short, popping sound (rolling hair near the ears) usually heard during inspiration

SITUATION: Hermie with a left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up of pink-tinged foamy sputum. Hermie suddenly becomes tachycardic, shows signs of hunger, and begins coughing frothy, pink-tinged sputum. Which of the following would the nurse anticipate when auscultating the client's breath sounds?

Notifying the physician

SITUATION: Hero, 8 years old, has two chest tubes connected to a disposable water sealed drainage syste of chest injuries from a vehicle accident.. The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300ml The hurse should give priority to:

Smoking

SITUATION: James is admitted to the coronary care unit to rule out MI. The client states *I am not sure If this is just angina, and I cannot understand the difference angina & heart attack pain". When assessing a client with angina, which of the following assessment data is considered a common precipitating factor for pain?

Intravenous drug use

SITUATION: Kenneth, a white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years ago and an aortic valve replacement 2 years ago. Aside from aortic valve replacement, which of the following if noted in Kenneth's history, indicates a predisposition for the development of endocarditis?

Streptococcus pneumonia

SITUATION: Margarette has been admitted to the hospital. Lung assessment reveals the following: crackles upon auscultation, percussion dulled and consolidation in this area upon X-ray. Based on the assessment findings the nurse can expect to plan care for her with pneumonia. Margarette Is admitted to the medical surgical floor with a diagnosis of bacterial pneumonia. The most common causative organism of community-acquired bacterial pneumonia is:

Acute pain

SITUATION: Marion, 56, was admitted to the medical ward for acute myocardial infarction management (AM1). Shortly after being admitted to the CCU for acute MI, Marion reports midsternal chest pain radiating down the left arm. You notice that Marion is restless, slightly diaphoretic, and has a temperature of 37.8 deg C, heart rate of 100 beats/min.; regular, slightly labored respirations at 26 breaths/min and a blood pressure of 150/90 mmHg. Which nursing diagnosis takes HIGHEST PRIORITY?

10

SITUATION: You are assigned in a medical ward and are caring for Lindsay who has been diagnosed of Chronic Obstructive pulmonary Disease (COPD. Lindsay was brought to the hospital because of severe respiratory distress. Lindsay admits to smoking one pack of cigarettes per day for the past 10 years. The nurse determines that the client has a smoking history of how many pack-years?

Kinking of the ventilator tubing

SITUATION: You are caring for Cardo who has respiratory failure. He is connected to mechanical ventilation. Cardo suffers adult respiratory distress syndrome as a consequence of shock. The patient's condition deterlorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

flail chest

SITUATION:Lyle comes into the ER following a motor vehicular accident. He is dyspneic and has severe pain. The left chest is sucked in during inspiration and it bulges out during expiration. The nurse understands these are symptoms most suggestive of which of the following?

Maintain the system lower than the client's chest

Which of the following will you consider as a PRIORITY when you teach the client to ambulate with drainage system?

Cover the insertion site with a Vaseline gauze

The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?

"My shoes fit really tight."

Which statement made by Ken would alert the nurse to the possibility of right-sided heart failure?

Increased cardiac output

The majority goal of therapy for a patient with a heart failure and pulmonary edema would be to:

Severe pain can produce shock and increase cardiac workload

The nurse caring for the patient recognizes that the relief of pain is a primary objective because:

Applies firm but gentle pressure with the hands to the fail segment

The nurse does which of the following to assist Lyle's respiratory status until help arrives?

The client demonstrate the ability to tolerate increasing activity without chest pain

The nurse is evaluating a client who had a myocardial infarction (MI) 7 days ago. Which outcome indicates that the dient is responding favorably to the therapy?

356

The nurse is evaluating the ECG of a client experiencing myocardial infarction (MI). While conferring with the team, she correctly identifies which ECG changes associated with an involving MI? 1. Notched T-wave 3. T-wave inversion 5. ST-segment elevation 2. Presence of a U wave

Conserve energy

The nurse is formulating a teaching plan for an adult client with severe emphysema. The nurse should Instruct him to select activities that primarily

Restlessness, suprasternal retractions and Pa02 of 65

The nurse may expect Cardo with suspected early ARDS to exhibit which of the following?

Cough with pink frothy sputum

The nurse on a cardiac unit is caring for Hermie admitted with an acute exacerbation of heart failure. The nurse concludes that the client is developing pulmonary edema after observing which change in the client?

Lying in bed on the unaffected side with the head of the bed elevated 45 degrees

The nurse will be preparing Mang Sebastian for thoracentesis. She should assist him to which of the following positions for the procedure?

Increased PaC02, decreased Pa02, and decreased pH

The nurse would anticipate which of the following ABG results in a client experiencing a prolonged, severe asthma attack?

increased Pa02

The physician evaluate the most recent set of arterial blood gases (ABGs) of a patient with acute respiratory distress syndrome (ARDS) and orders to increase the positive end expiratory pressure (PEEP). Based on this change in therapy, the nurse should anticipate which of the following ABG findings?

Oxygen therapy can eliminate the stimulus for breathing in a patient with chronic lung disease.

The physician prescribes oxygen at 2 liters per minute via nasal cannula. Which statement best describes what Lindsay's oxygen therapy is maintained at their relatively low level?

Red

The school nurse interprets the peak expiratory flow rate for a client with asthma. Which zone signals a medical alert and indicates that the client may need their inhaler?

Ethambutol (Myambutol) and isoniazid (INH)

The treatment plan for a client newly diagnosed with tuberculosis is likely to include which of the following

What did you do when the pain started?

You are obtaining a history of Angina Pectoris who is admitted with acute chest pain. Which question will be MOST HELPFUL for you to ask?

Participating in regular exercise

You should have regular amount of exercise activities

Ischemia of the heart muscles

What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion?

Oxygen saturation of 91%

When assessing Lyle who has a fail chest injury, a nurse identifies all of the following findings. To which finding should the nurse give priority in planning care for Lyle?

Decreases when unsaturated fats are substituted for saturated fats

When teaching a client with heart disease about risk factors, what should the nurse tell the client about cholesterol? Cholesterol:

Breathing through pursed lips

Which method would best prevent air from entering the pleural cavity after removal of the patient's chest tubes?

Enhance myocardial oxygenation

Which of the following actions is the first priority of care for a client exhibiting signs and symptoms of coronary artery disease?

Positive chest x-ray

Which of the following assessment findings should indicate to a nurse that a patient has active tuberculosis?