NCLEX-PN

A nurse is providing 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 doing which of the following?

Avoiding exposure to either very hot or very cold weather Rationale: The client should avoid extreme hot or cold temperatures to avoid placing undue stress on the cardiovascular system. The client should space activities throughout the day rather than save them for the end of the day when the client is more fatigued. The client should eat smaller meals so less blood flow is diverted for the work of digestion. Exercise is important, but the client should keep most items stored at heart level, to prevent straining and increased intrathoracic pressure, which can decrease cardiac output.

An ambulatory clinic nurse is interviewing a client who is complaining of flu-like symptoms. The client suddenly develops chest pain. Which question would best help the nurse to discriminate pain caused by a noncardiac problem?

"Does the pain get worse when you breathe in?" Rationale: Chest pain is assessed using the standard pain assessment parameters, (characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms). Options 1, 2, and 4 may or may not help determine the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse tells the client that:

"The medication causes the pupil to constrict and will lower the pressure in the eye." Rationale: Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork.

Hyperglycemia

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Hypoglycemia

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pleurisy

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pulmonary sarcoidosis

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A client with suspected Guillain-Barré syndrome has a lumbar puncture performed. The cerebrospinal fluid (CSF) is analyzed for protein. The nurse reviews the protein values and notes that the value that supports the diagnosis of Guillain-Barré syndrome is:

75 mg/dL Rationale: Normal CSF protein is 15 to 45 mg/dL. Seven to 10 days following the onset of symptoms of Guillain-Barré, the spinal fluid protein levels become extremely high.

A client who has had a radical neck dissection begins to hemorrhage at the incision site. Which action by the nurse would be contraindicated?

Applying manual pressure over the site Rationale: If the client begins to hemorrhage from the surgical site following radical neck dissection, the nurse elevates the head of the bed to maintain airway patency and prevent aspiration. The nurse applies pressure over the bleeding site and calls the health care provider immediately.

A nurse is planning to use an external cardiac defibrillator on a client. Which one of the following actions should the nurse perform to check the cardiac rhythm?

Applying the adhesive patch electrodes to the skin and moving away from the client Rationale: The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator position. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate. Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes (not standard electrocardiographic electrodes) that interact via telephone lines to a base station that controls any actual defibrillation. It is not necessary to hold defibrillator paddles against the client's chest with this device.

A nurse is reviewing the record of a client with acute respiratory distress syndrome (ARDS). The nurse determines that which finding documented in the client's record is consistent with the most expected characteristic of this disorder?

Arterial PaO2 of 48 Rationale: The most characteristic sign of ARDS is increasing hypoxemia with a PaO2 of less than 60 mm Hg. This occurs despite increasing levels of oxygen that are administered to the client. The client's earliest sign is an increased respiratory rate. Breathing then becomes labored, and the client may exhibit air hunger, retractions, and peripheral cyanosis.

A client with pneumonia is experiencing problems with ventilation as a result of accumulated respiratory secretions. The nurse determines that which of the following accurately indicates effectiveness of the treatments prescribed for this problem

Arterial blood gases indicate a pH of 7.4, Po2 of 80 mm Hg, Pco2 of 40 mm Hg. Rationale: Demonstration of adequate ventilation can only be accurately evaluated when both Po2 and Pco2 levels are known. The other options do not indicate adequate gas exchange. Remember that oxygen saturation index is a measure of the percent of oxygen attached to the available hemoglobin.

The nurse is caring for a client with glaucoma. Which of the following medications, if prescribed for the client, would the nurse question?

Atropine sulfate (Isopto Atropine) Options 1, 2, and 4 are miotic agents used to treat glaucoma. Option 3 is a mydriatic and cycloplegic medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

In preparation for cataract surgery, the nurse is to administer cyclopentolate (Cyclogyl) eyedrops. The nurse administers the eyedrops, knowing that the purpose of this medication is to:

Dilate the pupil of the operative eye. Rationale: Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis.

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which of the following findings would the nurse expect to note as confirming this diagnosis?

Elevated blood glucose and low plasma bicarbonate Rationale: In DKA, the arterial pH is less than 7.35, plasma bicarbonate is less than 15 mEq/L, the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood and urine. The client would be experiencing polyuria and Kussmaul's respirations. Coma may occur if DKA is not treated, but coma would not confirm the diagnosis.

The nurse is collecting data on a client with chronic airflow limitation (CAL) and notes that the client has a "barrel chest." The nurse interprets that this client has which of the following forms of CAL?

Emphysema Rationale: The client with emphysema has hyperinflation of the alveoli and has flattening of the diaphragm. These lead to increased anteroposterior diameter, which is referred to as "barrel chest." The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion.

A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN would assist the RN by placing the bed in which of the following positions for the reading?

Flat Rationale: To obtain a CVP measurement, the head of the bed should be flat in order for the readings to be accurate. The use of the other positions listed would result in false low or false high readings.

A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer, expecting to note that the ulcer:

Has a brownish or "brawny" appearance Rationale: Venous leg ulcers, also called stasis ulcers, are typically partial-thick wounds that extend through the epidermis and portions of the dermis. The skin of the lower leg is leathery, with a characteristic brownish or "brawny" appearance from the hemosiderin deposition. The edges of the ulcer are irregular and the tissue is a ruddy color. The client also may exhibit peripheral edema.

A nurse is caring for a client after thyroidectomy and monitoring for signs of thyroid storm. The nurse understands that which of the following is a manifestation associated with this disorder?

Hypotension Rationale: Clinical manifestations associated with thyroid storm include a fever as high as 106° F (41.1° C), severe tachycardia, profuse diarrhea, extreme vasodilation, hypotension, atrial fibrillation, hyperreflexia, abdominal pain, diarrhea, and dehydration. With this disorder, the client's condition can rapidly progress to coma and cardiovascular collapse.

A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial serum glucose level was 950 mg/dL. Intravenous (IV) insulin was started along with rehydration with IV normal saline. The serum glucose level is now 240 mg/dL. The nurse who is assisting in caring for the client obtains which of the following items, anticipating a health care provider's prescription?

IV infusion containing 5% dextrose Rationale: During management of DKA, when the blood glucose level falls to 300 mg/dL, the infusion rate is reduced and 5% dextrose is added to maintain a blood glucose level of about 250 mg/dL, or until the client recovers from ketosis. NPH insulin is not used to treat DKA; 50% dextrose is used to treat hypoglycemia. Phenytoin is not a normal treatment measure in DKA.

Anosognosia

In anosognosia, the client neglects the affected side of the body. The client may neglect the affected side (often creating a safety hazard as a result of potential injuries) or state that the involved arm or leg belongs to someone else.

A client is admitted to the hospital with a diagnosis of pleurisy. The nurse checks the client for which characteristic symptom of this disorder?

Knifelike pain that worsens on inspiration Rationale: A typical symptom with pleurisy is a knifelike pain that worsens on inspiration. This is a result of the friction caused by the rubbing together of inflamed pleural surfaces. This pain usually disappears when the breath is held because these surfaces stop moving. The client does not experience early morning fatigue or dyspnea relieved by lying flat.

A nurse is planning to instruct a client with diabetes mellitus who has hypertension about "sick day management." Which of the following does the nurse avoid putting on a list of easily consumed carbohydrate-containing beverages for use when the client cannot tolerate food orally?

Mineral water Rationale: Diabetic clients should take in approximately 15 g of carbohydrate every 1 to 2 hours when unable to tolerate food because of illness. Each of the beverages listed in options 1, 2, and 3 provides approximately 13 to 15 g of carbohydrate in a half-cup serving. Mineral water is incorrect for two reasons. First, it contains sodium and should not be used by the client with hypertension. Second, it is not a source of carbohydrates.

A nurse is preparing a plan of care to monitor for complications in a client who will be returning from the operating room following transsphenoidal resection of a pituitary adenoma. Which of the following does the nurse document in the plan as the priority nursing intervention for this client?

Monitor urine output. Rationale: The most common complication of surgery on the pituitary gland is temporary diabetes insipidus. This results from deficiency in antidiuretic hormone (ADH) secretion as a result of surgical trauma. The nurse measures the client's urine output to determine whether this complication is occurring. Options 1, 3, and 4 are also components of the plan, but option 2 clearly identifies the priority intervention for this type of surgery.

Betaxolol hydrochloride (Betoptic SR) eye drops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side effects of this medication?

Monitoring blood pressure Rationale: Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are systemic effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia.

The nurse is providing instructions to a client who will be self-administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to:

Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops. Rationale: Applying pressure on the nasolacrimal duct prevents systemic absorption of the medication.

A nurse is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L. The client asks the nurse why the oxygen is necessary. The nurse bases the response on which of the following?

Oxygen supply to the heart cells that is deficient results in angina pectoris pain. Rationale: The pain associated with angina is derived from ischemic myocardial cells. The pain is often associated with activity that places more oxygen demand on heart muscle. Supplemental oxygen helps meet the added demands on the heart muscle. Oxygen does not dilate blood vessels, prevent thrombus formation, or directly calm the client.

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which manifestation that differentiates pericarditis from other cardiopulmonary problems?

Pericardial friction rub Rationale: A pericardial friction rub is heard when there is inflammation of the pericardial sac during the inflammatory phase of pericarditis. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy. Anterior chest pain may be experienced with angina pectoris and myocardial infarction. Weakness and irritability are nonspecific complaints that could accompany a wide variety of disorders.

An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notes documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action in the care of the client?

Place the client on a cardiac monitor. Rationale: The client with decreased cardiac output should be placed on continuous cardiac monitoring so myocardial perfusion and presence of dysrhythmias can be most accurately assessed. Other cardiovascular data should be collected at least every 2 hours initially.

The anticipated intended effect of fludrocortisone acetate (Florinef) for the treatment of Addison's disease is to:

Promote electrolyte balance. Rationale: Florinef is a long-acting oral medication with mineralocorticoid and moderate glucocorticoid activity used for long-term management of Addison's disease. Mineralocorticoids act on the renal distal tubules to enhance the reabsorption of sodium and chloride ions and the excretion of potassium and hydrogen ions. In small doses, fludrocortisone acetate causes sodium retention and increased urinary potassium excretion. The client rapidly can develop hypotension and fluid and electrolyte imbalance if the medication is discontinued abruptly. Options 1, 3, and 4 are not associated with the effects of this medication.

A client has just undergone lumbar puncture (LP). The nurse assists the client into which most optimal position if tolerated by the client?

Prone, with a pillow under the abdomen Rationale: If it can be tolerated by the client, the optimal position following LP is prone with a small pillow under the abdomen. This position helps minimize or prevent continued leakage of cerebrospinal fluid (CSF) from the site by enlisting the aid of gravity. If the client cannot tolerate this position, the client should be positioned flat in bed and turned from side to side as necessary. It is important that the head of the bed remain flat to prevent CSF leakage and to prevent postprocedure headache.

A nurse assisting in caring for a client hospitalized with acute pericarditis is monitoring the client for signs of cardiac tamponade. The nurse determines that which finding is unrelated to possible cardiac tamponade?

Pulse rate of 58 beats per minute Rationale: Assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure, accompanied by pulsus paradoxus (a drop in inspiratory blood pressure by greater than 10 mm Hg). Bradycardia is the symptom that is unrelated.

A nurse is collecting data regarding a client after a thyroidectomy and notes that the client has developed hoarseness and a weak voice. Which nursing action is appropriate?

Reassure the client that this is usually a temporary condition. Rationale: Weakness and hoarseness of the voice can occur as a result of trauma of the laryngeal nerve. If this develops, the client should be reassured that the problem will subside in a few days. Unnecessary talking should be discouraged. It is not necessary to notify the registered nurse immediately. These signs do not indicate bleeding or the need to administer calcium gluconate.

A nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse takes which appropriate action?

Reports the finding to the registered nurse (RN) Rationale: If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the registered nurse, because this can indicate hemorrhage.

A client has undergone a right pneumonectomy. The nurse positioning this client following admission from the postanesthesia care unit avoids placing the client in which harmful position?

Right lateral Rationale: The client who has a pneumonectomy should not be positioned in the extreme lateral position. This could cause mediastinal shift and compression of remaining lung tissue. The other positions do not pose this risk for the client.

A nurse is collecting data on a client with chronic sinusitis. The nurse interprets that which of the following client manifestations is unrelated to this problem?

Severe evening headache Rationale: Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough caused by nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse on arising after sleep.

A nurse reinforces teaching with a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops?

Shakiness Rationale: Shakiness is a sign of hypoglycemia, and it would indicate the need for food or glucose. Fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia.

When preparing a client for a pericardiocentesis, how does the nurse position the client?

Supine with the head of bed elevated at a 45- to 60-degree angle Rationale: The client undergoing pericardiocentesis is positioned supine with the head of bed elevated to a 45- to 60-degree angle. This places the heart in proximity to the chest wall for easier insertion of the needle into the pericardial sac. The remaining options are incorrect positions for this procedure.

A nurse is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia?

Tall, peaked T waves Rationale: The symptoms of hyperkalemia relate to its effect on the myocardial muscle. These include changes noted on the ECG, such as tall, peaked T waves, prolonged P-R interval, widening of the QRS complex, shortening of the Q-T interval, and disappearance of the P wave. Other cardiac symptoms include ventricular dysrhythmias that may lead to cardiac arrest. ST-segment depression is noted in hypokalemia.

A nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. Based on this finding, the nurse determines that:

The system is functioning as expected. Rationale: Fluctuations in the water seal chamber are normal during inhalation and exhalation until the lung re-expands and the client no longer requires chest drainage. If fluctuations are absent, it could indicate an air leak, kinking, or that the lung has re-expanded.

A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. This type of anginal pain is best described as:

Variant angina Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often in the morning. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction.

A nurse is caring for a client with pheochromocytoma. The client is scheduled for an adrenalectomy. During the preoperative period, the priority nursing action would be to monitor the:

Vital signs Rationale: Hypertension is the hallmark of pheochromocytoma. Severe hypertension can precipitate a brain attack (stroke) or sudden blindness. Although all of the options are accurate nursing interventions for the client with pheochromocytoma, the priority nursing action is to monitor the vital signs, particularly the blood pressure.

The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply.

1 To avoid activities that require bending over 3. To place an eye shield on the surgical eye at bedtime 5. To contact the surgeon if a decrease in visual acuity occurs 6. To take acetaminophen (Tylenol) for minor eye discomfort Rationale: After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings would the nurse expect to note? Select all that apply.

3. 50 mL of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation Rationale: The bubbling of water in the water-seal chamber indicates air drainage from the client. This is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water-seal chamber may indicate an air leak, which is an unexpected finding. The fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed, the lung has re-expanded, or no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction-control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than 70 to 100 mL/hr is considered excessive and requires health care provider notification. The chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

A nurse is reviewing the health care record of a client with a new onset of pleurisy. The nurse notes documentation that the client does not have a pleural friction rub, which was auscultated the previous day. The nurse interprets that this is likely a result of:

Accumulation of pleural fluid in the inflamed area Rationale: Pleural friction rub is auscultated early in the course of pleurisy, before pleural fluid accumulates. Once fluid accumulates in the inflamed area, there is less friction between the visceral and parietal lung surfaces, and the pleural friction rub disappears.

A nurse is assisting in caring for a client with a supratentorial lesion. The nurse monitors which of the following as the critical index of central nervous system (CNS) dysfunction?

Level of consciousness Rationale: Level of consciousness is the most critical index of CNS dysfunction. Changes in level of consciousness can indicate clinical improvement or deterioration. Although blood pressure, temperature, and ability to speak may be components of the assessment, the client level of consciousness is the most critical index of CNS dysfunction.

A nurse is assisting in checking for Tinel's sign in a client suspected of having carpal tunnel syndrome (CTS). Which technique would the nurse expect to be used to elicit this sign?

Percuss the medial nerve at the wrist as it enters the carpal tunnel, and monitor for tingling sensations. Rationale: The presence of Tinel's sign is determined by percussing the medial nerve at the wrist as it enters the carpal tunnel. A tingling sensation over the distribution of the nerve occurs in CTS. The presence of Phalen's sign is determined by asking the client to flex the wrist at a 90-degree angle for 1 minute. Numbness and tingling over the distribution of the median nerve, the palmar surface of the thumb, and the index and middle fingers suggest CTS. Phalen's sign is also an indication of CTS.

A client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia (hyperreflexia). Which finding is indicative of this complication?

The client complains of a headache and the blood pressure is elevated. Rationale: Autonomic dysreflexia, also known as autonomic hyperreflexia, is a life-threatening syndrome. It is a cluster of clinical manifestations that results when multiple spinal cord autonomic responses discharge simultaneously. Exaggerated autonomic nervous system reactions to stimuli result in sudden hypertensive episodes with severe headache. The client may sweat profusely above the level of the cord lesion and complain of a stuffy nose. The knee-jerk response is not affected. Pupils may be dilated. Although a distended bladder is often the precipitating event, it is not indicative of dysreflexia, and not all clients with bladder distention exhibit dysreflexia.

A client had thoracic surgery 2 days ago and has a chest tube in place connected to a Pleur-Evac drainage system. The nurse notes continuous bubbling in the water seal chamber. The nurse determines that:

There is a leak in the system, which requires immediate investigation and correction. Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates that a leak exists somewhere in the system and air is being sucked into the apparatus. The nurse needs to assess the system and initiate corrective action, which may include notifying the health care provider. Bubbling may occur intermittently with the evacuation of a pneumothorax, but it should not be continuous, especially with a client who had surgery 2 days earlier. Hemothorax results in accumulation of drainage in the collection chamber but does not cause bubbling in the water seal chamber. Application of suction to the system causes bubbling in the suction control chamber but not the water seal chamber.

A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel and a hyphema has been diagnosed. The nurse would prepare to position the client:

On bedrest in a semi-Fowler's position A hyphema is the presence of blood in the anterior chamber. It is produced when a force is sufficient to break the integrity of the blood vessels in the eye. It can be caused by direct injury, such as penetrating injury from a BB pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bedrest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea.