NU372 Final exam practice questions

Which physical examination should the nurse implement first when assessing the client diagnosed with peptic ulcer disease?

Auscultate the clients bowel sounds in all four quadrants

The nurse is assessing a patient, who has many risk factors for the development of a DVT, for signs and symptoms of a deep vein thrombosis. What signs and symptoms below would possibly indicate a deep vein thrombosis is present?

-Redness -Pain -Warm extremity -Swelling

Which actions transmit the human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct.

-Sharing syringe needles -Breast-feeding a newborn -Anal intercourse

After giving a patient the initial dose of oral labetalol (Normodyne) for treatment of hypertension, which action should the nurse take?

Ask the patient to request assistance when getting out of bed.

A 78-year-old client who has hypertension is beginning treatment with furosemide. Considering the client's age, which would the nurse teach the client to do?

Change positions slowly.

Which activity places a client at risk for hyperthermia?

Performing strenuous activity in high humidity

The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain?

Place in side-lying position with knees flexed

A client with rheumatoid arthritis prescribed methotrexate has developed a fever. The nurse suspects that this might be related to which of the following?

The effect of prescribed medications on immune response

A client who is receiving atenolol for hypertension frequently reports feeling dizzy. Which effect of atenolol is responsible for this response?

Blocking the adrenergic response Rationale: The beta-adrenergic blocking effect of atenolol decreases the heart's rate and contractility; it may result in orthostatic hypotension and decreased cerebral perfusion, causing dizziness

A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a

CT scan

A pregnant woman diagnosed with hypertension was administered magnesium sulfate. Which prescribed medication would the nurse administer to prevent magnesium toxicity?

Calcium gluconate

A patient has just been diagnosed with hypertension and has a new prescription for captopril (Capoten). Which information is important to include when teaching the patient?

Change position slowly to help prevent dizziness and falls

Which of the following symptoms is most commonly associated with left-sided heart failure?

Crackles

Toxicity from which of the following meds may cause a pt to see a green-yellow halo around lights?

Digoxin

A child has a respiratory tract infection with a low-grade fever. When teaching the parents, which intervention would the nurse emphasize?

Giving small amounts of clear liquids frequently to prevent dehydration

The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?

Have the client sit down immediately

When a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia?

Having suction available during meals

A client has a history of a persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, and fever. Which risk would be assessed?

Human immunodeficiency virus (HIV) infection

Which instruction will the home health nurse give when teaching a client with arterial insufficiency of both lower extremities?

"Check pulses in the legs regularly."

Your patient has a deep vein thrombosis in the left lower extremity. The patient is prescribed continuous IV Heparin. Select all the nursing interventions that are appropriate for this patient:

-Measure leg circumference -Elevate affected extremity above heart level -Monitor the patient's aPTT level

A patient is receiving continuous IV Heparin for anticoagulation therapy for the treatment of a DVT. In order for this medication to have a therapeutic effect on the patient, the aPTT should be?

1.5-2.5 times the normal value range

The nurse in the emergency department received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?

43-year-old with a BP of 190/102 who is complaining of chest pain

Which of these clients seen at a health fair will be most at risk for hypertension

62-year-old African American man Rationale: African Americans have the highest risk for hypertension; before the age of 45, men are at higher risk than women.

diagnostics of appendicitis

Abdominal ultrasound X-rays WBC

For which complication is a client with gestational hypertension at risk?

Abruptio placentae Rationale: due to increased BP, vasospasms of placental vessels occur -> placenta may separate prematurely

What is the first intervention for a pt experiencing MI?

Administer oxygen

Which causative agent is common to both hyperthermia and hypothermia?

Alcohol

Which change in the client's lab results indicates that the client is in septic shock?

An increased serum lactate level

Which laboratory test would the nurse review for a client suspected to have rheumatoid arthritis?

Antinuclear antibody

The patient who has recently been experiencing runs of ventricular tachycardia suddenly loses consciousness. The patient is defibrillated, and the rate returns as the following. What should the nurse do first?

Begin compressions

Metoprolol is prescribed for a client with hypertension. The nurse monitors the client for which adverse effect?

Bradycardia Rationale: The client should be monitored for bradycardia, which can progress to heart failure or cardiac arrest.

A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect?

Epigastric pain radiating to the left shoulder

Diagnostic Testing for inflammation

Erythrocyte Sedimentation Rate (ESR) --> normal= 0-15mm/hr C-reactive protein (CRP) WBC BUN/Creatinine LFTs

The nurse is caring for a client with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol (Lopressor). Which monitoring is essential when administering the medication?

Heart rate

Which clinic manifestations would the nurse expect to find in a client who has acute HIV infection? SATA

Malaise Swollen lymph glands

When a client with hypovolemic shock has a hematocrit value of 25%, which fluid therapy will the nurse prepare to infuse?

Packed red blood cells Rationale: Blood replacement is needed to increase the oxygen-carrying capacity of the blood; the expected hematocrit for women is 37% to 47% and for men is 42% to 52%.

A client is prescribed rifampin after being exposed to active tuberculosis. Which finding would the nurse immediately report to the health care provider? Select all that apply.

Small, red, pinpoint areas on the arms

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best?

The blood clot interferes with perfusion in the lungs

Which nursing intervention would prevent septic shock in the hospitalized client?

Use aseptic technique during all invasive procedures.

risk factors of appendicitis

adolescent males low fiber diet high carb diet GI infections

Management of appendicitis

appendectomy - surgery

A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:

Hypokalemia

A client's ulcerative colitis signs and symptoms have been present for longer than 1 week. The nurse should assess the client for signs and symptoms of which of the following complications?

Hypokalemia

Which medication would be prescribed to reduce hypertension in a pregnant client?

Magnesium sulfate

After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108/minute. What should the nurse suspect is happening?

Right-sided HF

You're developing a plan of care for a patient who is at risk for the development of a deep vein thrombosis after surgery. What nursing intervention below would the nurse NOT include in the patient's plan of care to prevent DVT formation?

The nurse will apply sequential compression devices (SCDs) per physician's order to the patient's lower extremities every night at bedtime Rationale: Yes, the nurse would apply SCDs per MD order to help prevent DVTs, BUT they are to be applied and worn by the patient anytime they are in bed or sitting.

A client recovering from deep partial-thickness burns develops chills, fever, flank pain, and malaise. The primary health care provider makes a tentative diagnosis of urinary tract infection. Which diagnostic tests would the nurse expect the primary health care provider to prescribe to confirm this diagnosis?

Urinalysis with a urine culture and sensitivity

After multiple bee stings, a client experiences an anaphylactic reaction. The nurse determines that the clinical manifestations of an anaphylactic reaction are CAUSED by

a release of plasma proteins resulting in severe vasoconstriction.

A patient admitted with heart failure appears very anxious and complains of shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety (select all that apply)?

-Administer ordered morphine sulfate. -Position patient in a semi-Fowler's position -Instruct patient on the use of relaxation techniques -Use a calm, reassuring approach while talking to patient

You're patient has expressive aphasia. Select all the ways to effectively communicate with this patient?*

-Ask questions that require a simple response -Use a communication board

Possible Modifiable Risk Factors to reduce inflammation response

-High sugar and fat diet -low fiber intake -smoking -increased BMI -DM -Htn -over use of NSAIDs -drug abuse

A nurse is completing nutritional teaching for a client who has pancreatitis. Which of the following statements by the client indicates an understanding of the teaching? (SATA)

-I plan to eat small, frequent meals. -I will eat easy-to-digest foods with limited spice -I will use skim milk when cooking Rationale: Patients with pancreatitis should eat small, frequent, easy to digest, low-fat meals. Pt should avoid alcohol and caffeinated beverages.

Which clinic manifestations would the nurse expect to find in a client who has acute human immunodeficiency virus (HIV) infection? Select all that apply. One, some, or all responses may be correct.

-Malaise -Swollen lymph glands Rationale: Soon after being infected with HIV, many clients develop a flu-like syndrome called acute HIV infection. Clinical manifestations of this syndrome include malaise, swollen lymph glands, fever, sore throat, headache, nausea, diarrhea, muscle or joint pain, or a diffuse rash

During discharge teaching for a patient who experienced a mild stroke, you are providing details on how to eliminate risk factors for experiencing another stroke. Which risk factors below for stroke are modifiable?*

-Smoking -Obesity -Sedentary lifestyle

Which clinical manifestations would the nurse observe in a client experiencing a full-blown anaphylactic shock from a type I latex allergic reaction? Select all that apply. One, some, or all responses may be correct.

-Stridor -Hypotension -Dyspnea

Which assessment finding leads the nurse to suspect that an older client may have​ appendicitis? (Select all that​ apply.)

-Tenderness when pressing McBurney point -Confusion -Internal rotation of the left hip increases pain

The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. How would the nurse explain the increased risk for hypothermia in preterm infants?

Lack the subcutaneous fat that usually provides insulation

A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. The nurse should tell the client?

"Steroids are used in severe flare-ups because they can decrease the incidence of bleeding."

Which instruction would the nurse include in a health practices teaching plan for a female client with a history of recurrent urinary tract infections?

"Wear cotton underwear or lingerie."

Which is the primary cause of otitis media in young children?

An obstructed eustachian tube Rationale: A blocked eustachian tube impairs drainage and creates negative pressure; when the tube opens, bacteria are pulled into the middle ear.

appendicitis

Appendix becomes inflamed and edematous as a result of becoming kinked or occluded by a fecalith or lymphoid hyperplasia

A client with hypertension tells the nurse, "I took the blood pressure pills for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." Which is the best action for the nurse to take?

Ask the client questions to determine the current understanding of high blood pressure

Which of the following would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia?

Calcium gluconate

The nurse would include which instruction to the parents of a child being treated with oral ampicillin for otitis media?

Complete the entire course of antibiotic therapy.

The nurse is caring for a client diagnosed with rule out peptic ulcer disease. Which test confirms this diagnosis?

Esophagogastroduodenoscopy

When caring for a client hospitalized with deep vein thrombosis, which topic would the nurse include when doing discharge teaching about ways to avoid another venous thrombosis?

Frequent ambulation

In clients with human immunodeficiency virus (HIV), which potential complication is most important for the nurse to teach prevention strategies?

Infection Rationale: . Instructions regarding rest, nutrition, and avoidance of unnecessary exposure to people with infections help reduce the risk for infection

Which factor explains why a client who experiences an acute episode of rheumatoid arthritis has swollen finger joints?

Inflammation in the joint's synovial lining

When a client with peripheral arterial disease tells the nurse about having leg pain and weakness after walking a short distance, how will the nurse document this information?

Intermittent claudication Rationale: Intermittent claudication is pain that results when the arterial system is unable to provide adequate blood flow to the tissues in the presence of increased demands for oxygen and nutrients during exercise;

Which clinical manifestation is associated with cellulitis?

Lymphadenopathy (swelling of the lymph nodes)

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. Which type of room would the nurse assign this client?

Negative-airflow room

Which organism is a common opportunistic infection in a client infected with human immunodeficiency virus (HIV)?

Oropharyngeal candidiasis

An older client with shortness of breath is admitted to the hospital. The medical history reveals and a diagnosis of pneumonia 3 days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention?

Oxygen saturation: 89% Rationale: An oxygen saturation of less than 90% observed in a client with pneumonia indicates that the client is at risk of respiratory depression.

A woman with gestational hypertension experiences a seizure. Which of the following would be the priority?

Oxygenation

A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. The nurse should do which of the following first?

Provide parenteral rehydration therapy ordered by the physician

Which information will the nurse include when teaching a client with venous insufficiency about prevention of venous thrombosis?

Put on compression stockings before arising.

When a client with a history of hypertension that is usually successfully treated with medications has a blood pressure of 160/100 mm Hg during a clinic appointment, which action would the nurse take next?

Question the client about symptoms such as headache or chest pain.

A primary health care provider diagnoses the client's condition as otitis media. Which assessment finding supports that diagnosis?

Redness of the eardrum

A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix) in an effort to physiologically do what for the patient?

Reduce preload.

Which action would be the nurse's priority of care for a client with hypothermia?

Removing the client from the cold environment Rationale: Hypothermia is associated with a decrease in core body temperature, which requires interventions that lead to an increase in the client's internal body temperature. The client should be first removed from the cold environment. Electrolytes should be administered once the client's temperature is controlled

A client with acquired immunodeficiency syndrome (AIDS) and cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment would the nurse use? Select all that apply. One, some, or all responses may be correct

Surgical mask Gown Gloves Rationale: A gown, mask, and gloves when bathing the client prevent contact with feces, sputum, or other body fluids during intimate body care

Which suggestion would the nurse make to a client with rheumatoid arthritis who asks about ways to decrease morning stiffness?

Take a hot bath or shower in the morning. Rationale: Moist heat increases circulation and decreases muscle tension, which help relieve chronic stiffness

Which information would cause the nurse to withhold digoxin in the client with atrial fibrillation and heart failure?

The digoxin level is 2.8 mg/dL. Rationale: The therapeutic range for digoxin is 0.8 to 2.0 mg/mL; hold the medication because this client has digoxin toxicity

Which factor would the nurse consider when the parent of a 10-month-old infant expresses frustration that this is the baby's third otitis media in 3 months?

The eustachian tube is short and horizontal.

Which information would the nurse include when teaching about why women are more susceptible to urinary tract infections than men?

The length of the urethra

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

Troponin I Rationale: Troponin I levels rise rapidly & are detectable w/in 1 hour of myocardial injury

what kind of room would you place a patient with TB in?

negative pressure room

Which statement by an adolescent during an annual physical examination indicates the need for human immunodeficiency virus (HIV) testing?

I have shared needles when using drugs."

A client reports fever, redness, skin breakdown, and inflammation on the leg. Upon assessment, the nurse finds the area to be tender and edematous with diffused borders. The nurse would anticipate teaching the client about which condition?

Cellulitis

A client with tuberculosis receives instructions regarding isoniazid (INH) therapy from the assigned nurse. Which client statement indicates a misunderstanding of the content?

"I should apply sunscreen and wear sun-protective clothing while going outside." Rationale: This medication is not a photosensitive medication. All the rest of the statements are accurate.

Furosemide has been prescribed as part of the medical regimen for a client with hypertension. Which client statement indicates a need for medication education?

"This can decrease my vitamin K level." Rationale: Furosemide can produce hypokalemia, not vitamin K deficiency

The nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which clinical findings to this disease would the nurse expect the client to exhibit? Select all that apply. One, some, or all responses may be correct.

-Butterfly facial rash -Inflammation of the joints

Which statement by the nursing student indicates understanding of the precautions needed in the provision of care to a child who is human immunodeficiency virus (HIV) positive?

"I'll put on gloves if I'm going to be in contact with body fluids"

The nurse is assigning clients for the evening shift. Which of the following clients are appropriate for the nurse to assign to a licensed practical nurse to provide client care? Select all that apply.

-A client who underwent inguinal hernia repair surgery 3 hours ago -A client who is experiencing an exacerbation of his ulcerative colitis.

For which collaborative therapy for peritonitis following a ruptured appendix should the nurse prepare the​ client? (Select all that​ apply.)

-Antibiotics -Fluid resuscitation -Surgery

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement first? Select All that Apply

-Aspirin is an antiplatelet medication and should be administered orally. -Oxygen will help decrease myocardial ischeima, thereby decreasing pain

A teenage girl is being assessed for the possibility of appendicitis. Which other condition should the nurse​ consider? (Select all that​ apply.)

-Pelvic inflammatory disease -Ovulation -Ruptured ectopic pregnancy

Which condition may occur if the client does not seek medication attention for acute appendicitis within 24-36 ​hours? (Select all that​ apply.)

-Peritonitis -Perforation ​Rationale: If treatment is not​ initiated, tissue necrosis and gangrene result within 24-36 ​hours, leading to perforation​ (rupture).

You're educating a patient about transient ischemic attacks (TIAs). Select all the options that are incorrect about this condition:

-TIAs produce signs and symptoms that can last for several weeks to months. -TIAs don't require medical treatment Rationales: TIAs are caused by a temporary decrease in blood flow to the brain. TIAs is a warning sign that an impending stroke may occur

The nurse should understand that which of the following treatments for Second Degree Type II AV Block would be appropriate? (Select all that apply)

-Temporary pacemaker insertion -Atropine to increase heart rate if symptomatic -Coronary stent placement to improve blood flow to myocardium

A client who is experiencing an exacerbation of ulcerative colitis is receiving I.V. fluids that are to be infused at 125 mL/ hour. The I.V. tubing delivers 15 gtt/ mL. How quickly should the nurse infuse the fluids in drops per minute to infuse the fluids at the prescribed rate? ________________________ gtt/ minute.

31 gtt/ minute Rationale: formula: 125 mL/ 60 minutes × 15 gtt/ 1 mL = 31 gtt/ minute.

The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data require further intervention?

A decrease in systolic BP of 20 mm Hg from lying to sitting Rationale: this indicates orthostatic hypotension -> can indicate bleeding

A nurse is working in the labor and delivery unit. What statement does the nurse understand is true regarding new born thermogenesis?

Brown fat produces heat generation, and heat transfer to the peripheral circulation.

A client arrives for an influenza vaccination and reports a low-grade fever with a cough. Which action would the nurse take next?

Check the temperature and current history.

Which characteristic of urine changes in the presence of a urinary tract infection (UTI)?

Clarity

An adolescent has been admitted with a history of symptoms of fatigue, intermittent fever, weight loss, and arthralgia, and the diagnosis is systemic lupus erythematosus. Which is the best intervention at this time?

Education about diet, rest, and exercise

A client with chronic venous insufficiency has ankle edema. Which action would the nurse take?

Elevate the legs.

A client develops a deep vein thrombophlebitis in her leg 3 weeks after giving birth and is admitted for anticoagulant therapy. The nurse would anticipate developing a teaching plan for which anticoagulant?

Heparin

When a client with pneumonia is experiencing dyspnea because of difficulty expectorating thick respiratory secretions, which action by the nurse will be most helpful?

Offer fluids at frequent intervals

When caring for a client with peripheral arterial insufficiency, how would the nurse position the client's feet and legs?

Place them slightly lower than the head and chest.

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?

Platelet count: 82,000/L Rationale: This platelet count is low and could indicate heparin-induced thrombocytopenia

A client with human immunodeficiency virus (HIV) reports dyspnea on exertion, increased heart rate, a persistent dry cough, and a persistent low-grade fever. The nurse auscultates bilateral crackles in the lower lung lobes. Which organism would the nurse suspect is responsible for this condition?

Pneumocystis jiroveci Rationale: Pneumocystis jiroveci causes pneumonia, which is the most common opportunistic infection in clients infected with the human immunodeficiency virus (HIV).

Which of the following should be a priority focus of care for a client experiencing an exacerbation of Crohn's disease?

Promoting bowel rest.

The nurse is assessing a client who had a bowel resection 4 hours ago. Which finding would the nurse identify as an early sign of shock?

Restlessness Rationale: In the early stage of shock, the client has increased epinephrine secretion. This, in turn, causes the client to become restless, anxious, nervous, and irritable

A health care provider prescribes a diuretic for a client with hypertension. Which mechanism of action explains how diuretics reduce blood pressure?

They reduce the circulating blood volume.

The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What should the nurse do next?

Withhold the dose and report the potassium level Rationale: The normal potassium level is 3.5-5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to digoxin toxicity.

Inflammation

a nonspecific but complex response to reduce the effects of what the body sees as harmful. Inflammation may result from an injury or an underlying infection

manifestations of appendicitis

continuous, mild, generalized upper abdominal pain pain intensifies over hours and localizes to RLQ aggravated by movement rebound tenderness at McBurney point low-grade fever anorexia nausea vomiting.

the critical care nurse is preparing to initiate an IV drip of dopamine to a client in shock. What goal of this treatment should the nurse identify?

maintenance of adequate mean arterial pressure

The nurse is caring for a surgical client who develops a wound infection during hospitalization. Which classification would this infection belong to?

nosocomial

signs and symptoms of inflammation

pain, swelling, redness, heat, impaired function

complications of appendicitis

perforation/rupture peritonitis and abscess

s/s of a ruptured appendicitis is

sudden disappearance of pain

The nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). Which recommendations are essential for the nurse to include? Select all that apply. One, some, or all responses may be correct.

-"Wear a large-brimmed hat." -"Take your temperature daily." -"Balance periods of rest and activity."

s/s of a perforation of appendicitis

increased and high fever

Which nursing action will be most helpful in preventing transmission of influenza in crowded communities?

Educating about the importance of having annual vaccinations

When caring for a client with pneumonia, which nursing intervention is the highest priority?

Employ breathing exercises and controlled coughing

A client with rheumatoid arthritis has been taking a corticosteroid medication for the past year. Prolonged use of corticosteroids puts this client at increased risk for which complication?

Decreased white blood cells

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?

Deep tendons reflexes 2+

You're educating a patient about Warfarin (Coumadin) and how it is used to treat blood clots. Which statements by the patient require you to re-educate them about how this medication works? Select all that apply:

-"This medication will help dissolve the blood clot." -"This medication starts working immediately after the first dose." Rationale: Warfarin (Coumadin) does NOT dissolve blood clots. It prevents blood clots from forming. Warfarin takes about 3-5 days of scheduled doses to start achieving a therapeutic INR level

The nurse has administered an antibiotic, a proton pump inhibitor, and Pepto- Bismol for peptic ulcer disease secondary to H. pylori. Which data would indicate to the nurse the medications are effective?

A decrease in gastric distress

Which assessment findings would the nurse identify in a client with clinical manifestations of rheumatoid arthritis (RA)? Select all that apply. One, some, or all responses may be correct

*Development of antinuclear antibodies *Inflammatory disease pattern *Bilateral involvement of metacarpophalangeal joints

Which patient below is at most risk for a hemorrhagic stroke?

A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago. Rationale: Risk factors for a hemorrhagic stroke is uncontrolled hypertension, history of brain aneurysm, old age (due to aging blood vessels.

The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom(s)?

Anorexia and nausea Rationale: Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity

A client admitted after using crack cocaine develops ventricular fibrillation. After determining unresponsiveness, which action should the nurse take next?

Defibrillate at 200 J

Which intervention should the nurse implement with the client diagnosed with dilated cardiomyopathy?

Discuss a heart transplant, which is a definitive treatment

Which statement made by the nurse will be most significant when teaching strategies to reduce the risk for developing antibiotic-resistant infections?

Do not skip any prescribed doses of your antibiotics

Which intervention would the nurse perform to prevent disease transmission when caring for a hospitalized client with influenza?

Don a mask in the room

Which clinical manifestations are associated with a diagnosis of tuberculosis? Select all that apply.

Hemoptysis Anorexia Night sweats

The client with a history of peptic ulcer disease is admitted into the intensive care unit with frank gastric bleeding. Which priority intervention should the nurse implement?

Insert a nasogastric tube and begin saline lavage Rationale: this directly stops the bleeding

The nurse identifies 12 mm of induration at the site of a client's tuberculin purified protein derivative (PPD) test. Which rational would the nurse use to explain this test?

The result indicates a need for further tests and a chest x-ray. Rationale: The test result is positive, not negative; thus further testing is necessary. It is the most accurate skin test for tuberculosis (TB) because of the testing material and the intradermal method used

Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease?

Use of non steroidal anti inflammatory drugs (NSAIDs)

A 38-year-old female is brought to the Emergency Department with complaints of her "heart beating out of her chest". She is diaphoretic, tachypneic and her BP is 70/40. The cardiac monitor shows supraventricular tachycardia. Valsalva maneuvers and three doses of Adenosine have not been successful. The nurse should immediately:

prepare the patient for synchronized cardioversion

A 21-year-old female is seen in the Emergency Department for vomiting and diarrhea for 3 days. Her BP is 94/64 and her EKG rhythm shows that she is sinus tachycardia. The best action for the nurse to take initially is to:

start IV and bolus normal saline per protocol. Rationale: because the patient is dehydrated due to vomiting and diarrhea and needs IV fluids

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because

the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease

Which are risk factors that are known to contribute to atherosclerosis-related diseases? (Select all that apply.)

-Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL -Smoking -Type 2 diabetes

A nurse is caring for a newborn immediately after birth . Which of the following actions by the nurse reduces evaporative heat loss by the newborn ?

Drying the newborn's skin thoroughly

A nurse is assessing a client who has pancreatitis. Which of the following actions should the nurse take to assess the presence of Cullen's sign.

Inspect the skin around the umbilicus Rationale: Cullen's sign is indicated by a bluish-gray discoloration in the periumbillical area

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?

Large chefs salad and muffin Rationale: Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. The chefs salad most likely has too many leafy green vegetables, which contain high amounts of vitamin K.

The client diagnosed with a myocardial infarction is six hours post-right femoral percutanous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse?

The client is complaining of numbness in the right foot

A client arrives at a health clinic stating, "I am here to have my tuberculin skin test read." The nurse notes that there is a 7-mm indurated area at the injection site. Which statement made by the nurse correctly describes this result?

"The result indicates that you are infected with the tuberculosis organism."

A client expresses concern regarding the lack of annual flu vaccines because of a supply and demand problem. Which response by the nurse is best?

"There are other things you and your family can do to prevent the flu, such as hand washing."

The client with peptic ulcer disease (PUD) asks the nurse whether licorice and slippery elm might be useful in managing the disease. What is the nurse's best response?

"These herbs could be helpful. However, you should talk with your physician before adding them to your treatment regimen."

A client with ulcerative colitis is to take sulfasalazine (Azulfidine). Which of the following instructions should the nurse provide for the client about taking this medication at home? Select all that apply.

-Drink enough fluids to maintain a urine output of at least 1,200- 1,500 mL per day. -Discontinue therapy if symptoms of acute intolerance develop and notify the health care provider. -Avoid activities that require alertness.

The nurse administers amiodarone (Cordarone) to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? Select all that apply.

-QT interval -Heart rate and rhythm -Magnesium level

When a client with peripheral arterial disease returns to the nursing unit after a femoral angiogram, which action will the nurse take first?

Assess the client's affected leg.

A client with atrial fibrillation with rapid ventricular response has received medication to slow the ventricular rate. The pulse is now 88. For which additional therapy does the nurse plan?

Anticoagulation Rationale: Because of the risk for thromboembolism, anticoagulation is necessary.

Which finding by the nurse who is caring for a client after major abdominal surgery may indicate impending hypovolemic shock?

Client report of feeling very thirsty Rationale: With hypovolemic shock, extravascular fluid depletion leads to client feeling of thirst. With hypovolemia, urine output will decrease due to compensatory mechanisms designed to retain volume

Which client is at an increased risk for hospital-acquired pneumonia? Select all that apply. One, some, or all responses may be correct.

Client who was admitted to the hospital 5 days ago for abdominal pain Rationale: Hospital-acquired pneumonia occurs in non-intubated clients and begins 48 hours after admission. A client admitted 5 days ago with abdominal pain would meet the criteria and is at increased risk for hospital-acquired pneumonia. A client admitted the previous day has not been in the hospital at least 48 hours. A client on mechanical ventilation is intubated and does not meet the criteria for hospital-acquired pneumonia. A client who has been on an airplane with other ill individuals would be at risk for community-acquired pneumonia. A client in the emergency department has not been admitted to the hospital.

Which assessment finding will the nurse expect when caring for a client who has cardiogenic shock?

Cold, clammy skin

When developing the plan of care for a client with rheumatoid arthritis, which client consideration would the nurse include?

Comfort

Which assessment data support to the nurse the clients diagnosis of gastric ulcer?

Complaints of epigastric pain 30-60 minutes after ingesting food.

After a short hospitalization for an episode of a transient ischemic attack (TIA) related to hypertension, a client is discharged on a regimen that includes chlorothiazide. Which instruction will the nurse give the client regarding nutrition?

"Eat more dark green, leafy vegetables such as spinach." Rationale: The client should increase the dietary intake of potassium because of potassium loss associated with chlorothiazide.

When a client with venous insufficiency has questions about the brownish discoloration of the skin on the legs, which response will the nurse make to explain the discoloration?

"There is leakage of red blood cells [RBCs] through the vein wall."

Which nursing interventions would the nurse provide to an older client with hypertension? Select all that apply. One, some, or all responses may be correct.

-Advise the client to limit salt intake -Teach stress management -Instruct the client to quit smoking

The nurse is preparing to administer a vaccine to a child. Which conditions, if present, would allow for the safe administration of the vaccine? Select all that apply. One, some, or all responses may be correct.

-Current antimicrobial therapy -Mild to moderate local reactions -Recent exposure to infectious diseases

Which changes that occur with aging increase the risk for hypothermia in older adults? Select all that apply. One, some, or all responses may be correct.

-Decreased amount of body fat -Diminished energy reserves -Chronic medical conditions

Which clinical manifestations would the nurse expect when assessing a client who is diagnosed with cardiogenic shock? Select all that apply. One, some, or all responses may be correct.

-Tachycardia -Restlessness -Bradypnea

The nurse assesses for which client symptoms that indicate hyperthermia? Select all that apply. One, some, or all responses may be correct.

-Vasodilation -Dry and flushed skin -Decreased urinary output

When teaching a client with hypertension about a 2-gram sodium diet, which foods would the nurse instruct the client to avoid? Select all that apply. One, some, or all responses may be correct

-canned chili -Luncheon meat

A client taking multiple medications for hypertension develops a persistent, hacking cough. Which antihypertensive medication class would the nurse identify as the likely cause of the cough?

Angiotensin-converting enzyme (ACE) inhibitors Rationale: When ACE is inhibited, the increase of kinins in the lung can cause bronchial irritation, leading to the common adverse effect sometimes referred to as an ACE cough

A client is admitted to the hospital, and benazepril is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication?

Assess for dizziness.

While performing cardiac surgery, the cardiologist intentionally induces hypothermia in the client. Which rationale explains this intervention by the cardiologist?

To prevent tissue ischemia Rationale: surgeons intentionally induce hypothermia to decrease the oxygen requirement of the tissues and ultimately prevent tissue ischemia.

Intravenous furosemide has been prescribed for a client with severe edema and hypertension. Which subjective clinical manifestations lead the nurse to suspect that the furosemide is infusing too rapidly? Select all that apply. One, some, or all responses may be correct.

-Tinnitus -Weakness -Leg cramps Rationale: tinnitus is a CNS side effect of furosemide, weakness and leg cramps result from hypokalemia caused by an overload of furosemide, nausea and anorexia are side effects of dehydration that may occur with overload of furosemide. Dry mouth as well.

The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include? Select all that apply

-Weighing the client daily. -Monitoring the I.V. infusion rate hourly. -Taping all I.V. tubing connections securely.

A 54-year-old male patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first?

Assist the patient to a sitting position with arms on the overbed table.

When administering furosemide (Lasix) to a client who does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels?

Consume melons and baked potatoes.

The nurse is caring for a client on a telemetry unit with a regular heart rhythm and rate of 60; a P wave precedes each QRS complex, and the PR interval is 0.24 second. Additional vital signs are as follows: blood pressure 118/68, respiratory rate 16, and temperature 98.8° F. The following medications are available on the medication record. What action should the nurse take?

Continue to monitor. Rationale: The client is displaying sinus rhythm with first-degree atrioventicular heart block; this is usually asymptomatic and does not require treatment

Which finding will the nurse expect when caring for a client who is in hypovolemic shock?

Cool skin temperature Rationale: Shunting of blood to vital organs such as the heart and brain occurs in hypovolemic shock, leading to cool skin because of decreased skin perfusion.

A client with hypothermia is brought to the emergency department. Which treatment would the nurse anticipate?

Core rewarming with warm fluids Rationale: Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment.

A client is admitted with cellulitis of the left leg and a temperature of 103°F (39.4°C). The primary health care provider prescribes intravenous (IV) antibiotics. Which action is the priority before administering the antibiotics?

Determine the client's allergies.

Which finding is indicative of hypothermia in a newborn? Select all that apply. One, some, or all responses may be correct.

Hypoglycemia