PN2 Exam 2 Concept Map

A client experiencing a sever asthma attack has the following arterial blood gas results PH 7.33; PCO2 48mm Hg HCO 26 mEq/L. Which order should the nurse implement first?

Albuterol nebulizer

The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which finding requires further evaluation?

Ankle-brachial index of 0.65

.Which of the following would the nurse most likely assess in a client diagnosed with right-sided heart failure?

Ascites

.The post-anesthesia care nurse is caring for a client who just had a mitral valve replacement surgery. The client's arterial blood gases are pH 7.22; HCO3- 21 mEq/L; PCO2 65 mm Hg and PO2 58 mm Hg. Which is the priority action by the nurse?

Assessing the client's airway

The nurse is caring for a group of clients on a pulmonary unit. The nurse can delegate which task to unlicensed assistive personnel (UAP)

Assisting a client with adjusting their nasal cannula.

A client is experiencing an acute asthmatic attack. The client is noted to have respirations of 40 breaths/min pulse 132 beats/min, oxygen saturation 86% on room air, and lung sounds with audible wheezing. Which findings indicate achievement of the desired outcome of the treatment with levalbuterol?

Pulse 96 beats/min and oxygen saturation of 92 on room air

When teaching a client about propranolol hydrochloride, what information should the nurse include in the education for the client?

Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction

The nurse is assessing a client diagnosed with an abdominal aortic aneurysm (AAA). Which of the following sounds did the nurse likely auscultate during the assessment?

Bruit

Client is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which of these statements by the client is most consistent with the diagnosis?

" I cant get shoes on at the end of the day"

When a client with hypertension who has a new prescription for atenolol returns to the health clinic after two weeks for a follow-up visit, the blood pressure is unchanged from the previous visit. Which action should the nurse take first?

Question the client about whether the medication is actually being taken

.Which of the following statements should the nurse teach a client who is receiving a heparin infusion?

APartial thromboplastin time values determine the dosage of heparin

A client is diagnosed with acute peripheral arterial occlusion. The nurse should prepare to provide which of the following interventions for this client?

Administer heparin as prescribe

A nurse working with clients with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. A client communicates the need for additional teaching by which of the following statements?

"I will avoid exercise."

Which of the following statements indicates a client's understanding of managing their obstructive sleep apnea?

'It is possible that my sleep apnea can be corrected if I exercise and watch my diet."

A client is receiving spironolactone to treat bilateral lower extremity edema. The nurse should instruct the client to make which nutritional modification to prevent an electrolyte imbalance?

(C) Decrease foods high in potassium

The provider ordered Normal Saline with 40 mEg of KCL in infuse at 100 mL/hr. The first liter bag was hung at 2300. What time does the nurse anticipate needing to hang the second bag of IV fluids? (Record answer in military time

0900

Client is receiving an I infusion of heparin sodium at 1,500 units/hr. The drug concentration is heparin sodium 25,000 units/250mL. What is the rate (in mU/hr) the nurse must infuse the medication at? (Round the answer to the nearest whole number. Do not use a trailing zero)

15

The nurse is notifying the health care provider via telephone of a change in the condition of a client diagnosed with an exacerbation of asthma. Arrange the nursing statements in order as they would be communicated using the SBAR method

4, 2. 1, 5, 3

Order for dobutamine to infuse at 10mcg/kg/min. The client weighs 155lb. The pharmacy supplied a bag of dobutamine 250mg/250mL. What is the rate (in ml/hr) the nurse must infuse the mediation at? (Round the answer to the nearest whole number. Do not use a trailing zero.?

42

The health care provider has just prescribed warfarin sodium for a client with a deep vein thrombosis(OVT). The nurse knows that this client is still receiving intravenous heparin. Which is the nurse's best action?

Administer the medications as prescribed.

A client who underwent a lobectomy and has a water seal chest drainage system appears to have an increased work of breathing and a faster respiratory rate than 1 hour ago. The client's pulse rate is also increased. The nurse should do which of the following?

A) Check the tubing to ensure that the drain is not lying on it or kinking it

The nurse is reviewing a medical record for a client with hypertension. Which of the following medications may be used in the management of hypertension?

A) Losartan B) Metroprolol D) Torsemide F) Clonidine

A nurse is assessing a male client who has a diagnosis of acute arterial occlusion. Which of the following findings should the nurse expect to find on the affected extremity? SATA

A) Pain B) Pulselessness C) Paresthesia D) Paralysis F) Pallor

Which findings are significant data to gather from a client who has been diagnosed with pneumonia? SATA

A) Quality of breathing sounds C) Occurrence of chest pain E) Color of anil beds

A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following clinical manifestations are expected findings? SATA

A) Tachypnea B) persistent cough E) Orthopnea

The nurse suspects a client is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) when which of the following is assessed. SATA

A) cough B) Dyspnea on exertion F) Sputum production

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease. Which of the following interventions require extra care by the nurse?

Administering pain medications

Which assessment finding for a client receiving furosemide 40mg twice daily to treat stage 2 hypertension is most important to report to the health care provider?

B Blood potassium level of 3.3 mEq/

A client is undergoing diagnostic testing for infective endocarditis. Which of the following laboratory tests would be most useful in diagnosis?

B) Blood cultures

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition?

B) Breathlessness

Which laboratory test will be most useful to the nurse in determining whether a client admitted with acute shortness of breath has heart failure?

B-type natriuretic peptide (BNP Cholesterol)

Which finding requires immediate intervention when planning care for an adolescent with cystic fibrosis (CF)?

Chest pain with dyspnea

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results рН = 7.32 PaCO2 = 62 mm Hg Pa02 = 46 mm Hg HC03- = 28 mEg/L Vital Signs Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Heart rate = 110 beats/min Oxygen saturation = 76% on room air Which action should the nurse take first?

D) Initiate oxygenation therapy to increase oxygen saturation to 92%,

A client who has a history of pulmonary valve stenosis tells the healthcare provider, 1 don't have a lot of energy anymore, and both of my feet get swollen in the late afternoon." Which of these problems does the healthcare provider conclude is the likely cause of these clinical findings?

D)Right-side heart failure

A client has a history of heart failure and has been prescribed furosemide, digoxin and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused refusing to eat, and complaining of nausea. The nurse should assess the client for signs of:

Digoxin toxicity

.Isoniazid and rifampin have been prescribed for a client with tuberculosis. A nurse reviews the medical record of the client. Which of the following noted in the client's history would require the nurse to question the order for these medications?

Hepatitis C

The nurse is assessing a client with COPD. Which requires immediate intervention?

Inability to speak

.Which of the following should the nurse instruct a client who is newly diagnosed with hypertension on?

It is a lifelong process

Which of the following conditions is most commonly responsible for right heart failure?

Left heart failure

A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first?

Maintain adequate oxygenation

A client receiving a heparin infusion demonstrates signs of acute bleeding. Which of the following should the nurse anticipate the provider to prescribe for to this client?

Protamine sulfate

1) A client is having laboratory tests conducted to confirm a diagnosis of arteriosclerosis. Which of the following laboratory values would support this client's medical diagnosis? (Select all that apply)

Serum Cholesterol 285 mg/dL High-density lipoprotein (HDL) 30 mg/dl

A client with an acute exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. How can the nurse best position the client to improve gas exchange?

Sitting up at the bedside or in a chair and leaning slightly forward

The nurse is preparing a teaching plan for a client who is being discharged after being admitted for atherosclerosis. The client has been taking simvastatin 40 mg for the last two years. The lab results for the client's lipid panel results are total cholesterol 195 mg/dL; triglycerides 106 mg/dL; and high-density lipoprotein (HDL) 69 mg/dL. Which action should the nurse take?

Tell the client that the cholesterol levels are within normal limits

Of the following client assignments made by the charge nurse, which would be questioned?

The LPN with 20 years of experience caring for a diabetic client complaining of a headache and with a blood pressure of 210/150 mm Hg

A client admitted with an abdominal aortic aneurysm (AAA). For which of the following complications should the nurse be most concerned?

aneurysm rupture

Which arterial blood gas (ABG) values are expected with hypoventilation?

pH 7.29; PaCO2 64 mm

A client with chronic bronchitis who has a new prescription for a fluticasone and salmeterol combination inhaler asks the nurse the purpose of using two drugs. Which is the best response by the nurse?

A) One drug decreases inflammation, and the other is a bronchodilator

A nurse assesses a client in preparation for receiving a blood transfusion. Pre-transfusion vitals are temperature 98.2 F, heart rate 82 beats/minute, respirations 18 breaths/minute, blood pressure 102/76 mm Hg, oxygen saturation 96% on room air. Fifteen minutes after starting the transfusion, the nurse measures the following vital signs. Which of the following is the highest priority for action?

Temperature 100.6 F

Which action by a client with asthma indicates a good understanding of the nurse's teaching about peak flow meter use?

The client uses the albuterol metered-dose inhaler for peak flows in the yellow zone