PNII Exam 2

The nurse is caring for a client with newly diagnosed hypertension. What statement by the client indicates adequate understanding of his or her diet restrictions?

"I will give my canned soups to the food pantry."

What information about nutrition does the nurse teach a client with chronic obstructive pulmonary disease (COPD)? (Select all that apply.)

-Avoid drinking fluids just before and during meals." -"Rest before meals if you have dyspnea." -"Have about six small meals a day."

A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?

1 cup canned black beans

the provider ordered normal saline with 20 mEq of KCL to infuse at 100 ml/hr. the first liter bag was hung at 0600. what time does the nurse anticipate needing to hang the second bag of IV fluids? record answer in military time

1600

the nurse is notifiying the health care provider via telephone of a change in condition of a client diagnosed with acute exacerbation of asthma. arrange the nursing statements in order as they would be communicated using the SBAR method. 1. mr. smith was admitted yesterday wiht an exacerbation of asthma. he typically controls his asthma with oral medications and inhalers at home. he is ordered albuterol treatments twice daily. oxygen is prescribed at 2 L nasal cannula. 2. i am notifying you because bob smith has become increasingly short of breath with audible wheezing this afternoon 3. i recommend that we increase his oxygen and prescribe an extra albuterol treatment 4. hello, my name is nurse jones from unit D 5. respirations are now 32 breaths/minute. the pulse oximeter is 89% on 2 L nasal cannula; lungs reveal wheezing in all lung fields, slight nasal flaring

4, 2, 1, 5, 3

a client undergoes a purified protein derivative (PPD). when should the test be read?

48 to 72 hours after the test

a client is receiving an IV infusion of heparin sodium at 1,500 units/hr. the drug concentration is heparin sodium 25,000 units/1000 mL. what is the rate mL/hr the nurse must infuse the medication at? record the answer to the nearest whole number

60

order for dobutamine to infuse at 15 mcg/kg/min. the client weighs 200 lbs. the pharmacy supplied a bag of dobutamine 100 mg/100 mL. what is the rate in mL/hr the nurse should infuse the medication at?

82

A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take?

Administer a short acting B2 agonist (SABA)

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism?

Assess legs for redness Apply elastic compression stockings Perform passive range of motion exercises

A nurse caring for a client who has hypertension and asks the nurse about prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions?

Asthma

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?

Breathlessness

A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dl and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following?

Cellular hypoxia

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Check the clients vital signs

The nurse is caring for four clients with asthma. Which client does the nurse assess first?

Client whose heart rate is 120 beats/min

A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change?

Decrease in tissue perfusion

A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication?

Decreased blood pressure

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client?

Dyspnea Barrel chest Clubbing of the fingers

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?

Edema

The nurse is caring for postoperative client who has chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?

Fluctuation of the fluid level within the water seal chamber

Which statement indicates that the client understands teaching about the use of long-acting beta2 agonist medications?

I will take this medication daily to prevent an acute attack."

A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?

If I could lose about 50 pounds, I might stop having so many apneic episodes

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the clients care?

Impaired tissue perfusion

The nurse is teaching a client with pneumonia ways to clear secretions. Which intervention is the most effective?

Increasing fluids to 2 L/day if tolerated

A nurse is caring for a client who has peripheral arterial disease. Which of the following symptoms should the nurse expect to find in the early stage of the disease

Intermittent claudication

A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side.

Left pedal pulse

A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make

Medication will prevent wheezing Medication will open airways Medication will decrease coughing episodes

The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure?

Middle-aged woman with aortic stenosis

A nurse in a provider's office is assessing a client who reports occasional atypical chest pain, palpitations, and exercise intolerance. On auscultation, the nurse notes a systolic click. The nurse should recognize this finding as a manifestation of which of the following condition

Mitral valve prolapse

A nurse in a providers office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis

Night sweats Low-grade fever Blood in sputum

The nurse is assessing a client who reports claudication after walking a distance of one block. The nurse notes a painful ulcer on the fourth toe of the client's right foot. What condition do these findings correlate with?

Peripheral arterial disease

A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for the client?

Peripherally inserted central catheter

A nurse is caring for a client who receives furosemide to treat heart failure. Which of the following laboratory values should the nurse monitor for this client due to this medication?

Potassium

A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). What assessment finding requires action by the nurse?

Potassium of 2.9 mEq/L

A nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone. Which of the following instructions should the nurse provide?

Rinse the mouth after administration

The nurse is assisting the hospitalized client with his food selections for breakfast. The client is on a low-cholesterol diet. What recommendations are most appropriate for this client?

Skim milk, oatmeal, banana, orange juice, coffee

A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder?

Smoking cessation

A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia

Spironolactone

A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron deficiency anemia. The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals. Which of the following responses should the nurse make?

Taking the medication between meals will help you absorb the medication more efficiently

A nurse is teaching a client who has asthma about how to use albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?

The client holds his breath for 10 seconds

a nurse is evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results pH: 7.32 PaCO2: 62 mm Hg PaO2: 46 mm Hg HCO3: 28 mEq/L Vital Signs respiratory rate = 12 bpm blood pressure: 145/65 mm Hg heart rate: 110 bpm oxygen saturation: 76% on room air which action should the nurse take first?

a. administer a short-acting beta 2 agonist inhaler

a nurse is assessing a client who has chronic venous insufficiency. which of the follwoing findings shoudl the nurse expect?

a. edema

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?

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

a nurse cares for a client who had a chest tube placed for 6 hours ago and refuses to take deep breaths because of the pain. which action should the nurse take?

administer pain medication and enocurage the client to take deep breaths

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

administer the medications as prescribed

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 hte calf during exercise that disappears at rest. which finding requires further evaluation?

ankle-branchial index of 0.65

a client with bacterial pneumonia becomes increasingly restless and confused. temperature is 100 F, and pulse, blood pressure and respirations are increased since the last assessment 6 hours ago. which action should the nurse take first?

assess oxygen saturation

with which client does the nurse anticipate complications from obstructive sleep apnea following abdominal surgery?

b. 28-year-old who is 80 lbs (38.4 kg) overweight and has a short neck

a client is admitted with an abdominal aortic aneurysm (AAA). for which of the following complications should the burse be most concerned?

b. aneurysm rupture

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

b. paresthesia c. pallor d. pulselessness e. pain f. paralysis

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

b. sputum production c. dyspnea on exertion

a client is having laboratory tests conducted to confirm a diagnosis of atherosclerosis. which of the following laboratory values would support this client's medical diagnosis? (SATA)

b. triglycerides 400 mg/dL e. serum-cholesterol 300 mg/dL f. high-density lipoprotein (HDL) 25 mg/dL

when teaching a client about propanolol hydrochloride, what information should the nurse incude in the education for the client?

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

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

blood cultures

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

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

c. administer heparin as prescribed

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? (SATA)

c. atorvostatin d. spironolactone f. amlodipine

which of the following would the nurse most likely assess in a client diagnosed wiht right-sided heart failure?

c. distended neck veins

the nurse is considering the risk factors for a client's development of primary hypertension. which of the following are modifiable risk factors for the client? SATA

c. level of physical activity e. amount of fat and salt in the diet f. stress

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

c. pulse 96 bpm and oxygen saturation of 92% on room air

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?

c. question the client about whether the medication is actually being taken

a nurse is caring for a client who arrived at an emergency department with status asthmaticus. based on the progress note: blood pressure 140/90 mm Hg, pulse 104 bpm, temperature at 98.4 F. respiratory rate 34 bpm, and lung sounds noted with audible wheezing; ABG's are pH 7.22; PaCO2 69 mm Hg; and HCO3 -26 mEq/L. the nurse suspects that the client has what abnormality?

c. respiratory alkalosis

of the following client assignments made by the charge nurse. which would be questioned? a. the RN with eight years of experience caring for a client with peripheral vascular disease and total cholesterol of 390 mg/dL b. the RN with ten years of experience caring for a client with a history of pulmonary embolism and receiving heparin therapy c. 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

c. 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 nurse is caring for a client who has heart failure and is taking digoxin daily. the client refused breakfast and is complaining of nausea and weakness. which of the following actions should be priority for the nurse?

check the client's vital signs and rhythm

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

check the tubing to ensure that the client is not lying on it or kinking it

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

d. B-type natriuretic peptide (BNP)

a nurse is assessing a client who has right ventricular heart failure. which of the following findings should the nurse expect?

d. 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 as follows; pH 7.22, HCO3- 21 mEq/L, PCO2 65 mm Hg. which is the priority action by the nurse?

d. 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 assisstive personnel (UAP)?

d. assissting a client with adjusting his or her nasal cannula

the parents of a child diagnosed with cystic fibrosis ask the nurse how their child developed the disease. which of the following should the nurse explain to these parents?

d. cystic fibrosis is an x-linked disorder

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

early morning blood pressure reading of 164/90 mm Hg

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 conditions is most commonly responsible for right heart failure?

left heart failure

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?

one drug decreases inflammation and the other is a bronchodilator

which of the following statements should the nurse teach a client who is receiving a continuous heparin infusion?

partial thromboplastin time values determine the dosage of heparin

a nurse is completing discharge planning for a client who has bacterial endocarditis. the client will need to receive 12 weeks of antibiotic therapy. which of the following venous access devices should the nurse identify as appropriate for the client?

peripherally inserted central catheter (PICC)

the nurse is assessing a client for risks in the development of varicose veins. which of the following findings would increase this client's risks?

prolonged standing

a cient receiving warfarin is demonstrating signs of acute bleeding. which of the following should the nurse anticipate the provider to prescribe for this client?

protamine sulfate

a client comes into the emergency department with acute shortness of breath and a cough that produces pink, frothy sputum. admission assessment reveals crackles and wheezes, a blood pressure of 85/46 mm Hg, a heart rate of 122 beats/minute, and a respiratory rate of 38 breaths/minute. the client's medical history included diabetes mellitus (DM), hypertension (HTN), and heart failure. which of the following disorders should the nurse suspect?

pulmonary edema

the nurse is assigned to a cleint who just arrived at the emergency room after a motor vehicle accident and has multiple rib fractures. knowing the client could potentially have a pneumothorax. what are the signs and symptoms the nurse would correlate with this condition?

respiratory distress

a client who has a history of pulmonary valve stenosis tells the healthcare provider. "I dont have a lot of energy anymore and both of my feet get swollen in the late afternoon in the late afternoon." which of these problems does the healthcare provider conclude is the likely cause of the findings?"

right-sided failure

a nurse reviews the labs for a newly admitted heart failure client and notes a serum potassium (K+) level of 5.6 mEq/L. upon reviewing the client's medications, the nurse realizes which of the following medications most likely contributed to this electrolyte imbalance?

spironolactone

a nurse is assessing a client who is taking lisinopril to treat hypertension. which finding is the highest priority to report?

swelling of the tongue

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 hte 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

a nurse assesses a client in preparation for receiving blood transfusion. pre-transfusion vitals are temperature, 98.2 F, heart rate 82 beats/minute, 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