Test 3
A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report: A. Having a decreased ability to perceive colors B. Loss of central vision C. Having a loss of peripheral vision D. Seeing bright flashes of light and floaters
A
A patient with a head injury after a motorcycle crash arrive in the ED complaining of shortness of breath and severe eye pain. Which action will the nurse take first? A. Check the patients oxygen saturation B. Assess cranial nerve function C. Administer the prescribed analgesic D. Examine the eye for evidence of trauma
A
The nurse suspects that the client with stable angina is experiencing a side effect of the prescribed drug metoprolol if the: A. Blood pressure is 90/54 B. Client is restless and agitated C. Client complains about feeling anxious D. Cardiac monitor shows sinus rhythm
A Beta blockers can cause hypotension and bradycardia
The nurse is reviewing the lab test results for a client who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? A. Serum creatinine of 2.8 B. Serum potassium if 4.5 C. Serum hemoglobin of 14.7 D. Blood glucose level of 96
A Increase creatinine indicates renal damage caused by the hypertension
A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6. The nurse administers 1 SL NTG tablet. After 5 minutes the client states that his chest pain is now a severity of 2 which of the following actions should the nurse take? A. Administer another NTG tablet B. Initiate a peripheral IV C. Call the rapid response team D. Obtain a 12 lead ECG
A We want the pain to be 0
A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse should instruct the client to monitor for which of the following complications? A. Pulmonary embolism B. Bradycardia C. Peripheral vascular disease D. Hypertension.
A due to blood pooling up
A nurse is teaching the partner of a client who had an acute MI about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzyme studies? A. Cardiac enzymes will identify the location of the MI B. These lab tests help determine the degree of damage to the heart tissue C. These tests will enable the provider to determine the heart structure and mobility of the valves D. Cardiac enzymes assist in dug paint the presence of pulmonary congestion
B Enzymes most commonly measured are CPK and troponin
A nurse is providing teaching to a client who has stable angina and a new prescription of transdermal NTG. Which of the following instructions should the nurse include? Select all that apply A. Apply the patch to dry skin and cover the area with plastic wrap B. Apply the patch to a hairless area and rotate sites C. Apply a new patch each morning D. Remove the patch for 10-12 hours daily E. Apply a new patch at the onset of anginal pain
B,c,d
A nurse in the emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following lab tests are used to diagnose MI? A. LDL B. Troponin C. Creatinine D. Myoglobin E. CK-MB
B,d,e
Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction? A. Assist the patient to a supine position B. Use sterile applicator to clean the ear canal before irrigating C. Fill the irrigation syringe with body temp water D. Occlude the ear canal with the syringe while irrigating
C
The nurse is assessing a client who has been admitted to the ICU with a hypertensive emergency. Which finding is important to report to the HCP? A. Urine output of 8 hours is 150 less than the fluid intake B. Tremors are noted in fingers when the client extends the arms C. The client cannot move the left arm and leg when asked to do so D. The client complains of a headache with a pain level of 8/10
C. Inability to move left arm and leg indicates that a stroke may be occurring and requires immediate action to prevent further neurological emanate
A 42 year old women with Meniere's disease is admitted with vertigo, nausea, vomiting. Which nursing intervention will be included in the care plan? A. Change clients position frequently B. Increase caffeine intake C. Place client I'm Trendelenburg D. Encourage the client to restrict lateral head movements
D
A nurse is providing teaching for a client who has a new diagnosis of stable angina. The nurse should give the client which of the following information about stable anginal pain? A. The pain usually lasts longer than 30 minutes B. The pain persists with rest and nitrates C. The pain is always relieved with change of position D. Exerting and anxiety can trigger the pain
D
What should be done for ventricular fibrillation? A. Turn client on left side and take BP B. Administer amiodarone C. Prepare to intubate with an endotracheal tube D. Call a code and defibrillate
D
A nurse is reviewing the laboratory test results of a client who has atrial fibrillation and is taking warfarin. For which of the following results should the nurse notify the provider? A. Hct 44% B. Hgb 16 C. Platelets 190,000 D. PT 55 seconds
D the expected range for PT is 10-12 seconds
A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristic should the nurse expect? A. Slow B. Irregular C. Not palpable D. Bounding
B
A nurse in the emergency is assessing a client who is having a suspected acute MI. Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? Select all that apply A. N/V B. Diaphoresis C. Pain radiating to neck D. Ashen skin color E. Elevated ST segment
All of them
A client who has been treated for chronic open angle glaucoma for 5 years asks the nurse "how does Glaucoma damage my eyesight" the nurse responds: A. Leads to detachment of the retina B. Causes increased intraocular pressure C. Is caused by a decreased blood flow to the retina D. Results from chronic sclera inflammation
B
A nurse in the ED is planning care for a client who is having an acute MI. The nurse should plan to administer which of the following medications after the initial acute phase to manage the clients pain and anxiety? A. Oxygen B. Morphine C. Aspirin D. NTG
B
An adult client is complaining of problems with hearing. Which of the clients medications is ototoxic? A. Levothyroxine B. Vitamin B12 C. Furosemide D. Digoxin
C
The nurse has just finished teaching a hypertensive client about the newly prescribed ACE inhibitor Lisinopril. Which client statement indicates that more teaching is needed? A. I can expect some swelling around my lips and face B. The doctors may order a blood potassium level occasionally C. The medication may not work well if I take aspirin D. I will call the doctor if I notice I have a frequent cough
A
A 75 year old client has sensior-neural hearing loss. The nurse expected this client to present with which of the following findings? A. Client can't understand speech B. Sound transmission go the inner ear is impaired C. The client can not hear sound D. Hearing aids are helpful
A
A nurse is providing teaching to a client who has stable angina and a new prescription for NTG oral sustained released capsules. Which of the following instructions should the nurse include? A. Swallow the capsule whole B. Take 1 capsule at the onset of angina pain C. Stop taking the medication if side effects are troublesome D. Take the medication with meals
A
An older client reports hearing loss, otalgia, and a feeling of fullness in bilateral ears. The nurse should examine the ears for which of the following? A. Accumulation of cerumen in the external canal B. Accumulation of cerumen in the internal canal C. External otitis D. Exopthalmus
A
The results of an audiometery test indicates that a client hears 95% of the time at 5 decibels. Based on these results, which action is he nurse most likely to take? A. Use normal conversation speech when speaking to the client B. Prepare a brochure about different types of hearing aids C. Explain the purpose and procedure of caloric testing D. Ask the client which ear is better and direct the voice toward that side
A
A nurse is caring for a client who is on warfarin therapy for atrial fibrillation. The clients INR is 7.2. Which of the following medications should the nurse administer? A. Protamine sulfate B. Vitamin K C. No medication required D. Atropine
B
A nurse is caring for a client who reports a new onset of a severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing an MI? A. Check clients BP B. Perform a 12 lead ECG C. Auscultation heart tones D. Determine if pain radiates to the left arm
B
A nurse is performing blood pressure screenings at a local health fair. While obtaining subjective assessment data from a client with hypertension, the nurse learns that the client has a family history of hypertension and she herself has high cholesterol and lipid levels. The client says she smokes one pack of cigs daily and drinks about a pack of beer every day. The nurse notes what non-modifiable risk factor for hypertension? A. Closer adherence to medical regime B. Family history of hypertension C. Hyperlipidemia D. Excessive alcohol intake
B
A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? A. Double vision is a common symptom B. Without treatment it can cause blindness C. Use of eye drops will improve vision over time D. Glaucoma is caused by inadequate production of fluid in the eye
B
An older client has been diagnosed with possible white coat hypertension. Which planned action by the nurse best addresses the suspected cause of hypertension? A. Instruct the client about the need to decrease stress levels B. Teach the client how to self monitor and record BP at home C. Schedule the client for regular BP checks in the clinic D. Inform the client and caregiver that major Dietary changes will be needed
B
The nurse is teaching a client with hypertension about his antihypertensive medications, hydrochlorothiazide and enalapril. What is important to include in this teaching? A. Increased fluid intake because of increased loss of body fluids B. Stand up slowly to decrease the problem with dizziness C. When you begin to feel better the doctor will take you off your medications D. Stay out of the sunshine, and make sure you have adequate sodium intake
B
The nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication which of the following actions should the nurse take? A. Measure BP B. Measure HR C. Weigh the client D. Offer the client a light snack
B because digoxin decreases the HR and it should be held if the HR is less than 60
Which assessment finding alerts the nurse to provide client teaching about primary open angle glaucoma development? Select all that apply A. Rings and halos in visual field B. Painless C. Progressive loss of peripheral visual acuity D. Opacity of lens E. Central visual acuity 20/20
B, c, e
The nurse obtains the following data when assessing a client who experienced an ST segment elevation myocardial infarction (STEMI) 2 days ago. Which information is most important to report to the health care provider? A. The troponin level is still elevated B. Bilateral crackles in the mid lower lobes C. The client denies having a heart attack D. Occasional premature atrial contractions
B. Crackles indicate the patient may be developing heart failure which is a complication of an MI
A registered nurse is observing a student nurse who is doing a physical assessment on a client. The RN will need to intervene immediately if the student nurse: A. Presses on the skin over the tibia for 10 seconds to check for edema B. Palpates both carotid arteries simultaneously to compete pulse quality C. Places the client in a left lateral position to check for pout of maximum impulse D. Documents a murmur heard along the right stern border as a pulmonic murmur
B. Carotid pulses should never be palpated at the same time The other assessments should be corrected but are not dangerous to the patient
A client who works in a machine shop has a suspected metal foreign object in the eye. Which test is contraindicated for this client? A. CT B. Corneal staining with fluorescence C. MRI D. Ultrasonography
C
A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing a ventricular tachycardia. The nurse should anticipate the need for taking which of the following actions? A. Defibrillation B. CPR C. Synchronized cardio version D. Radio frequency ablation
C
A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? A. The p wage follows every QRS B. The T wave us in the inverted position C. The p wave falls before the QRS D. The QRS comped is wide and bizarre
C
A client newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a client with prolonged uncontrolled hypertension is at risk for developing what health problem? A. Glaucoma B. Anemia C. Acute kidney injury D. Right ventricular hypertrophy
C Hypertension affects kidney, cardiovascular (MI), brain, and eyes
A client with a history of hypertension treated with diuretic and an ACE Inhibitor arrives in the ED complaining of a severe headache and nausea and has a BP of 238/118. Which questions should the nurse ask to follow up on these findings? A. Have there been recent stressful events in your life? B. Have you recently taken any antihistamines C. Have you consistently take your medication D. Did you take any acetaminophen today
C Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Antihistamine and acetaminophen do not increase BP. Stressful events do not increase BP as high as what this patient is at.
A nurse is teaching a client who has stable angina pectoris about starting therapy with sublingual NTG. The nurse should include which of the following instructions regarding how to take the medication? A. Take this medication with 8 ounces of water B. Take one tablet every 15 minutes during an acute attack C. Take this medications after each meal and at bedtime D. Take one tablet at the first indication of chest pain
D
Reports of painless, floating spots before the eyes, flashes of light, and loss of an area of vision as part of the clients description of the reason for seeking health care should be interpreted by the nurse as possible signs of what? A. Wet macular degeneration B. Acute glaucoma C. Corneal abrasion D. Retinal detachment
D
Which assessment finding for a client who is receiving furosemide to treat stage 2 hypertension is most important to report to the healthcare provider? A. Most recent BP is 168/94 B. Serum potassium of 3.0 C. Orthostatic systolic BP decrease of 12 D. Blood glucose level of 175
B Hypokalemia is a frequent adverse effect of loop diuretic and can cause life threatening dysrhythmias
A nurse is reviewing lab results for a newly admitted clients in the cardiovascular unit. Which lab result is most important to communication to the provider as soon as possible? A. Increased triglyceride level B. Elevated troponin level C. Very low homocysteine level D. Elevated high sensitive c reactive protein level
B. If tropinin is elevated it indicates the patient has had an acute MI. the other lab values indicate increased risk of coronary artery disease but are not associated with acute cardiac problems that need immediate intervention
