Uworld Adult Gastrointestinal and Cardiovascular
The nurse is assisting with a colorectal cancer screening using the guaiac fecal occult blood test. Place the steps for completing this test in the correct sequence. All options must be used. 1. Document the results in the electronic medical record 2. Obtain supplies, wash hands, and apply non sterile gloves 3. Open the back of the slide and apply 2 drops of developing solution to the boxes on the slide 4. Open the slide flap and use the wooden applicator to apply 2 separate stool samples to the boxes on the slide 5. Wait 30-60 seconds
ANS: 2, 4, 3, 5, 1 The guaiac fecal occult blood test detects microscopic blood in the stool and is useful as a colorectal cancer screening test. A blue color on the Hemoccult slide paper is a positive result an indicates the presence of blood in the stool
The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention? 1. The client cannot remember what was done yesterday. 2. The client has a painful red area on the buttocks 3. The client has a new dependent edema of the feet 4. The client has strong, foul smelling urine.
ANS: 3 New onset of dependent edema of the feet could represent congestive heart failure. This is an urgent medical condition that needs prompt evaluation for characteristic signs (eg, weight gain, lung crackles) treatment.
The nurse working in the intensive care unit hears an alarm coming from a client's room. On entering the room, the nurse sees the rhythm displayed in the exhibit on the monitor. The nurse recognizes it as which rhythm? click on the exhibit button for additional information 1. Asystole 2. Atrial fibrillation 3. Ventricular fibrillation 4. Ventricular tachycardia
ANS: 3 The nurse should recognize VF, a potentially lethal dysrhythmia. The ECG shows irregular waveforms of varying shapes and amplitudes. The client is unresponsive, pulseless, and apneic. Rapid treatment should include CPR, defibrillation, and drug therapy (eg, epinephrine, vasopressin, amiodarone)
A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? SATA 1. I don't plan on eating any more frozen meals 2. I plan to take my diuretic pill in the morning 3. I will weigh myself at least every other day 4. I'm going to look into joining a cardiac rehabilitation program 5. Ibuprofen works best for me when I have pain
ANS: 3, 5 Discharge education for the client with chronic heart failure should include daily weights, drug regimens, diet, and exercise plans. The use of any NSAIDS is contraindicated in heart failure as these contribute to sodium retention, and therefore fluid retention.
A client is admitted with sever acute pancreatitis. While obtaining the client's blood pressure, the nurse notices a carpal spasm. What laboratory result would the nurse assess in response to this symptom? 1. Decreased albumin 2. Elevated troponin 3. Hyperkalemia 4. Hypocalcemia
ANS: 4 Complications of acute severe pancreatitis include hyperglycemia, hypocalcemia, hypovolemia, and ARDS. Trousseau's (carpal spasm) and Chvostek's (facial twitching) signs are an indication of hypocalcemia from the decrease in threshold for contraction.
The nurse is teaching about the importance of dietary fiber at a community health fair. Which health benefits of consuming a fiber rich diet should the nurse include in the teaching plan? SATA 1. Helps prevent colorectal cancer 2. Improves glycemic control 3. Promotes weight loss 4. Reduces risk of vascular disease 5. Regulates bowel movements
ANSL 1, 2, 3, 4, 5 Dietary fiber increases stool bulk and makes stool softer and easier to pass. A fiber rich diet helps prevent constipation, decreases risk of colorectal cancer, promotes weight loss, improves blood glucose control, and decreases serum cholesterol levels, which reduces the risk of coronary artery disease and stroke.
Angina pectoris is defined as chest pain brought on by myocardial ischemia (decreased blood flow to the heart muscle). Any factor that increases oxygen demand or decreases oxygen supply to cardiac muscle may cause angina, including the following" Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole (time of maximum blood flow to the myocardium) Intense emotion (eg, anxiety, fear). Initiates the sympathetic nervous system and increases cardiac workload.
Temperature extremes: usually cold exposure and hypothermia (vasoconstriction); Occasionally hyperthermia (vasodilation and blood pooling) Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide: nicotine causes vasoconstriction and catecholamine release. Stimulants (eg, cocaine, amphetamines): Increase heart rate and causes vasoconstriction. Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm) Decrease blood flow to myocardium.
The practical nurse is collecting data on a client with acute diverticulitis. Which finding will the nurse report immediately to the registered nurse? 1. Abdominal pain has progressed to the left upper quadrant 2. Hemoglobin is 11.2 g/dL 3. Lying on side with knees drawn up to abdomen and trunk flexed 4. White blood cell count is 12,000/mm (12x10/L)
ANS: 1 Diverticula are saclike protrusions or outpouchings of the intestinal mucosa of the large intestine caused by increased intraluminal pressure (chronic constipation). The left (descending, sigmoid) colon is the most common area for diverticula to develop. Diverticulitis is caused by inflammation of diverticula of the large intestine that can lead to abscess, perforation, peritonitis, and/or bleeding. Peritonitis is a potential fatal complication that should b e reported to the RN
A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first? 1. Auscultate breath sounds 2. Check for peripheral edema 3. Measure the client's vital signs 4. Review the client's weight log over the past several days.
ANS: 1 The nurse should prioritize focused assessments based on the ABCs (airway, breathing, circulation) of assessment with heart failure client who is short of breath and coughing. Assessment should include auscultation of breath sounds and measurement of respiratory rate and oxygen saturation.
The telemetry nurse is reviewing a client's cardiac rhythm strip. What is the correct interpretation for this strip? 1. Atrial place rhythm 2. First-degree atrioventricular block with bigeminy 3. Sinus rhythm with premature ventricular contractions 4. Ventricular placed rhythm with failure to sense
ANS: 1 The rhythm strip of a client with a single=chamber atrial pacemaker displays a pacer spike before the P wave, followed by a QRS complex, on an electrocardiogram (ECG). The P wave may appear normal or somewhat distorted following the spike. Atrial pacemakers are often for clients experiencing sinoatrial node dysfunction. (eg, atrial fibrillation, bradycardia, heart blocks.
When monitoring a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination? SATA 1. Flank pain radiating to the groin 2. Ingestion of high-protein food before onset of pain 3. Low-grade fever with chills 4. Pain at the umbilicus 5, Right upper-quadrant pain radiating to the right shoulder
ANS 3, 5 Cardinal symptoms of acute calculous cholecystitis include pain in the right upper quadrant and referred pain to the right shoulder and scapula a few hours after eating high-fat foods. Associated symptoms include low-grade fever, chills, nausea, vomiting, and anorexia.
A client admitted 3 days ago with upper gastrointestinal bleeding underwent an endoscopic procedure to stop the bleeding. The client is started on a clear liquid diet today. Which foods are appropriate for the nurse to offer the client ? SATA 1. Apple juice 2. Cherry popsicle 3. Chicken broth 4. Frozen yogurt 5. Unsweetened tea 6. Vanilla ice cream
ANS: !, 3, 5 a client recovering form abdominal surgery first consumes ice chips after demonstrating adequate bowel function (return of bowel sounds and passing flatus). After ice chips, postoperative diet progression continues to clear liquids, full liquids, soft diet, and then regular diet. Educational objective: A postoperative diet begins with ice chips and progresses to clear liquids, full liquids, soft diet, and then regular diet. Clear liquids with red dyes should not be given to clients gastrointestinal bleeding.
The nurse assessing a client with an upper gastrointestinal bleed would expect the client's stool to have which appearance? 1. Black tarry 2. Bright red bloody 3. Light gray clay colored 4. Small, dry, rocky hard masses
ANS: 1
The nurse is caring for 4 clients. Which client should the nurse see first? 1. 2 day post abdominal aortic aneurysm repair with weak pedal pulses and mottled skin on the legs. 2. 2 days post coronary bypass graft surgery with a white blood cell count of 18,000 .mm 3. Chronic heart failure with peripheral edema and shortness of breath on exertion 4. Pneumothorax with a chest tube to negative suction and subcutaneous emphysema
ANS: 1 A weak or absent pedal pulse and a cool or mottled extremity in a client who is post abdominal aortic aneurysm repair can indicate an arterial or graft occlusion, leading to possible life-or limb threatening ischemia.
The nurse is reinforcing discharge instructions for several clients. Which client should receive information about the need for prophylactic antibiotics prior to dental procedures? 1. Client who had mechanical aortic valve replacement. 2. Client who had mitral valvuloplasty repair 3. Client who had myocardial infraction with subsequent heart failure 4. Client who has mitral valve prolapse with regurgitation
ANS: 1 Clients with any form of prosthetic material in their heart valves or who have an unrepaired cyanotic congenital heart defect or a prior history of infective endocarditis (IE) should take prophylactic antibiotics prior to dental procedures to prevent development of IE.
A client with aortic stenosis is scheduled for surgery in 2 weeks. The client reports episodes of angina and passing out twice at home. Which would be the best response by the nurse to explain the appropriate activity for this client at this time? 1. Avoid strenuous activity before the surgery. 2. Continue to exercise even if angina occurs. It will strengthen your hear muscle. 3. Take short walks 3 times a day 4. There are no activity restrictions unless angina occurs.
ANS: 1 Clients with sever aortic stenosis are at risk for developing syncope and sudden death with exertion. The left ventricle cannot push enough blood into the aorta to meet the body's demands due to the valve stenosis.
The nurse is reinforcing teaching of proper technique for colostomy irrigation for the home health client. Which client action indicates that further instruction is required? 1. Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place. 2. Fills irrigation container with 500-1000 mL of lukewarm tab water and flushes the irrigation tubing. 3. Hangs the irrigation container on a hood at the level of the shoulder approximately 18-24 inches above the stoma. 3. Slowly opens the roller clamp, allowing the irrigation solution to flow, but clamps the tubing when cramping occurs.
ANS: 1 Colostomy irrigation allows the client to create a bowel regimen and to apply a dressing or smaller pouch device the stoma. To properly irrigate the stoma, use 500-100 mL of lukewarm water, hang the bag 18-24 inches above the stoma, use the cone-tipped irrigator to slowly infuse the solution, and allow stool to drain through the sleeve and into the toilet.
A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action? 1. Auscultate the client's breath sounds 2. Encourage the client to increase fluid intake 3. Report the findings to the supervising registered nurse 4. Start an IV line for diuretic administration.
ANS: 1 Decreased urine output of <20 mL/hr could be due to low vascular volume (dehydration, blood loss), decreased renal perfusion (low cardiac output), intrinsic kidney injury, or urine outflow obstruction (enlarged prostate, kinked Foley catheter). The nurse should always assess the client first and then report to the supervising registered nurse and health care provider.
A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? SATA 1. Amphetamine use 2. Cigarette smoking 3. Cold exposure 4. Dees sleep 5. Sexual intercourse
ANS: 1, 2, 3, 5 Angina pectoris is chest pain caused by myocardial ischemia. Any factor that increases oxygen demand or decrease oxygen supply may deprive the myocardium of necessary oxygen needed to function effectively
The nurse is reviewing a client's health history during a primary care visit. Which of the following findings should the nurse identify as risk factors for developing hypertension? SATA 1. African American ethnicity 2. Diabetes mellitus type 2 3. Frequent stress at work 4. LDL of 94 mg/dL 5. Smoking of 1 pack of cigarettes daily
ANS: 1, 2, 3, 5 Key risk factors for developing hypertension include African American ethnicity, increasing age, positive family history, smoking, excessive sodium and alcohol use, diabetes mellitus, obesity, hyperlipidemia, chronic stress, and sedentary lifestyle. Untreated hypertension increases client risk for coronary artery disease, stroke, heart failure, and renal failure.
A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should the nurse reinforce to deduce the risk of future episodes? SATA 1. Drink plenty of fluids' 2. Exercise regularly 3. Follow a low-fiber diet 4. Include whole grains, fruits, and vegetables in the diet 5. Increase intake of red meat
ANS: 1, 2, 4 Diverticular disease of the colon is a condition in which there are sac-like protrusions in the large intestine (diverticula). Diverticulitis occurs when diverticula become infected and inflamed. Complications of diverticulitis include abscess, fistula formation, intestinal obstruction, peritonitis, and sepsis. Diverticulitis occurs when diverticula become infected and inflamed. Complications of diverticulitis include abscess, fistula formation, intestinal obstruction, peritonitis, and sepsis. Diverticular bleeding occurs when a blood vessel next to one of these pouches bursts; this may cause blood in the stool.
The nurse is preparing to administer 40 mg of oral furosemide. Prior to administering the medication, the nurse should evaluate which parameters? SATA 1. Blood pressure 2. Blood urea nitrogen 3. Liver enzymes 4. Potassium 5. White blood cell count
ANS: 1, 2, 4 When administering furosemide, it is important to closely monitor the client's vital signs, serum electrolytes (potassium), and kidney function test (blood urea nitrogen, creatine) prior to administration to prevent side effects such as hypokalemia, hypotension, and kidney injrury.
A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? SATA 1. Apply cool, moist washcloths to the affected areas. 2. Keep the fingernails trimmed short to minimize skin scratching. 3. Take a hot bath or shower to alleviate itching sensations. 4. Use skin protectant or moisturizing cream over unbroken skin. 5. Wear cotton gloves or long-sleeved clothing to avoid scratching.
ANS: 1, 2, 4, 5 A client with cirrhosis may experience pruritus (itching) due to the buildup of bile salts beneath the skin. Comfort measures include encouraging the client to cut nails short and wear long-sleeved cotton shirts and cotton gloves. Baking soda baths, calamine lotion, and cool, wet cloths also help. Cholestyramine increases the excretion of bile salts through feces, thereby decreasing itching.
A client who developed heart failure after a myocardial infarction is scheduled to be discharge this afternoon. Based on the discharge data, the nurse plans to reinforce which home care instructions? SATA (click on the exhibit button for additional information) exhibit 1-vitals signs T: 98.2 F, B/P: 108/72 mm Hg, HR: 62/min, R: 16/min,SpO2: 96%. exhibit-2- Discharge meds: Captopril 12.5 mg by mouth, 3 times daily, Digoxin. 0.25 mg by mouth, daily, Spironolactone: 25 mg by mouth, twice daily, Carvedilol: 12.5 mg by mouth, twice daily. 1. Hot to take own pulse 2. Monitoring daily weight 3. Need to monthly INR testing 4. Need to increase foods high in potassium 5. Reduction of sodium in diet 6. Use of home oxygen
ANS: 1, 2, 5 Client with heart failure would need to measure weight daily, restrict sodium and fluid intake, and know how to take a pulse. Clients being discharged with heart failure should understand weight monitoring diet, medication regimen, activity, and symptoms to report.
Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy? SATA 1. "I will clarify with my health care provider taking enteric-coated medications." 2. "I will irrigate the colostomy to promote regular bowel movements." 3. "I will limit eating foods such as broccoli and cauliflower to reduce odor." 4. "I will restrict my fluid intake to 2,000 milliliters of fluid a day." 5. "I will wait for the pouch to become completely full before emptying the contents."
ANS: 1, 3 Proper care of the ostomy and pouching device in clients with a colostomy includes ensuring sufficient fluid intake, preventing gas and odor, and clarifying enteric-coated medications.
A client 4 days post colostomy is preparing to be discharged home. Which findings are concerning and should be further investigated? SATA 1. Client states, "I will need home health to empty the pouch." 2. Client states. "There is a little gas in the colostomy bag." 3. No bowel sounds are present and the client report nausea. 4. Skin surrounding the stoma is red and excoriated 5. Stoma is red, edematous, and smaller than the previous day.
ANS: 1, 3, 4 After a colostomy the stoma should be beefy red and edematous but will begin to shrink over the course of a few days as inflammation subsides. There should be no mucocutaneous separation (eg, separation of the stoma from the abdominal wall), unusual bleeding (eg, dark red, purple, black). Appliances should be resized during the first several weeks to ensure proper fit, preventing skin breakdown (eg, excoriation) due to stool coming into contact with the skin.
The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statement indicate a correct understanding of the instructions? SATA 1. I will apply moisturizing lotion on my legs every day 2. I will elevate my legs at night when I am sleeping 3. I will keep my legs below heart level when sitting 4. I will start walking outside wit my neighbor 5. I will use a heating pad to promote circulation
ANS: 1, 3, 4 Peripheral artery disease increases the risk of tissue necrosis and limb loss. Management focuses on improving blood flow and circulation to the extremities through lifestyles changes and medications.
The nurse is reinforcing discharge instructions with a client following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? SATA 1. Add high-protein foods to diet 2. Consume high-carbohydrate meals 3. Eat small, frequent meals 4. Increase intake of fluids with meals 5. Lie down after eating
ANS: 1, 3, 5 Following a partial gastrectomy, many clients experience dumping syndrome, which occurs when gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine. This results in hypotension, abdominal pain, nausea/vomiting, dizziness, generalized sweating, and tachycardia. The symptoms usually diminish over time.
A healthy 50 year old client asks the nurse. What must I do in preparation for my screening colonoscopy? Which instructions should the nurse reinforce to correctly answer the client's questions? SATA 1. No food or drink is allowed 8 hours prior to the test 2. Prophylactic antibiotics are taken as prescribed 3. Smoking must be avoided after midnight 4. The day prior the procedure your diet will be clear liquids 5. You will drink polyethylene glycol as directed the day before
ANS: 1, 4, 5
During morning rounds, the nurse notices that a client who was admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? SATA 1. Compare current mental status to previous findings 2, Encourage the client to ambulate in the hallway 3. Hold the client's morning dose of lactulose 4. Monitor the client's ammonia level 5. Observe the client's hand movements with the arm extended.
ANS: 1, 4, 5 Hepatic encephalopathy is a serious complication of end of stage liver disease caused by high levels of ammonia in the blood. Assessment findings include confusion, lethargy, and asterixis, coma and death can occur if this condition remains untreated. Pharmacologic treatment include lactulose and antibiotics (eg, rifaximin). The client with worsening encephalopathy is not stable enough for discharge.
An older client comes to the outpatient clinic for a routine physical examination and health screening. Which findings does the nurse recognize as possible indications of colorectal cancer? SATA 1. Abdominal pain 2. Blood in the stools 3. Change in bowel habits 4. Low hemoglobin level 5. Unexplained weight loss
ANS: 1. 2. 3. 4. 5 Clients over age 50 should receive routine colorectal cancer screening for symptoms such as blood in the stool, anemia, abdominal discomfort, change in bowel habits, and weight loss. Symptoms result from intestinal polyps or tumors that cause intestinal bleeding, obstruction, and impaired intestinal absorption.
Which appearance of a stoma immediately after colostomy requires that the practical nurse contact the supervising RN immediately? 1. Brick red with slight moisture 2. Dusky with moderate edema. 3. Pink with slight oozing of blood. 4. Rosy with no stool produced.
ANS: 2 A health stoma has the characteristics of mucosal tissue and should appear vascular and moist. Indication of decreased blood supply (pale, dusky, or cyanotic color changes) should be reported to the RN and health care provider immediately.
A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective? 1. "I'm not worried about the device firing now because I know it won't hurt." 2. "I will let my daughter fix my hair until my health care provider says I can do it." 3. "I will look into public transportation because I won't be able to drive again." 4. "I will notify my travel agent that I can no longer travel by plan."
ANS: 2 After placement of an implantable cardioverter defibrillator, clients are instructed to avoid lifting the arm on the side of the ICD above the shoulder (until cleared by the health care provider) to avoid dislodging the lead wire system.
A client has just returned from the cardiac catheterization laboratory for a permanent pacemaker placement. How should the nurse document the rhythm on the client's cardiac monitor? Click on the exhibit button for additional information 1. Atrial paced rhythm 2. Atrioventricular paced rhythm 3. Biventricular paced rhythm 4. Ventricular paced rhythm
ANS: 2 An atrioventricular pacemaker (also known as a sequential or dual chamber pacemaker) paces the right atrium and right ventricle in sequence. Two pacer spikes are visible on the ECG, one prior to the P wave and a second prior to the QRS complex. Atrioventricular pacemakers improve cardiac synchrony between the atria and ventricles.
A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F, B/P 108/70 mm Hg, HR 88/min, and R 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of hear failure? 1. Arterial blood gases (ABGs) 2. B-type natriuretic peptide (BNP) 3. Cardiac enzymes (CK-MB) 4. Chest x=ray
ANS: 2 BNP is a peptide that causes natriuresis. B-type natriuretic peptides are made, stored, and released primarily by the ventricles. They are produced in response to stretching of the ventricles due to the increased blood volume and higher levels of extracellular fluid ( Fluid overload) that accompany heart failure. Elevation of BNP>100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea.
A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off? 1. Hematocrit of 30% 2. Partial thromboplastin time of 110 seconds 3. Platelet count of 80,000/mm 4. Prothrombin time of 11 seconds
ANS: 2 Heparin infusions require close monitoring by the nurse. The partial thromboplastin tie is the laboratory value required to accurately monitor the therapeutic effects of heparin.
The nurse is caring for a client with cholelithiasis and acute cholecystitis. The client suddenly vomits 250 mL of greenish-yellow emesis and reports severe right upper quadrant pain with radiation to the right shoulder. Which intervention would have the highest priority? 1. Administer promethazine suppository 2. Initiate NPO status 3. Insert nasogastric tube set to low suction 4. Obtain prescription for pain medication
ANS: 2 The highest priority intervention for an actively vomiting client with cholecystitis is maintenance of strict NPO status to avoid stimulation of the gallbladder. Additional intervention include management of nausea /vomiting , pain, and fluid and electrolyte balance, and gastric decompression.
An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse? 1. it should take about 6=8 weeks before your symptoms improve 2. Tell me what you had to eat yesterday 3. We will refer you to the dietitian 4. You must not be following your diet
ANS: 2 When a client with celiac disease does not experience symptom relief being on a gluten free diet, it is most important for the nurse to assess the underlying cause. The most common reason for persistent symptoms is failure to follow the strict gluten free diet
The nurse is reinforcing discharge instructions to a client who has had coronary artery bypass grafting. Which teachings are correct? SATA 1. No sexual activity for at least 6 weeks postoperatively 2. Notify the health care provider (HCP) of redness, swelling, or drainage at the incision site. 3. Refrain from lifting objects weighing >5lb (2.26 kg) until approved by the HCP 4. Take a shower daily without soaking chest and leg incisions 5. Use lotion on incision sites when changing dressing if the areas are dry.
ANS: 2, 3, 4 Discharge teaching for a client recovering from coronary artery bypass grafting should include instruction related to hygiene (showering instead of bathing, no soaking or applying lotions to incisions). mediations, activity level (no lifting of objects >5lb (2.26 kg), no driving for 4-6 weeks) sexual activity (resume when able to walk 1 block or climb 2 flights of stairs without symptoms), and symptoms to report to the health care provider (chest pain or shortness of breath during rest, signs of infection).
The nurse reinforces discharge instructions to a client who was hospitalized for deep venous thrombosis that has now resolved. Which instructions should the nurse include to prevent reoccurrence? SATA 1. Do not travel by car or airplane for at least 3-4 weeks 2. Drink plenty of fluids daily and limit caffeine and alcohol intake 3. Elevate legs on a footstool when sitting and dorsiflex the feet often. 4. Resume the walking or swimming exercise program as soon as possible after getting home 5. Sit in a cross-legged yoga position for 5-10 minutes as this benefits circulation
ANS: 2, 3, 4 Discharge teaching for a client who had deep venous thrombosis emphasizes minimization of risk factors (eg, venous stasis, hypercoagulability of blood, endothelial damage) and interventions to promote blood flow and venous return and prevent reoccurrence (eg, adequate fluid intake, frequent position changes, elevation of the legs, regular exercise, smoking cessation)
The nurse is inspecting the legs of a client with a suspected lower-extremity deep venous thrombosis. Which of the following clinical manifestations should the nurse expect? SATA 1. Blue, cyanotic toes 2. Calf pain 3. Dry, shiny, hairless skin 4. Lower leg warmth and redness 5. Unilateral leg edema
ANS: 2, 4, 5 A deep venous thrombosis (DVT) is a blood clot formed in large veins, typically of the lower extremities, that occurs commonly from decreased activity or mobility. Clinical manifestations of a lower extremity DVT include unilateral edema, calf pain or tenderness to touch, warmth, erythema, and low-grade fever.
The client is scheduled to have a cardiac catheterization. Which of the following findings would cause the nurse to question the safety of the test proceeding? SATA 1. Elevated serum C-reactive protein level 2. History of previous allergic reaction to IV contrast 3. Prolonged PR interval ECG 4. Received metformin today for type 2 diabetes mellitus 5. Serum creatinine of 2.5 mg/dL
ANS: 2, 4, 5 Cardiac catheterization uses IV iodinated contrast to assess for obstructed coronary arteries. IV iodinated contrast is avoided in clients who had a previous allergic reaction to contrast agents, have renal impairment, or, in some cases, who recently received metformin.
The nurse is reinforcing about constipation to a client. Which of the following client statements indicate appropriate understanding of the teaching? SATA 1. "Drinking more caffeinated drinks such as tea and soda helps to stimulate the bowel." 2. "Having a routine for bowel movements is important, but I should not wait if I feel the urge." 3. "I can use an over-the-counter laxative every other day." 4. "I should try to eat more fruits and vegetables every day." 5. "Increasing my daily exercise level may help keep my bowel movements regular."
ANS: 2, 4, 5 Constipation is a symptom of many disease processes, procedures, and medications. To prevent constipation, educate the client to increase daily fiber intake, drink 2-3 L of fluids daily, increase daily activity levels, and initiate a bowel regimen (eg, avoiding delay of defecation, defecating at the same time each day).
The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client's comfort? SATA 1, Encourage adequate sodium intake 2. Place client in semi-Fowler position 3. Place client in Trendelenburg position 4. Provide alternating air pressure mattress 5. Use music to provide a distration
ANS: 2, 4, 5 In a client with cirrhosis and ascites, discomfort is often due to pressure of the fluid on the surrounding organs. Shortness of breath occurs due to the upward pressure exerted by the abdominal ascites on the diaphragm, which restricts lung expansion.
A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The practical nurse is assisting the RN in preparing the client for paracentesis. Which nursing actions should be implemented prior to the procedure? SATA 1. Obtain informed consent for the procedure. 2. Place the client in high Fowler's position. 3. Place the client on npo status. 4. Request that the client empty the bladder. 5. Take baseline vital signs and weight.
ANS: 2, 4, 5 Paracentesis removes fluid from the abdominal cavity to improve symptoms or provide a specimen for testing. The client should be instructed to void prior to procedure and be placed in high Fowler's position. Abdominal girth, weigh, and vital sings should be recorded before and monitored after paracentesis.
A client is in suspected shock state from major trauma. Which parameters best indicate the adequacy of peripheral perfusion? SATA 1. Apical pulse 2. Capillary refill 3. Lung sounds 4. Pupillary response 5. Skin color and temperature
ANS: 2, 5 The adequacy of blood flow to peripheral tissues is determined by measuring capillary refill and assessing skin color and temperature; these are usually within normal limits during the initial and compensatory stages of shock.
After assisting a client with a lower gastrointestinal bleed back to bed, the nurse finds approximately 600 mL of frank red blood in the toilet. The client is pale and diaphoretic and reports dizziness. Which action should the nurse perform first? 1. Document the output and vital signs 2. Draw blood for hemoglobin and hematocrit 3. Lower the head of the bed. 4. Notify the registered nurse
ANS: 3 Acute blood loss is a medical emergency, and the nurse must intervene quickly Lowering the head of the bed or placing the client in the supine position maintains blood perfusion to the brain and other vital organs. This can be done quickly to help stabilize the client before other interventions are performed.
The nurse is reinforcing instructions to a client scheduled for cardiac pharmacologic nuclear stress testing. Which client statements indicate appropriate understanding? 1. "I can smoke 1 cigarette the day of the test so that I won't have withdrawal." 2. "I should eat a hearty breakfast the morning of the test to avoid nausea." 3. "I should stop drinking coffee 24 hours before the procedure ." 4. "I should take my usual dose of insulin the day of the test."
ANS: 3 Clients scheduled for cardiac nuclear pharmacologic stress testing should not eat, drink, or smoke on the day of the test, they should avoid caffeinated products for 24 hours before the test and avoid taking certain cardiac medications (eg, nitrates, beta blockers) unless otherwise instructed by the health care provider.
The telemetry nurse is reviewing the cardiac monitors of 4 clients. Which cardiac rhythm is the priority of intervention by the nurse? 1. Atrial fibrillation 2. Premature ventricular contractions 3. Ventricular Fibrillation 4. Ventricular tachycardia
ANS: 3 Clients with ventricular fibrillation, a lethal arrhythmia, require immediate treatment with CF and defibrillation. A pulse may be present in ventricular tachycardia, so it should be addressed as soon as possible. Atrial fibrillation and premature ventricular contractions are pulsatile rhythms.
The nurse is caring for a hospice client with advanced heart failure who is having trouble breathing. Which comfort intervention should the nurse implement fist? 1. Administer PRN albuterol by nebulizer 2. Assist with guided imagery to relieve anxiety 3. Elevate the head of the bed 4. Give PRN sublingual morphine
ANS: 3 Dyspnea (eg, difficulty breathing) is a common symptom in the hospice client with advanced heart failure. Excess fluid volume and decreased cardiac output produce pulmonary edema, impairing gas exchange and causing dyspnea. Elevating the head of the bed reduces abdominal pressure on the diaphragm, making it easier for the client to breathe. It is an effective intervention that can be implemented first, quickly, and easily.
The emergency department nurse is caring for a 70-year-old client with a history of type 2 diabetes mellitus who reports sudden-onset nausea, sweating, dizziness, and fatigue. The nurse should anticipate the initiation of which protocol? 1. Food poisoning 2. Influenza 3. Myocardial infarction 4. Stroke
ANS: 3 Early recognition and treatment of heart attach are critical. Women, the elderly, and clients with a history of diabetes may not have the classic heart attack symptoms of dull chest pain with radiation down the left arm. Instead, they can have "atypical" symptoms such as nausea, vomiting, belching, indigestion, diaphoresis, dizziness, and fatigue.
A graduate student, who has been studying for final exams and using energy drinks to stay awake, comes to the clinic reporting a fluttering feeling in the chest. The student is connected to the cardiac monitor that displays the rhythm in the exhibit. The nurse recognizes this as which rhythm? click on the exhibit button for additional information. 1. Atrial fibrillation 2. Sinus rhythm with premature atrial contractions 3. Sinus rhythm with premature ventricular contractions 4. Ventricular tachycardia
ANS: 3 Premature ventricular contractions (PVCs) are wide and distorted and occur early in the underlying rhythm. They are usually not harmful in the client with a healthy heart PVCs in the client with myocardial infarction indicate ventricular irritability and should be assessed immediately.
The nurse is caring for a client after percutaneous placement of a coronary stent for a myocardial infarction. The client rates lower back pain as 5 on a scale of 0-10 and has blood pressure of 140/92 mm Hg. The cardiac monitor shows sinus rhythm with occasional premature ventricular contractions. Which prescription should the nurse administer first? (Exhibit-Laboratory: Potassium 3.3 mEq/L, Sodium 149 mEq/L, Glucose 157 mg/dL.) 1. Captopril PO every 8 hours 2. Morphine IV PRN for pain 3. Potassium chloride IVPB once 4. Regular insulin subcutaneous with meals.
ANS: 3 Prompt potassium replacement is the priority action for hypokalemic clients with myocardial infarction because they are at increased risk for life threatening dysrhythmias (eg, heart block, ventricular tachycardia, ventricular fibrillation) and cardiac arrest.
A client with a permanent pacemaker with continuous telemetry calls the nurse and reports feeling lightheaded and dizzy. The client's blood pressure is 75?55 mm Hg. What is the nurse's priority action? Click the exhibit button for additional information. 1. Administer atropine 0,5 mg IV 2. Administer dopamine 5 mcg/kg/min IV 3. Initiate transcutaneous pacing 4. Notify the health care provider
ANS: 3 Signs and symptoms of a failing pacemaker include failure to capture (pacer spikes without associated QRS complexes) with bradycardia and hypotension . The nurse should use a transcutaneous pacemaker to stabilize the client until the internal pacemaker can be repaired or replaced.
The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next? 1.. Check for a carotid pulse for at least 10 seconds 2. Provide rescue breaths at a rate of 10-12/min 3. Resume chest compressions at a rate of 100/min 4. Use the jaw-thrust maneuver to assess the airway.
ANS: 3 The basic life support sequence is compressions, airway, and breathing (mnemonic CAB). High quality CPR is associated with improved client outcomes and begins with High-quality chest compressions (ie, 100-120/min, 2-2.4 in deep). Any unwitnessed collapse system and obtaining an automated external defibrillator. If not shock is advised, the nurse should resume high-quality chest conpressions.
A client is admitted to the emergency department after a fall with dizziness and light headedness. Blood pressure is 88/62 mm Hg, and the cardiac monitor displays the rhythm in the exhibit. The nurse recognizes it as which rhythm? click on the exhibit button for additional information 1. Complete heart block 2. 1st-degree heart block 3. Sinus bradycardia 4. Sinus rhythm
ANS: 3 The nurse should be able to recognize SB on the ECG and assess for clinical significance (eg, chest pain, syncope, hypotension) in the client. Initial expected treatment for symptomatic clients includes atropine and transcutaneous pacing.
A client with mitral valve prolapse has been experiencing occasional palpitations, lightheadedness, and dizziness. The health care provider prescribes a beta blocker. What additional teaching should the nurse reinforce for this client? 1. Avoid aerobic exercise 2. Ensure you receive antibiotics prior to dental work 3. Stay well hydrated and avoid caffeine 4. Wear a medial alert bracelet
ANS: 3 The nurse should teach the client with mitral valve prolapse (MVP) to stay hydrated, avoid caffeine and alcohol, exercise regularly, reduce stress, and take beta blockers as prescribed for palpitations and chest pain. Nitrates are usually not effective for MVP related chest pain.
The nurse is caring for a client diagnosed with ulcerative colitis and prescribed sulfasalazine. Which instructions should be reinforced at discharge? SATA 1. Avoid small, frequent meals 2. Consume a cup of coffee with each meal if desired 3. Continue medication even after resolution of symptoms 4. Eat a low-residue, high-protein, high-calorie diet. 5. Increase fluid intake to at least 2000 mL/day
ANS: 3, 4, 5 Dietary management of ulcerative colitis includes eating small, frequent meals, following a low-residue high-protein, high-calorie diet, taking supplemental vitamins and minerals: avoiding caffeine, alcohol and tobacco; and drinking at least 2000-3000 mL/day of fluid. Continued use of sulfasalazine prevents relapse and prolongs symptom remission.
The nurse caring for a client with an ileal conduit observes that the stoma appears bluish gray. What is the nurse's best action? 1. Administer an antibacterial agent and assess for additional signs of infection 2. Document the findings and continue to monitor for changes 3. Measure the stoma and obtain a larger pouching device 4. Report the findings to the health care provider immediately
ANS: 4
The client was diagnosed 6 months ago with hypertension and had a recent emergency department visit for a transient ischemic attack. The client's blood pressure today is 170/88 mm Hg. What teaching topic is a priority for the nurse to reinforce with this client? 1. Decreasing sodium intake 2. Decreasing stress levels at work and home 3. Increasing activity level 4. Taking blood pressure medications as prescribed
ANS: 4 A major problem with long term management of hypertension is poor adherence to the treatment plan. The nurse should teach the client the importance of taking blood pressure medications as prescribed.
A client with an implantable cardioverter defibrillator (ICD) develops ventricular tachycardia (VT) with a pulse while admitted to the medical unit. The ICD fires multiple times without successfully stopping the VT, causing the client become confused and difficult to rouse. Which action by the nurse is appropriate? 1. Attempt to stimulate a vagal response by having the client cough 2. Deactivate the client's implantable cardioverter defibrillator with an external magnet 3. Obtain a STAT 12 lead ECG to verify the cardiac rhythm 4. Prepare for synchronized cardioversion with the external defibrillator
ANS: 4 Am implantable cardioverter defibrillator (ICD) is a device used to sense life threatening arrhythmia and discharge electrical shocks to correct the arrhythmia. If a client experiences repeated ICD shocks without dysrhythmia resolution, the nurse should obtain a manual external defibrillator and initiate cardiac life support
The nurse is reinforcing discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective? 1. "I'm glad that I can continue taking my Ginkgo biloba." 2. "I will increase my intake of leafy green vegetable." 3. "I will start applying vitamin E to my chest incision after showering." 4. "I will shave with an electronic razor from now on."
ANS: 4 Clients who are on anticoagulants should avoid aspirin, NSAIDS, and other over the counter or herbal products (eg, Ginkgo biloba) that can increase bleeding risk. They should also avoid behaviors that increase the risk of clotting (eg, eating excess green leafy vegetables).
After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is most concerning? 1. Client rates leg pain as "7" 2. Negative Homan signs 3. Prominent varicose veins bilaterally 4. Right calf is 4 cm larger than left calf
ANS: 4 Deep venous thrombosis (DVT) is a major concern in clients with unilateral leg pain after prolonged immobilization (eg, air travel, surgery) or those with obesity, pregnancy 0r other hypercoagulable states (eg, cancer). 80% of DVTs start in the veins of the calf and move into the popliteal and femoral veins. Classic symptoms include unilateral leg edema, local warmth, erythema, and low-grade fever (in clients with obesity or immobility). Therefore, the swelling in one leg is highly concerning.
A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin Which client statement regarding digoxin toxicity indicates that teaching reinforcement is needed? 1. " I must visit my health care provider to check my drug levels." 2. "I should report to my health care provider if develop if I develop nausea and vomiting." 3. "I should tell my health care provider if my heart rate is below 60 bets per minute." 4. "I will need to increase my potassium intake."
ANS: 4 Drug toxicity is common with digoxin due to its narrow therapeutic range. Drug levels are frequently monitored. Nonspecific gastrointestinal symptoms similar to gastroenteritis are common and can lead to serious cardiac arrhythmias if not recognized.
The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed? 1. "I need to raise the head of my bed on blocks by at least 6 inches." 2. "I will remain sitting up for several hours after I eat any food." 3. "If My reflux and abdominal pain don't improve. I might need surgery." 4. "Losing weight may reduce my reflux, so I plan to take a weight lifting class."
ANS: 4 Hiatal hernia is characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to diaphragmatic weakness. Nurses educating clients with hiatal hernia about symptom management should instruct them to avoid activities that increase abdominal pressure (eg, weight lifting), sleep with the head of the bed elevated, and remain upright for several hours after meals.
The nurse is reinforcing education to a client with irritable bowel syndrome who is experiencing diarrhea. Which of these meals selected by the client indicates an understanding of diet management? 1. Beans, yogurt, and a fruit cup. 2. Beef, broccoli, and a glass of wine. 3. Eggs, a bagel, and black coffee. 4. Steak, tomato basil soup, and cornbread.
ANS: 4 Irritable bowl syndrome is a chronic condition characterized by altered intestinal motility, causing abdominal discomfort with diarrhea and/or constipation. Clients can manage symptoms by avoiding gas-production foods (eg, broccoli), caffeine, alcohol, and gastrointestinal irritants (eg, high-fructose corn syrup, spices, dairy products) and by increasing fiber.
The nurse monitors a client who has followed a vegan diet for several years. Which client statement would indicate a possible complication resulting from a vegan diet? 1. I have had some visual disturbances while driving at night. 2. I have had trouble falling asleep over the past few months 3. Scaly patches of skin are developing on my elbows and knees 4. Sometimes my hands and feet get a tingling sensation
ANS: 4 People who follow a vegan diet eat only plant based foods and omit animal proteins and byproducts such as milk and eggs. They do not have an adequate intake of vitamin B12 (cobalamin) and are at risk for developing megaloblastic anemia and neurological manifestations. Vitamin B12 deficiency affects the entire nervous system, from peripheral nerves to the spinal cord and brain. Peripheral neuropathy manifests as tingling and numbness. Spinal cord involvement can cause gait problems. Brain involvement causes memory loss/dementia (late).
A nurse is reinforcing discharge instructions to a client during the fifth hospitalization for pulmonary edema caused by congestive heart failure exacerbation. Which statement by the client indicates that further teaching is required? 1. "I should supplement my potassium intake." 2. "I should weigh myself daily." 3. "Moderate exercise may be helpful in my condition." 4. "Potato chips are an acceptable snack in moderation."
ANS: 4 The client is likely dealing with some level of denial regarding the diagnosis of congestive heart failure. Any client statement that does not indicate understanding of the importance of salt avoidance should be addressed to help the client avoid further hospitalizations related to this condition.
A client with chronic heart failure calls the clinic to report a weight gain of 3 lb over the last 2 days. Which information is most important for the nurse to ask this client? 1. Diet recall for this current week 2. Fluid intake for the past 2 days 3. Medications and dosages taken over the past 2 days 4. Presence of shortness of breath, coughing, or edema
ANS: 4 The client with chronic heart failure is at risk for exacerbations. Clients should be instructed to report a weight gain of 3 lb over 2 days or a 3.5 lb gain over a week. The nurse's priority assessment should be any physiological signs of symptoms of fluid overload.
A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse reinforces teaching to the client that the pain will improve with which of the following? 1. Coughing and deep breathing 2. Left lateral position 3. Pursed-lip breathing 4. Sitting up and leaning forward
ANS: 4 The most common cause of acute pericarditis is a recent viral infection. It is an inflammation of the visceral and/or parietal pericardium. Pericarditis is characterized by sharp, pleuritic chest pain. It is aggravated during inspiration and coughing. Pain is typically relieved by sitting up and leaning forward. Treatment includes a combination of nonsteroidal anti-inflammatory drugs or aspirin plus colchicine.
A 62 year old client admitted to the telemetry unit after an acute myocardial infarction 3 days ago reports that the left calf is very tender and warm to the touch. Which nursing intervention is the priority? 1. Asking the client how long the leg has been tender and warm 2. Checking the electrocardiogram for ectopic beats 3. Obtaining vital signs, including pulse oximetry 4. Performing a neurovascular check on the lower extremities
ANS: 4 The nurse who suspects deep venous thrombosis should perform a thorough neurovascular assessment of the client's extremities. The assessment should include the presence and quality of dorsalis pedis and posterior tibial pulses, temperature of extremities, capillary refill, and circumference measurements of both calves and thighs. Both extremities should be assessed for comparison. The findings should be reported immediately to the health care provider.
The nurse is reviewing the telemetry strips of assigned clients. The rhythm stirp displayed in the exhibit is given to the nurse by the telemetry technician. The nurse recognizes it as which rhythm? 1. Atrial fibrillation 2. First degree atrioventricular block 3. Sinus bradycardia 4. Sinus rhythm
ANS: 4 To analyze electrocardiogram (ECG) strips, the nurse should measure the R-R interval to determine regularity and heart rate and then analyze the PR interval, QRS complex, and QT interval. A heart rate of 60-100/min and normal PR intervals, QRS complexes, and QT intervals indicate a normal sinus rhythm.
The practical nurse is assisting the registered nurse in caring for 4 clients. Which client is at greatest risk for the development of deep venous thrombosis? 1. 25-year-old client with abdominal pain who smokes cigarettes and takes oral contraceptives. 2. 55-year-old ambulatory client with exacerbation of chronic bronchitis and hematocrit of 56%. 3. 72-year-old client with a fever who is 2 days post coronary stent placement. 4. 80-year-old client who is 4 days postoperative from repair of a fractured hip.
ANS: 4 Deep venous thrombosis (DVT) is a frequent, often preventable complication of hospitalization, surgery, and immobilization. Factors that increase the risk for developing DVT include trauma, surgery (especially orthopedic, knee, hip), prolonged immobility/inactivity, oral contraceptives, pregnancy, varicose veins, obesity, smoking, and advanced age.
A client with heart failure has gained 5 lb over the last 3 days. The nurse reviews the client's blood laboratory results. Based on this information, what medication administration does the nurse anticipate? Click the exhibit button for additional information (exhibit-Laboratory results: Sodium 126 mEq/L. Potassium: 4.8 mEq/L, Calcium: 9.0 mg/dL) 1. 0.45% sodium chloride IV 2. Calcium gluconate 3. Furosemide 4. Sodium polystyrene sulfonate
ANSL 3 Heart failure is characterized by reduced cardiac output, which can reduce renal blood flow. Reduced renal blood activates the renin-angiotensin system, resulting in fluid volume excess and dilutional hyponatremia. Loop diuretics (eg, furosemide) promote free water excretion, allowing for hemoconcentration and increased sodium levels.
Clients with Cirrhosis and ascites: Positioning the client in semi-Fowler or Fowler position can promote comfort, as this position can reduce the pressure on the diaphragm. In semi-fowler position, the head of the bed is elevated 30-45 degrees, in fowler position, elevation is 45-60 degrees. Side-lying with the head elevated can also be a position of comfort for the client with ascites as it allows the heavy, enlarged abdomen to rest on the bed, reducing pressure on internal organs and allowing for relaxation.
Meticulous skin care is a priority due to the increased susceptibility of skin breakdown from edema, ascites and pruritus. It is important to use a specialty mattress and implement a turning schedule of every w2 hours. A distraction can take the client's mind off the current symptoms and may also help promote comfort in many different situations. Some of these distractions include listening to music, watching television, playing video games, or taking part in hobbies.
Dumping Syndrome: Recommendations to delay gastric emptying include: Consume meals high in fat, protein, and fiber, which take more time to digest and remain in the stomach longer than carbohydrates. These foods also help meet the body's energy needs. Avoid consuming fluids with meals because this causes stomach contents to pass faster into the jejunum, which worsen symptoms. Fluid intake should occur up to 30 minutes before or after meals.
Slowly consume small, frequent meals to reduce the amount of food in the stomach. Avoid meals high in simple carbohydrates (eg. sugar, syrup) because these may trigger symptoms when the carbohydrates break down into simple sugars. Avoid sitting up after a meal because gravity increases gastric emptying. Instead, lying down after meals is encouraged.
