Cardio Exam 4 Practice

The nurse obtains a blood pressure of 172/82 mm Hg for a patient. What is the patient's mean arterial pressure (MAP)?

112 mm Hg MAP = (SBP + 2 DBP)/3

When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial blood pressure (BP) of 147/82 mm Hg and an ankle pressure of 112/74 mm Hg. The nurse calculates the patient's ankle-brachial index (ABI) as ________ (round up to the nearest hundredth).

ANS: 0.76 The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP.

A normal measurement between the sternal angle and the highest visible level of jugular vein distention is A. Less than 4 cm B. 4 to 6 cm C. 7-10 cm D. Maximum of 7 cm

ANS: A

A nurse is planning the discharge of a client following recovery from an exploratory laparotomy. The client has a history of chronic back pain and limited ability to ambulate. The nurse plans for further discharge teaching when the client states a. "I can leave my elastic antiembolic (TEDS) stockings off once I get home." b. "I should be eating a diet high in protein, calories, and vitamin C now and when I get home." c. "An alternative method to control pain and reduce swelling is applying ice to my incision." d. "I use my incentive spirometer every 2 hours so I can reach my volume goal before discharge."

ANS: A

When assessing for complications of hyperparathyroidism, the nurse should monitor the client for a. bone destruction b. tetany c. seizures d. graves' disease

ANS: A

Which instruction is a key aspect of teaching for the patient on anticoagulant therapy? a. monitor for and report any signs of bleeding b. do not take acetaminophen (Tylenol) for a headache c. decrease your dietary intake of foods containing vitamin K d. arrange to have your blood drawn twice a week to check drug effects

ANS: A

Which intervention should a nurse plan to incorporate in the care of a surgical client to decrease the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE)? a. Use of intermittent compression devices on the lower extremities b. administration of heparin intravenously c. coughing and deep breathing exercises d. isometric leg exercises

ANS: A

Which of the following commonly occurs in male patients who are taking multiple antihypertensive agents? a. impotence b. increased libido c. increased weight d. bradycardia

ANS: A

Which patient statement to the nurse is most consistent with the diagnosis of venous insufficiency? a. "I can't get my shoes on at the end of the day." b. "I can't ever seem to get my feet warm enough." c. "I have burning leg pain after I walk two blocks." d. "I wake up during the night because my legs hurt."

ANS: A Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day. The other patient statements are characteristic of peripheral artery disease.

Which nursing intervention is appropriate for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/μL during chemotherapy? a. Test all stools for occult blood. b. Encourage fluids to 3000 mL/day. c. Provide oral hygiene every 2 hours. d. Check the temperature every 4 hours.

ANS: A Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

The nurse is emptying the bedside commode of a patient with chronic leukemia and notes that the stool is very dark. Which assumption should guide the nurses action? a. The patient may be bleeding. b. The patient may be dehydrated. c. The patient is most likely on iron supplements. d. The patient ate something that turned the stool a dark color.

ANS: A Black stools are a sign of gastrointestinal bleeding. C. D. Iron supplements and some foods may change stool color, but if the patient has leukemia, the nurse cannot assume that the cause is unimportant. B. Dehydration is associated with constipation, not dark stools.

When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first? a. Duplex ultrasound b. Contrast venography c. Magnetic resonance venography d. Computed tomography venography

ANS: A The duplex ultrasound is the most widely used test to diagnose VTE. Contrast venography is rarely used now. Magnetic resonance venography is less accurate for calf veins than pelvic and proximal veins. Computed tomography venography may be used but is invasive and much more expensive than the duplex ultrasound.

The nurse is reviewing the laboratory test results for a patient 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 mg/dL b. Serum potassium of 4.5 mEq/L c. Serum hemoglobin of 14.7 g/dL d. Blood glucose level of 96 mg/dL

ANS: A The elevated serum creatinine indicates renal damage caused by the hypertension. The other laboratory results are normal.

A child is admitted in thyrotoxic crisis. Which manifestations should a nurse expect to observe during assessment? Select all that apply a. delirium b. hypothermia c. bradycardia d. nausea e. vomitting

ANS: A, D, E

A 47 year old male patient is admitted to the hospital with a blood pressure of 240/118 accompanied by confusion and stupor. He has been taking clonidine (Catapres) and hydrochlorothiazide (HCTZ) for several years for management of his hypertension. His wife is 32 years old and looks more like 25. The nurse recognizes that the patient's hypertensive crisis could have been precipitated by a. additional use of histamines b. abrupt withdrawal of the drug therapy c. toxic side effects of combination therapy d. use of aspirin (ASA) without consulting his physician

ANS: B

An older client with osteoarthritis is taking celecoxib (Celebrex). After reviewing the client's laboratory values for the past 3 months, what should be a clinic nurse's priority when assessing the client? BUN 6 months ago 13 mg/dL 3 months ago 19 mg/dL Today 28 mg/dL Creatinine 6 months ago 0.8 mg/dL 3 months ago 1.2 mg/dL Today 1.8 mg/dL a. Review urinalysis results b. Measure the client's blood pressure c. Ask the client if there has been any weight gain d. Auscultate the client's heart sounds

ANS: B

Patient has an acute arterial occlusion. She is extremely anxious and fearful about losing her leg. As the nurse, you select a nursing diagnosis of anxiety. What nursing intervention would be most appropriate for Ms. Schwartz? a. ask her friends to sit with her and support her while she's being prepared for surgery b. assess her current level of anxiety and her ability to control it c. talk with her family and ask them to explain what will happen to her d. sedate her so that she is very sleepy before preparing her for surgery

ANS: B

The client is discovered to have a popliteal aneurysm. Because of the aneurysm, a nurse should closely monitor the client for a. thoracic outlet syndrome b. ischemia in the lower limb c. pulmonary embolism d. Raynaud's phenomenon

ANS: B

The health care provider prescribes levothyroxine for a patient with hypothyroidism. After teaching about this drug, the nurse determines that further instruction is needed when the patient says a. "I can expect the medication dose may need to be adjusted." b. "I only need to take this drug until my symptoms are improved." c. "I can expect to return to normal function with the use of this drug." d. "I will report any chest pain or difficulty breathing to the doctor right away."

ANS: B

The patient is admitted with CHF and hypertension. Medical management and nursing care that would have the highest priority would be aimed at a. decreasing the patient's cardiac output b. decreasing the patient afterload c. increasing the patient cardiac automaticity d. increasing the end diastolic fiber stretch

ANS: B

What assessment findings are typically seen in a patient with a deep vein thrombophlebitis? a. purple discoloration of the entire leg with striae b. redness, swelling, and tenderness along a superficial vein c. redness along the inner aspects of the calf with diminished pedal pulse d. absent pulse, pedal edema, dusky color, and coldness to touch

ANS: B

When analyzing an EKG strip of a patient with a regular cardiac rhythm, the nurse finds there are 25 small boxes from one R wave to the next. The nurse calculates the patient's heart rate to be a. 50 bpm b. 60 bpm c. 75 bpm d. 90 bpm

ANS: B

A nurse is evaluating the blood pressure (BP) results for multiple clients with cardiac problems on a telemetry unit. Which BP reading suggests to the nurse that the client's mean arterial pressure (MAP) is abnormal and warrants notifying the physician? a. 94/60 mm Hg b. 98/36 mm Hg c. 110/50 mm Hg d. 140/78 mm Hg

ANS: B A MAP of less than 60 mmHg indicates that there is inadequate perfusion to organs. MAP = (SBP + 2DBP)/3

The nurse is caring for a 70-yr-old patient who takes hydrochlorothiazide and enalapril (Norvasc). The patient's blood pressure (BP) continues to be high. Which patient information may indicate a need for a change? a. Patient takes a daily multivitamin tablet. b. Patient uses ibuprofen to treat osteoarthritis. c. Patient checks BP daily just after getting up. d. Patient drinks wine three to four times a week.

ANS: B Because use of nonsteroidal antiinflammatory drugs (NSAIDs) can prevent adequate BP control, the patient may need to avoid the use of ibuprofen. A multivitamin tablet will help supply vitamin D, which may help lower BP. BP decreases while sleeping, so self-monitoring early in the morning will result in obtaining pressures that are at their lowest. The patient's alcohol intake is not excessive.

Which finding indicates to the nurse that demeclocycline is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH)? a. Weight has increased. b. Urinary output is increased. c. Peripheral edema is increased. d. Urine specific gravity is increased.

ANS: B Demeclocycline blocks the action of antidiuretic hormone (ADH) on the renal tubules and increases urine output. An increase in weight or an increase in urine specific gravity indicates that the SIADH is not corrected. Peripheral edema does not occur with SIADH. A sudden weight gain without edema is a common clinical manifestation of this disorder.

When caring for a patient with metastatic cancer, the nurse notes a hemoglobin level of 8.7 g/dL and hematocrit of 26%. What associated clinical manifestations does the nurse anticipate observing? a. Thirst b. Fatigue c. Headache d. Abdominal pain

ANS: B The patient with a low hemoglobin and hematocrit is anemic and would likely have fatigue. Fatigue develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation to carry out cellular functions. Thirst, headache, and abdominal pain are not related to anemia.

A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? a. Plan for emergency tracheostomy. b. Administer IV calcium gluconate. c. Prepare for endotracheal intubation. d. Begin thyroid hormone replacement.

ANS: B The patient's clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve the stridor. Thyroid hormone replacement may be needed eventually but will not improve the symptoms of hypocalcemia.

The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? a. Urine output over 8 hours is 250 mL less than the fluid intake. b. The patient cannot move the left arm and leg when asked to do so. c. Tremors are noted in the fingers when the patient extends the arms. d. The patient reports a headache with pain at level 7 of 10 (0 to 10 scale).

ANS: B The patient's inability to move the left arm and leg indicates that a stroke may be occurring and will require immediate action to prevent further neurologic damage. The other clinical manifestations are also likely caused by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes.

Which clinical manifestations can the nurse expect to see in both patients with Buerger's disease and patients with Raynaud's phenomenon? (Select all that apply) a. intermittent low-grade fevers b. sensitivity to cold temperatures c. gangrenous ulcers on fingertips d. color changes of fingers and toes e. episodes of superficial vein thrombosis

ANS: B, C, D

The nurse is teaching a women's group about ways to prevent hypertension. What information should the nurse include? (Select all that apply.) a. Lose weight. b. Limit beef consumption. c. Limit sodium and fat intake. d. Increase fruits and vegetables. e. Exercise 30 minutes most days.

ANS: B, C, D, E Primary prevention of hypertension is to make lifestyle modifications that prevent or delay the increase in BP. Along with exercise for 30 minutes on most days, the DASH eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP. Beef includes saturated fats, which should be limited. Weight loss may or may not be necessary, depending on the person.

Important nursing intervention(s) when caring for a patient with Cushing syndrome include (select all that apply) a. restricting protein intake. b. monitoring blood glucose levels. c. observing for signs of hypotension. d. administering medication in equal doses. e. protecting patient from exposure to infection.

ANS: B, E

A client's blood pressure is being taken at a screening clinic. Which client statement to a nurse demonstrates awareness of having a risk factor for hypertension? a. "My doctor told me my body mass index is 23." b. "I usually have a glass of wine or two to unwind when I come home from work." c. "I should get my blood pressure checked more often because I am African American." d. "I have colds during the winter, so I see my physician to get the flu vaccine every year."

ANS: C

A hospital nurse is teaching coworkers how to prevent varicose veins. Which recommendation by the nurse is most accurate? a. wear low-heeled comfortable shoes b. move your legs back and forth often c. wear support hose or thromboembolic deterrent stockings (TEDS) d. wear clean, white cotton socks with tennis shoes

ANS: C

A patient is taking four antihypertensives. Which of the following instructions is significant for her? The nurse instructs the patient to a. expect urine color changes b. avoid cold temperatures c. change positions slowly d. avoid eating aged cheeses

ANS: C

The nurse measures a patient's blood pressure in the left arm and the reading is 200/118 mm Hg. The first action the nurse should take is to a. notify the physician b. inquire about the presence of kidney disease c. check the patient's blood pressure in the right arm d. recheck the patient's blood pressure in the same arm in 30 seconds

ANS: C

The pathologic factors associated with thrombophlebitis are increased blood coagulability, stasis of blood and a. vasodilation of the vessel wall b. vasoconstriction of the vessel wall c. injury to the vessel wall d. occlusion in the vessel wall

ANS: C

The patient with mild to moderate HTN commonly experiences: a. frequent episodes of syncope b. difficulty in hearing c. no symptoms d. severe headaches and occasional fatigue

ANS: C

In most hypertensive people, the main cause of the disorder is a. being black b. being black and poor c. being black, poor, and highly stressed d. unknown

ANS: D

When assessing a patient with hyperthyroidism, the nurse should expect the patient to exhibit a. increased appetite, slow pulse, dry skin b. loss of weight, constipation, listlessness c. protruding eyeballs, slow pulse, sluggishness d. nervousness, weight loss, increased appetite

ANS: D

Which treatment should the nurse anticipate for an otherwise healthy person with an initial VTE? a. IV argatroban as an inpatient b. IV unfractionated heparin as an inpatient c. Subcutaneous unfractionated heparin as an outpatient d. Subcutaneous low-molecular-weight heparin as an outpatient

ANS: D

The most common type of leukemia in adults in western countries is a. acute myelocytic leukemia b. acute lymphocytic leukemia c. chronic myelocytic leukemia d. chronic lymphocytic leukemia

ANS: D Chronic lymphocytic leukemia is a disease primarily of older adults.

A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? a. Anorexia b. Vomiting c. Oral ulcers d. Lip swelling

ANS: D Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy but are not immediately life threatening.

The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to administer this medication correctly? a. Remove the air bubble in the prefilled syringe. b. Aspirate before injection to prevent IV administration. c. Rub the injection site after administration to enhance absorption. d. Pinch the skin between the thumb and forefinger before inserting the needle.

ANS: D The nurse should gather together or "bunch up" the skin between the thumb and the forefinger before inserting the needle into the subcutaneous tissue. The nurse should not remove the air bubble in the prefilled syringe, aspirate, nor rub the site after injection.

The patient with an adrenal hyperplasia is returning from surgery after an adrenalectomy. The nurse should monitor the patient for what immediate postoperative complication? a. Vomiting b. Infection c. Thromboembolism d. Rapid blood pressure changes

ANS: D The risk of hemorrhage is increased with surgery on the adrenal glands as well as large amounts of hormones being released in the circulation, which may produce hypertension and cause fluid and electrolyte imbalances to occur for the first 24 to 48 hours after surgery. Vomiting, infection, and thromboembolism may occur postoperatively with any surgery.

While obtaining nursing history from a 23 year old patient the nurse recognizes the most significant info is that

a. He had a respiratory infection 3 weeks ago

Patients with DVT have

a. Increased risk for developing pulmonary emboli

What drug is used in HTN crisis?

a. Nipride

55 year-old female patient receiving of radiation for Hodgkin's. Blood studies reveal moderate leukopenia. What is the nursing diagnosis for this patient?

a. Risk for infection

One of the interventions the nurse will utilize in the management of buerger's disease

a. encourage patient to stop smoking

The nurse assesses risk for hypertension with patient modified factors

a. exercise

What is the purpose of chemotherapy?

a. goal is to kill cells or to prevent from replicating

What will affect pulse ox monitoring?

a. hypotension

S/s associated with peripheral artery disease will include

a. loss of hair of the lower extremities

Effects of Heparin can be reversed by

a. protamine sulfate

What stage of lymphoma is identified with involvement of two lymph node regions on both sides of diaphragm?

a. stage 3

A patient with infective endocarditis develops sudden left leg pain with pallor, paresthesia, and a loss of peripheral pulses. What should be nurse's initial action? a. notify the HCP of the change in perfusion b. start anticoagulant therapy with IV heparin c. elevate the leg to improve the venous return d. position the patient in reverse Trendelenburg

ANS: A

After a hypophysectomy for acromegaly, immediate postoperative nursing care should focus on a. frequent monitoring of serum and urine osmolarity. b. parenteral administration of a GH-receptor antagonist. c. keeping the patient in a recumbent position at all times. d. patient teaching regarding the need for lifelong hormone therapy.

ANS: A

An accidental removal of the parathyroid glands during a thyroidectomy can cause the following a. tetany b. adrenocortical stimulation c. myxedema d. hypovolemic shock

ANS: A

An unresponsive client is admitted to an emergency room. The client's cardiac rhythm is extremely irregular with no measurable heart rate, no P waves, and no QRS complexes. A nurse leading the resuscitation team should direct the team to perform which action first? a. Defibrillate b. Administer epinephrine c. Perform synchronized cardioversion d. Prepare for pacemaker insertion

ANS: A

Signs and symptoms associated with peripheral arterial diseases will include a. loss of hair in the lower extremities b. warm, moist skin c. descending pallor with ascending rubor d. brisk capillary refill

ANS: A

What is a nursing priority when caring for a patient with hypothyroidism? a. Patient teaching related to levothyroxine b. Providing a dark, low-stimulation environment c. Closely monitoring the patient's intake and output d. Initiating precautions related to radioactive iodine therapy

ANS: A A euthyroid state is most often achieved in patients with hypothyroidism by the administration of levothyroxine. It is not necessary to closely monitor intake and output. Low stimulation and radioactive iodine therapy are used to treat hyperthyroidism.

The nurse is developing a discharge teaching plan for a patient diagnosed with thromboangiitis obliterans (Buerger's disease). Which expected outcome has the highest priority for this patient? a. Cessation of all tobacco use b. Control of serum lipid levels c. Maintenance of appropriate weight d. Demonstration of meticulous foot care

ANS: A Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger's disease. Other therapies have limited success in treatment of this disease.

A patient with multiple myeloma is at risk for hypercalcemia. Which nursing intervention is most important for the patient with hypercalcemia? a. Encourage fluids. b. Offer citrus juices and fruits. c. Place the patient on a low-sodium diet. d. Discourage intake of alcoholic beverages.

ANS: A Fluids dilute calcium and flush the kidneys to reduce risk of kidney stones. B. C. D. Citrus, low-sodium diet, and alcohol do not directly affect calcium levels.

Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this drug when the patient reveals a history of: a. asthma. b. daily alcohol use. c. peptic ulcer disease. d. myocardial infarction (MI).

ANS: A Nonselective B-blockers block B1- and B2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. B-Blockers will have no effect on the patient's peptic ulcer disease or alcohol use. B-Blocker therapy is recommended after MI.

The nurse observes that phlebitis has developed at a patient's peripheral IV site over the past several hours. Which intervention should the nurse implement first? a. Remove the patient's IV catheter. b. Apply an ice pack to the affected area. c. Decrease the IV rate to 20 to 30 mL/hr. d. Administer prophylactic anticoagulants.

ANS: A The priority intervention for superficial phlebitis is removal of the offending IV catheter. Decreasing the IV rate is insufficient. Anticoagulants are not normally required, and warm, moist heat is often therapeutic.

The patient with systemic lupus erythematosus is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What interventions should be included in the plan of care? (Select all that apply.) a. Obtain daily weights. b. Limit fluids to 1000 mL/day. c. Administer diuretics as ordered. d. Monitor for signs of hypernatremia. e. Minimize turning and range of motion. f. Elevate the head of the bed at 10 degrees or less.

ANS: A, B, C, F The care for the patient with SIADH will include limiting fluids to 1000 mL/day or less to decrease weight, increase osmolality, and improve symptoms and keeping the head of the bed elevated at 10 degrees or less to enhance venous return to the heart and increase left atrial filling pressure, thereby reducing the release of ADH. Measure weights daily and maintain accurate intake and output. Monitor for signs of hyponatremia. Frequent turning, positioning, and range-of-motion exercises are important to maintain skin integrity and joint mobility.

A nurse teaches individuals at a seminar that essential hypertension, if untreated, predisposes a client to (Select all that apply) a. stroke b. cirrhosis c. renal failure d. myocardial infarction e. peripheral artery disease

ANS: A, C, D, E

Which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm? a. Record hourly chest tube drainage. b. Monitor fluid intake and urine output. c. Assess the abdominal incision for redness. d. Counsel the patient to plan for a long recovery time.

ANS: B Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound.

A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? a. Buttock, upper outer quadrant b. Abdomen, anterior-lateral aspect c. Back of the arm, 2 in away from a mole d. Anterolateral thigh, with no scar tissue nearby

ANS: B Enoxaparin (Lovenox) is a low-molecular-weight (LMW) heparin that is given as a deep subcutaneous injection in the right and left anterolateral abdomen. All subcutaneous injections should be given away from scars, lesions, or moles.

When reviewing the patient's hematologic laboratory values after a splenectomy, the nurse would expect to find a. RBC abnormalities b. increased WBC count c. decreased hemoglobin d. decreased platelet count

ANS: B Splenectomy can have a dramatic effect in increasing peripheral RBCs, WBCs, and platelet counts.

A client receiving a loop diuretic should be encouraged to eat which of the following foods? Select all that apply. a. Angel food cake. b. Banana. c. Dried fruit. d. Orange juice. e. Peppers.

ANS: B, C, D

A nurse is providing hospice care to a client diagnosed with cancer. The client is in the last hours of life and is experiencing significant pain. The client expresses a desire to be alert in order to spend time with family members. Which strategy will address this problem? a. Standardized care b. Client education c. Therapeutic judgement d. Reassessment

ANS: C

The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? a. Weak pedal pulses b. Absent bowel sounds c. Blood pressure of 138/88 mm Hg d. 25 mL of urine output over the past hour

ANS: C The blood pressure is typically kept at less than 120 mm Hg systolic to minimize extension of the dissection. The nurse will need to notify the health care provider so that B-blockers or other antihypertensive drugs can be prescribed. The other findings are typical with aortic dissection and should also be reported but do not require immediate action.

A patient with lymphoma wants to attend a family members wedding but is extremely fatigued. The nurse develops a plan for Activity Intolerance related to symptoms of lymphoma. How will the nurse know if the plan has been effective? a. The patient is able to sleep 8 hours at night. b. The patient can list three ways to combat fatigue. c. The patient attends the family members wedding. d. The patient verbalizes understanding of the importance of gradually increasing activity.

ANS: C The patient's goal is to attend the wedding, so attendance tells the nurse the patient had enough energy to go. A. Sleep does not guarantee relief from fatigue. B. D. Listing or verbalizing things is not evidence of tolerance to activity.

Which assessment finding for an adult admitted with Graves' disease requires the most rapid intervention by the nurse? a. Heart rate 136 beats/min b. Severe bilateral exophthalmos c. Temperature 103.8° F (40.4° C) d. Blood pressure 166/100 mm Hg

ANS: C The patient's temperature indicates that the patient may have thyrotoxic crisis and that interventions to lower the temperature are needed immediately. The other findings also require intervention but do not indicate potentially life-threatening complications.

The UAP is taking orthostatic vital signs. In the supine position, the blood pressure (BP) is 130/80 mm Hg, and the heart rate (HR) is 80 beats/min. In the sitting position, the BP is 140/80, and the HR is 90 beats/min. Which action should the nurse instruct the UAP to take next? a. Repeat BP and HR in this position. b. Record the BP and HR measurements. c. Take BP and HR with patient standing. d. Return the patient to the supine position.

ANS: C The vital signs taken do not reflect orthostatic changes, so the UAP will continue with the measurements while the patient is standing. There is no need to repeat or delay the readings. The patient does not need to return to the supine position. When assessing for orthostatic changes, the UAP will take the BP and pulse in the supine position, then place the patient in a sitting position for 1 to 2 minutes and repeat the readings, and then reposition to the standing position for 1 to 2 minutes and repeat the readings. Results consistent with orthostatic changes would have a decrease of 20 mm Hg or more in systolic BP, a decrease of 10 mm Hg or more in diastolic BP, and/or an increase in HR of greater than or equal to 20 beats/min with position changes.

A patient who has hyperthyroidism is treated with radioactive iodine (RAI). What information should the nurse include in discharge teaching? a. Take radioactive precautions with all body secretions. b. Symptoms of hyperthyroidism should be relieved in about a week. c. Symptoms of hypothyroidism will occur as the RAI therapy takes effect. d. Discontinue the antithyroid medications that were taken before the RAI therapy.

ANS: C There is a high incidence of post radiation hypothyroidism after RAI, and the patient should be monitored for symptoms of hypothyroidism. RAI has a delayed response, with the maximum effect not seen for 2 to 3 months, and the patient will continue to take antithyroid medications during this time. The therapeutic dose of radioactive iodine is low enough that no radiation safety precautions are needed.

A patient is scheduled for transsphenoidal hypophysectomy to treat a pituitary adenoma. What should the nurse include in preoperative teaching? a. Cough and deep breathe every 2 hours postoperatively. b. Remain on bed rest for the first 48 hours postoperatively. c. Avoid brushing teeth for at least 10 days after the surgery. d. You will be positioned flat with a cervical collar after surgery.

ANS: C To avoid disruption of the suture line, the patient should avoid brushing the teeth for 10 days after surgery. It is not necessary to remain on bed rest after this surgery. Coughing is discouraged because it may cause leakage of cerebrospinal fluid (CSF) from the suture line. The head of the bed should be elevated 30 degrees to reduce pressure on the sella turcica and decrease the risk for headaches. A cervical collar is not needed.

A patient receiving chemotherapy for chronic myelocytic leukemia has irritated mucous membranes. Which mouth care intervention should the nurse include in the plan of care? a. Brush teeth twice a day with a firm toothbrush. b. Use waxed floss between meals and at bedtime. c. Use sponge Toothettes to clean teeth after meals. d. Swab teeth and mucous membranes four times daily with lemon-glycerin swabs.

ANS: C Toothettes are soft and will not further irritate the mucous membranes. A. B. A firm toothbrush or flossing can cause bleeding. D. Lemon-glycerin swabs are drying.

Which actions for a patient at risk for venous thromboembolism could the nurse delegate to unlicensed assistive personnel (UAP)? a. Monitor for any bleeding after anticoagulation therapy is started. b. Tell the patient to call immediately if any shortness of breath occurs. c. Apply sequential compression devices whenever the patient is in bed. d. Ask the patient about use of any herbal medicines or dietary supplements.

ANS: C UAP training includes the use of equipment that requires minimal nursing judgment, such as sequential compression devices. Patient assessment and teaching require more education and critical thinking and should be done by the registered nurse (RN).

A patient is being prepared for splenectomy. What is the purpose of the order for a vitamin K injection? a. It corrects a dietary deficiency. b. It helps correct underlying anemia. c. It corrects clotting factor deficiencies. d. It replaces vitamin K lost during night sweats.

ANS: C Vitamin K is important in the clotting process and is often ordered prior to a splenectomy to correct clotting factor deficiencies. D. Vitamin K is not lost during night sweats. A. There is no evidence of dietary deficiency in the question. B. Blood transfusions are ordered to correct anemia.

An 82-year-old patient in a long-term care facility is newly diagnosed with hypothyroidism. The nurse will need to consult with the health care provider before administering the prescribed a. Docusate (Colace) b. Ibuprofen (Motrin) c. Diazepam (Valium) d. Cefoxitin (Mefoxin)

ANS: C Worsening of mental status and myxedema coma can be precipitated using sedatives, especially in older adults. The nurse should discuss the use of diazepam with the health care provider before administration. The other medications may be given safely to the patient.

In the patient with hodgkin's disease, a charactertic cell presence is necessary for proper diagnosis. This cell is called the a. Belcher cell b. Bence-Jones cell c. Epstein-Barr cell d. Reed Sternberg cell

ANS: D

Multiple drugs are often used in combinations to treat leukemia and lymphoma because a. there are fewer toxic and side effects. b. the chance that one drug will be effective is increased. c. the drugs are more effective without causing side effects. d. the drugs work by different mechanisms to maximize killing of malignant cells.

ANS: D Combination therapy is the mainstay of treatment for leukemia. The 3 purposes for using multiple drugs are to (1) decrease drug resistance, (2) minimize the drug toxicity to the patient by using multiple drugs with varying toxic effects, and (3) interrupt cell growth at multiple points in the cell cycle.

The most definitive test for diagnosis of an abdominal aneurysm is a. flat plate of the abdomen b. CT scan of the abdomen c. laboratory coagulation studies d. arteriogram

ANS: D? Ask in class but on answer sheet is D

Patient with DVT returning from OR, what to do?

a. Measure calf

Following diagnostic testing for an enlarged cervical lymph node, a healthcare-provider informs a 20 year old female client a diagnosis of Hodgkin's disease and explains the disease process and recommended treatment. Which statement, overheard by a nurse when the client telephoned her parents, indicates that the client understands the diagnosis and treatment? a. "I am so relieved; I was worried that I had cancer and there wasn't anything that could be done to treat it." b. "I have a good chance of being cured with radiation therapy, chemotherapy, or a combination of both." c. "I will need to have a laparotomy to stage the disease before I can start irradiation and chemotherapy. " d. "I am so upset; I wanted to go to college, marry, and raise a family. Now, I won't be able to do any of this."

ANS: 2

A nurse is reviewing a serum laboratory report for a client following surgery. Results include WBCs 18,000 K/uL, SCr 2.2 mg/dL, K 3.5 mEq, and Hgb 6.8 mg/dL. Per the physician's orders, the nurse assesses the client, removes the subclavian venous access device, and sends the tip for culture. In which order should the nurse perform the remaining physician's orders? Prioritize the nursing actions. _____ Administer cefazolin sodium (Ancef) 1 gram IV _____ Administer 1 unit packed red blood cells _____ Prime the blood tubing with 0.9% NaCl _____ Insert a new intravenous access device _____ Send the nursing assistant to obtain the blood from blood bank _____ Verify the client's identification and complete the checks for safe administration of the blood product

ANS: 2, 6, 4, 1, 3, 5

A client returns from surgery performed 2 hours ago.A nurse expects the client to be more alert and notices intermittent apnea. The client's blood pressure had been in the low 100s and is now 90/54 mm Hg. The client is difficult to awaken. Which steps should be taken by the nurse to obtain immediate assistance? Prioritize the nurse's actions by placing each step in the correct order. ______ Assist in the reassessment of the client ______ Contact the surgeon ______ Request the rapid response team ______ Prepare necessary equipment including an oximeter and noninvasive BP monitor ______ Communicate using a handoff method such as SBAR ______ Be present to answer questions and obtain supplies and medications ______ Contact the client's family

ANS: 4, 5, 1, 2, 3, 6, 7

A nurse is ambulating an elderly client using a transfer belt for support. The client begins to experience signs and symptoms of orthostatic hypotension. Which steps should be taken by the nurse to prevent the client from falling? Prioritize the nurse's actions by placing each step in the correct order. _____ Support and ease the client to the floor, allowing the client to slide down the forward leg _____ Call for help _____ Bend at the knees _____ Assess the client for injuries _____ Use the transfer belt to pull the client toward the forward leg _____ Protect the client's head from hitting objects on the floor _____ Assume a broad stance with the stronger leg somewhat behind the other leg

ANS: 5, 1, 3, 7, 4, 6, 2

A 72 year old client with a deep vein thrombosis in the left leg and a history of a brain tumor is hospitalized for 3 days. The client's care plan indicates a nursing diagnosis of imbalanced nutrition: less than body requirements related to poor appetite and decreased oral intake. Which assessment finding would best indicate a need to revise the care plan related to the nursing diagnosis? a. oral mucous membranes are dry due to dehydration b. daily intake and output reveal that daily caloric intake is inadequate c. client is not receptive to education regarding nutrition d. client states that he/she is not hungry

ANS: A

A HCP adds a second medication for blood pressure control for a client whose blood pressure has not been well-controlled with one antihypertensive medication. If the HCP orders the following medication combinations, which combination should the nurse question? a. Atenolol (Tenormin) and metoprolol (Lopressor) b. Metolazone (Zaroxolyn) and valsartan (Diovan) c. Captopril (Capoten) and furosemide (Lasix) d. Bumetanide (Bumex) and diltiazem (Cardizem)

ANS: A

A child diagnosed with acute nonlymphoid leukemia is admitted to a hospital with a fever and neutropenia. To avoid the complications associated with neutropenia, which nursing interventions should a nurse include in the child's plan of care? a. placing the child in a private room, restricting ill visitors, and using strict hand washing techniques b. encouraging a well balanced diet, including iron-rich foods, and helping the child ovid overexertion c. offering a moist, bland, soft diet, using toothettes rather than a toothbrush, and providing frequent saline mouthwashes d. avoiding rectal temperatures, avoiding injections, and applying direct pressure for 5 to 10 minutes after venipuncture

ANS: A

A female client is to receive chemotherapy and radiation for Hodgkin's lymphoma with cervical and axillary node involvement. A nurse evaluates the client is coping positively when the client states a. "I selected a wig that matches my hair color, but I will miss my own hair." b. "I am so glad that the chemotherapy and radiation treatments won't cause me to lose my hair." c. "The chemotherapy-drug combination will prevent mucositis and immunosuppression." d. "I have faith that my doctor will be able to cure me and I won't have any long-term effects."

ANS: A

A nurse obtains the following assessment data for a client diagnosed with acute myeloid leukemia. For which finding should a nurse plan interventions first? a. pain from mucositis b. weakness and fatigue c. T 99, HR 100, RR 20, BP 132/64 mm Hg d. ecchymosis and petechiae noted on arms

ANS: A

A nurse takes a client's blood pressure with an automatic blood pressure machine. The blood pressure is 86/56 mm Hg with a pulse rate of 64 beats per minute. Which action should the nurse do first? a. Assess the client for dizziness and assess the skin on the extremities for warmth b. Obtain a manual blood pressure cuff and retake the client's blood pressure c. Elevate the head of the client's bed d. Read the client's medical record and determine the client's normal range of blood pressure

ANS: A

A patient is admitted with the diagnosis of primary hyperparathyroidism. The nursing action that should be included in this patient's plan of care is the a. assurance of a large fluid intake b. provision of a high-calcium diet c. maintenance of absolute bedrest d. institution of seizure precautions

ANS: A

A patient with Hodgkin's disease is undergoing external radiation therapy on an outpatient basis. After two weeks of radiation therapy, he tells the nurse that he is so tired he can hardly get out of bed in the morning. An appropriate goal for the nurse to plan with the patient is to a. establish a daily walking program b. exercise vigorously when fatigue is not noticable c. consult with a psychiatrist for the treatment of depression d. maintain bedrest until the radiation treatment is completed

ANS: A

The most common condition associated with aortic aneurysm is a. hypertension b. pulmonary embolism c. congestive heart failure d. cardiogenic shock

ANS: A

This condition illustrated in the photo on the left is a symptom associated with a. hyperthyroidism (Graves' disease) b. hypothyroidism c. hyperparathyroidism d. hypoparathyroidism

ANS: A

To control the side effects of corticosteroid therapy, the nurse teaches the patient who is taking corticosteroids to a. increase calcium intake to 1500 mg/day b. perform glucose monitoring for hypoglycemia c. obtain immunizations due to high risk for infections d. avoid abrupt position changes because of orthostatic hypotension

ANS: A

When a patient returns from the postanesthesia care unit following a subtotal thyroidectomy, the nurse should immediately a. place a tracheostomy set at the bedside b. give the patient clear liquids c. instruct the patient not to speak d. keep the patient supine for 24 hours

ANS: A

Which type of lymphatic has the higher mortality rate? a. Non-Hodgkin's lymphoma b. Hodgkin's disease c. Lymphatic drainage disorder d. Multiple myeloma

ANS: A

Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation.

ANS: A A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used.

Despite a high dosage, a male patient who is taking nifedipine (Procardia XL) for antihypertensive therapy continues to have blood pressures over 140/90 mm Hg. What should the nurse do next? a. Assess his adherence to therapy. b. Ask him to make an exercise plan. c. Teach him to follow the DASH diet. d. Request a prescription for a thiazide diuretic.

ANS: A A long-acting calcium-channel blocker such as nifedipine causes vascular smooth muscle relaxation, resulting in decreased systemic vascular resistance and arterial blood pressure and related side effects. The patient data the nurse has about this patient is very limited, so the nurse needs to begin by assessing adherence to therapy.

The nurse is preparing teaching for a patient with Hodgkin's disease. Which beverage should the nurse instruct this patient to avoid? a. Wine b. Coffee c. Ginger ale d. Orange juice

ANS: A Alcohol can induce pain in patients with Hodgkin's disease. B. C. D. Coffee, orange juice, and sodas do not cause pain in the patient with Hodgkin's disease.

The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first? a. Obtain vital signs. b. Teach wound care. c. Assess pedal pulses. d. Check the wound site.

ANS: A Bleeding is a possible complication after catheterization of the femoral artery, so the nurse's first action should be to assess for changes in vital signs that might indicate hemorrhage. The other actions are also appropriate but can be done after determining that bleeding is not occurring.

Which finding by the nurse when assessing a patient with Hashimoto's thyroiditis and a goiter will require the most immediate action? a. New-onset changes in the patient's voice b. Elevation in the patient's T3 and T4 levels c. Resting apical pulse rate 112 beats/min d. Bruit audible bilaterally over the thyroid gland

ANS: A Changes in the patient's voice indicate that the goiter is compressing the laryngeal nerve and may lead to airway compression. The other findings will also be reported but are expected with Hashimoto's thyroiditis and do not require immediate action.

The nurse is admitting a preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) daily. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? a. Vitamin K b. Cobalamin c. Heparin sodium d. Protamine sulfate

ANS: A Coumadin is a vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin (Coumadin).

A patient who has had a splenectomy complains of malaise. The nurse checks the patient's temperature and finds it is 102 F (39C). Which action by the nurse should take priority? a. Notify the physician. b. Encourage fluids to reduce fever and prevent dehydration. c. Administer acetaminophen to reduce fever and relieve discomfort. d. Explain to the patient that low-grade fevers are common after splenectomy because the spleen is part of the immune system.

ANS: A D. Fever in the post-splenectomy period signals overwhelming post-splenectomy infection. This can be deadly if not recognized and treated quickly, so notifying the physician is essential. B and C can be done after the physician has been contacted. D. 102 F is not low-grade fever.

The nurse is providing discharge instructions to a patient with diabetes insipidus. Which instruction about desmopressin acetate would be most appropriate? a. Expect to have some nasal irritation while using this drug. b. Monitor for symptoms of hypernatremia as a drug side effect. c. Report any decrease in urinary output to the health care provider. d. Drink at least 3000 mL of water per day while taking this medication.

ANS: A Desmopressin acetate is used to treat diabetes insipidus by replacing the antidiuretic hormone that the patient is lacking. Diuresis will be decreased and is expected. Inhaled desmopressin can cause nasal irritation, headache, nausea, and other signs of hyponatremia, not hypernatremia. Drinking too much water or other fluids increases the risk of hyponatremia. The patient should follow the provider's directions for limiting fluids and be taught to seek medical attention if they have severe nausea; vomiting; severe headache; muscle weakness, spasms, or cramps; sudden weight gain; unusual tiredness; mental/mood changes; seizures; and slow or shallow breathing.

The nurse is teaching a patient with acromegaly from an unresectable benign pituitary tumor about octreotide therapy. The nurse should provide further teaching if the patient makes which statement? a. "The provider will infuse this medication through an IV." b. "I will inject the medication in the subcutaneous layer of the skin." c. "The medication should decrease the growth hormone production to normal." d. "I will have my growth hormone level measured every 2 weeks for several weeks."

ANS: A Drug therapy is an option for patients whose tumors are not surgically resectable. The primary drug used is octreotide, a somatostatin analog. It reduces growth hormone (GH) levels to normal in many patients. Octreotide is given by subcutaneous injection three times a week. GH levels are measured every 2 weeks to K guide drug dosing, and then every 6 months until the desired response is obtained.

The nurse is caring for a patient admitted with a history of hypertension. The patient's medication history includes hydrochlorothiazide daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy? a. BP 128/78 mm Hg b. Weight loss of 2 lb c. Absence of ankle edema d. Output of 600 mL per 8 hours

ANS: A Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Because the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure.

The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism? a. Hypertension promotes atherosclerosis and damage to the walls of the arteries. b. Hypertension causes direct pressure on organs, resulting in necrosis and scar tissue. c. Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems. d. Hypertension increases blood viscosity, which causes intravascular coagulation and tissue necrosis distal to occlusions.

ANS: A Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, when atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues.

A patient with terminal lymphoma says to the nurse, I'm tired of being so fatigued all the time. Can't you just give me a big shot of morphine and help me end this suffering? Which response by the nurse is most appropriate? a. You sound frustrated. It must be difficult to feel so tired all the time. b. Are you sure that is what you want me to do? Maybe you should think about it first. c. That is really not appropriate to ask. Would you like a shot just to take away the pain? d. You have orders for morphine 10 to 15 mg. I don't think that's enough to end your suffering.

ANS: A It is not the role of the nurse to end a life it is appropriate to help lessen suffering. The nurses response allows the patient to further verbalize concerns, which the nurse can then address. B, C, and D do not address the patient's concern.

A patient with multiple myeloma is being cared for at home. Which nursing diagnosis should guide the nurse when teaching the family how to provide care for the patient? a. Risk for Injury related to compromised bone integrity b. Ineffective Tissue Perfusion related to vascular occlusion c. Risk for Deficient Fluid Volume related to bleeding disorder d. Ineffective Airway Clearance related to cervical lymphadenopathy

ANS: A Multiple myeloma causes destruction of the bone and widespread osteoporosis. B. C. D. It does not directly affect airway clearance, tissue perfusion, or fluid volume.

The patient is admitted with hypercalcemia, polyuria, and pain in the pelvis, spine, and ribs with movement. Which hematologic problem would most likely cause these manifestations? a. Multiple myeloma b. Thrombocytopenia c. Megaloblastic anemia d. Myelodysplastic syndrome

ANS: A Multiple myeloma typically manifests with skeletal pain and osteoporosis that may cause hypercalcemia, which can result in polyuria, confusion, or cardiac problems. Serum hyperviscosity syndrome can cause renal, cerebral, or pulmonary damage. Thrombocytopenia, megaloblastic anemia, and myelodysplastic syndrome are not characterized by these manifestations.

The nurse is caring for a patient after a parathyroidectomy. The nurse would prepare to administer IV calcium gluconate if the patient has which manifestations? a. Facial muscle spasms and laryngospasms b. Tingling in the hands and around the mouth c. Decreased muscle tone and muscle weakness d. Shortened QT interval on the electrocardiogram

ANS: A Nursing care for a patient after a parathyroidectomy includes monitoring for a sudden decrease in serum calcium levels causing tetany, a condition of neuromuscular hyperexcitability. If tetany is severe (e.g., muscular spasms or laryngospasms develop), IV calcium gluconate should be administered. Mild tetany, characterized by unpleasant tingling of the hands and around the mouth, may be present but should decrease over time without treatment. Decreased muscle tone, muscle weakness, and shortened QT interval are manifestations of hyperparathyroidism.

Which action by the patient with newly diagnosed Raynaud's phenomenon best demonstrates that the nurse's teaching about managing the condition has been effective? a. The patient exercises indoors during the winter months. b. The patient immerses hands in hot water when they turn pale. c. The patient takes pseudoephedrine (Sudafed) for cold symptoms. d. The patient avoids taking nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: A Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm rather than hot water to warm the hands. Pseudoephedrine is a vasoconstrictor and should be avoided. There is no reason to avoid taking NSAIDs with Raynaud's phenomenon.

The nurse is assessing a patient with a bleeding disorder and finds large purplish areas in the skin and oral mucosa. Which term should the nurse use to document this finding? a. Purpura b. Bleeding c. Petechiae d. Hemorrhage

ANS: A Purpura is the correct term for hemorrhage into the skin, mucous membranes, and organs. C. Petechiae are small pinpoint hemorrhages. B. D. Hemorrhage and bleeding are more general terms that do not most accurately describe the symptoms.

Which group of drugs will the nurse plan to include when teaching a patient who has a new diagnosis of peripheral artery disease (PAD)? a. Statins b. Antibiotics c. Thrombolytics d. Anticoagulants

ANS: A Research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other drug categories in PAD.

The patient has chronic venous insufficiency and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what patients "always" have ordered. Which assessment finding would indicate the application of compression stockings could harm the patient? a. Leg pain at rest b. High blood pressure c. Dry, itchy, flaky skin d. Elevated blood glucose

ANS: A Rest pain occurs as peripheral artery disease (PAD) progresses and involves multiple arterial segments. Compression stockings should not be used on patients with PAD. Elevated blood glucose, possibly indicating uncontrolled diabetes, and hypertension may or may not indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The RN should be the one to obtain the order and instruct the UAP to apply compression stockings if they are ordered.

The nurse is caring for a patient receiving high-dose oral corticosteroid therapy after a kidney transplant. Which side effect would the nurse monitor for as it presents the greatest risk? a. Infection b. Low blood pressure c. Increased urine output d. Decreased blood glucose

ANS: A Side effects of corticosteroid therapy include increased susceptibility to infection, edema related to sodium and water retention (decreasing urine output), hypertension, and hyperglycemia.

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find? a. Elevated D-dimers b. Elevated fibrinogen c. Reduced prothrombin time (PT) d. Reduced fibrin degradation products (FDPs)

ANS: A The D-dimer is a specific marker for the degree of fibrinolysis and is elevated with DIC. FDP is elevated as the breakdown products from fibrinogen and fibrin are formed. Fibrinogen and platelets are reduced. PT, PTT, aPTT, and thrombin time are all prolonged.

The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of an obese patient admitted with heart failure. Which action by the UAP will require the nurse to intervene? a. Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg/sec b. Waiting 2 minutes after position changes to take orthostatic pressures c. Taking the blood pressure with the patient's arm at the level of the heart d. Taking a forearm blood pressure if the largest cuff will not fit the patient's upper arm

ANS: A The cuff should be deflated at a rate of 2 to 3 mm Hg/sec. The arm should be supported at the level of the heart for accurate blood pressure measurements. Using a cuff that is too small causes a falsely high reading and too large causes a falsely low reading. If the maximum size blood pressure cuff does not fit the upper arm, the forearm may be used. Orthostatic blood pressures should be taken within 1 to 2 minutes of repositioning the patient.

Which action should the nurse take first to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? a. Collect a detailed diet history. b. Provide a list of low-sodium foods. c. Help the patient make an appointment with a dietitian. d. Teach the patient about foods that are high in potassium.

ANS: A The initial nursing action should be assessment of the patient's baseline dietary intake through a thorough diet history. The other actions may be appropriate, but assessment of the patient's baseline should occur first.

Which person would the nurse identify as having the highest risk for abdominal aortic aneurysm? a. A 70-yr-old man with high cholesterol and hypertension b. A 40-yr-old woman with obesity and metabolic syndrome c. A 60-yr-old man with renal insufficiency who is physically inactive d. A 65-yr-old woman with high homocysteine levels and substance use

ANS: A The most common cause of descending abdominal aortic aneurysm (AAA) is atherosclerosis. Male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol.

In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? a. Serum uric acid of 3.8 mg/dL b. Serum creatinine of 2.6 mg/dL c. Serum potassium of 3.5 mEq/L d. Blood urea nitrogen of 15 mg/dL

ANS: A The normal serum creatinine level is 0.6 to 1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other laboratory results are within normal limits.

A patient with newly discovered high BP has an average reading of 158/98 mmHg after 3 months of exercise and diet modifications. Which management strategy will be a priority for this patient? a. Drug therapy will be needed because the BP is still not at goal b. BP monitoring should continue for 3 months to confirm a diagnosis of hypertension c. Lifestyle changes are less important since they were not effective, and drugs will be started d. More changes in the patient's lifestyle are needed for a longer time before starting drug therapy

ANS: A The patient has hypertension, stage 1. Lifestyle modifications will continue, but starting drug therapy is a priority. Reducing BP can help to prevent serious complications related to hypertension.

A patient who is 2 days post femoral popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/VN) caring for the patient requires the registered nurse (RN) to intervene? a. The LPN/VN tells the patient sit in a chair for 2 hours. b. The LPN/VN gives the prescribed aspirin after breakfast. c. The LPN/VN assists the patient to walk 40 ft in the hallway. d. The LPN/VN places the patient in Fowler's position for meals.

ANS: A The patient should avoid sitting for long periods because of the increased stress on the suture line caused by leg edema and because of the risk for venous thromboembolism (VTE). The other actions by the LPN/LVN are appropriate.

The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a. 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain b. 52-yr-old with a blood pressure of 198/90 mm Hg who has intermittent claudication c. 50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL d. 43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria.

ANS: A The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention are needed. Intermittent claudication, elevated creatinine, and microalbuminuria show target organ damage but do not indicate acute processes.

A client with an abdominal aortic aneurysm is having a high resolution computed tomography (CT) scan to determine the feasibility for an endovascular repair. Which collaborative interventions should a nurse anticipate to decrease the client's likelihood of developing nephrotoxicity? a. administration of sodium bicarbonate 1 hour before injection of the intravenous (IV) contrast dye b. administration of 0.9% NaCl at 100 mL per hour before and after the CT scan c. administration of acetylcysteine (Mucomyst) orally before and after the study d. monitoring aPTT level before and after the CT scan e. placing the client on a low potassium diet

ANS: A, B, C

A child with Hodgkin's disease is treated with irradiation to the cervical area. The child's parent is concerned because the child lacks energy and is experiencing malaise. Based on this information, the nurse should further assess the child for (Select all that apply) a. hypothyroidism b. anemia c. impaired nutrition d. difficulty swallowing e. difficulty voiding

ANS: A, B, C, D

A nurse is caring for a pediatric client recently diagnosed with hypertension. Which diagnostic tests should the nurse anticipate being ordered for this client? Select all that apply. a. Complete blood count (CBC) b. Serum chemistry c. Renal ultrasound d. Drug screen e. Glucose tolerance test (GTT)

ANS: A, B, C, D

Which information should the nurse consider when planning care for older adult patients with hypertension? (Select all that apply.) a. Systolic blood pressure increases with aging. b. White coat syndrome is prevalent in older patients. c. Volume depletion contributes to orthostatic hypotension. d. Blood pressures should be maintained near 120/80 mm Hg. e. Blood pressure drops 1 hour after eating in many older patients. f. Older patients require higher doses of antihypertensive medications.

ANS: A, B, C, D, E Systolic blood pressure increases with age and patients older than age 60 years should be maintained below 150/90 mm Hg. Older adults are more likely to have elevated blood pressure when taken by health care providers (white coat syndrome). Older patients have orthostatic hypotension related to dehydration, reduced compensatory mechanisms, and medications. One hour after eating, many older patients have a drop in blood pressure. Lower doses of medications may be needed to control blood pressures in older adults related to decreased absorption rates and excretion ability.

A nurse is completing a health history and an assessment for a male adolescent client tentatively diagnosed with Hodgkin's lymphoma. Which findings should the nurse conclude support this diagnosis? Select all that apply a. firm, nontender lymph node enlargement in axillary area b. drenching night sweats c. unexplained fever with temperatures above 100.4 F d. unexplained weight loss of 10% or more in the previous 6 months e. a diet consisting mostly of seafood and saturated fats f. a brother who was also diagnosed with hodgkin's disease when he was an adolescent

ANS: A, B, C, D, F

A nurse is taking a history on an adolescent client who has a new onset of hypertension. The nurse is aware that a history of substance abuse may contribute to this condition and questions the adolescent. Which abused substances acknowledged by the adolescent could contribute to hypertension? Select all that apply. a. Amphetamines b. Cocaine c. Hallucinogens d. Alcohol e. Ecstasy f. Marijuana

ANS: A, B, C, E, F

A nurse explains to another nurse that chronic lymphocytic leukemia (CLL) is (Select all that apply) a. a malignancy of activated B lymphocytes b. the most common malignancy of older adults c. unresponsive to chemotherapy treatment d. often not treated in its early stages but the client is monitored e. an excessive accumulation of immature lymphocytes in the bone marrow f. often asymptomatic and diagnosed incidentally during routine physical examination

ANS: A, B, D, F

A patient is admitted to the hospital in a hypertensive emergency (BP 244/142 mm Hg). Sodium nitroprusside is started to treat the elevated BP. Which management strategies would be most appropriate for this patient? (Select all that apply) a. Measuring hourly urine output b. Continuous BP monitoring with an arterial line c. Decreasing the MAP by 50% within the first hour d. Maintaining bed rest and giving tranquilizers to lower the BP e. Assessing the patient for signs and symptoms of heart failure and changes in mental status

ANS: A, B, E Measure urine output hourly to assess renal perfusion. Patients treated with IV sodium nitroprusside should have continuous intra arterial BP monitoring. Hypertensive crisis can cause encephalopathy, intracranial or subarachnoid hemorrhage, acute left ventricular failure, MI, renal failure, dissecting aortic aneurysm, and retinopathy. The initial treatment goal is to decrease the mean arterial pressure (MAP) by no more than 25% within minutes to 1 hour. Patients receiving IV antihypertensive drugs may be restricted to bed rest. Getting up (e.g., to use the toilet/commode) may cause severe cerebral ischemia and fainting.

A client with symptoms of intermittent claudication receives treatment with a peripheral percutaneous transluminal angioplasty procedure with placement of an endovascular stent. During a follow up home visit, a nurse determines that the client is making lifestyle changes to decrease the likelihood of restenosis and arterial occlusion. Which observations of the client's actions support this condition? Select all that apply. a. states participating in an exercise program b. abstaining from nicotine c. wearing support hose d. states receiving foot care from a podiatrist e. following a low saturated low fat diet f. taking the medication rosuvastatin calcium (Crestor)

ANS: A, B, E, F

A registered nurse (RN) is acting as a preceptor for a new graduate nurse during the new nurse's second week of orientation. Which clients should a charge nurse assign to the graduate nurse under the supervision of the experienced RN? Select all that apply. a. a 16 year old client with moderate chronic asthma to be discharged in 24 hours b. a 5 year old with a tracheostomy needing trach care every shift c. a 12 year old client who had surgery for a ruptured appendix with a temperature of 99 F d. an 8 year old just admitted with a new diagnosis of leukemia e. a 4 year old diagnosed with hemophilia and admitted for a blood transfusion

ANS: A, C

The nurse is caring for a patient admitted with suspected hyperparathyroidism. Which manifestations would represent the expected electrolyte imbalance? (Select all that apply.) a. Nausea and vomiting b. Neurologic irritability c. Lethargy and weakness d. Increasing urine output e. Hyperactive bowel sounds

ANS: A, C, D Hyperparathyroidism can cause hypercalcemia. Signs of hypercalcemia include muscle weakness, polyuria, constipation, nausea and vomiting, lethargy, and memory impairment. Neurologic irritability and hyperactive bowel sounds do not occur with hypercalcemia.

Which assessment findings lead the nurse to suspect that an aneurysm rupture has occurred? Select all that apply. a. severe chest pain radiating to the back b. abdominal distention c. hypotension d. dyspnea e. oliguria

ANS: A, C, D, E

During a home visit, the nurse becomes concerned that a patient recovering from a splenectomy is at risk for infection. What did the nurse observe to come to this conclusion? (Select all that apply.) a. Received a manicure and pedicure. b. Washed hands before preparing lunch c. Poured a cup of tea after petting the cat d. Had a hot tub installed on the back patio e. Planting tomato plants in an outside garden

ANS: A, C, D, E Patient at risk for infection should be instructed to void working with dirt or soil, to avoid manicures and pedicures, to avoid hot tubs or Jacuzzis, and to wash hands after contact with pets, fresh flowers, or plants. B. Washing hands before preparing lunch decreases the risk for developing an infection.

The nurse is caring for a patient scheduled for tests to confirm the diagnosis of lymphoma. For which diagnostic tests should the nurse prepare the patient? (Select all that apply.) a. CT scan b. Cerebral angiogram c. Lymph node biopsy d. Lymphangiography e. Complete blood count

ANS: A, C, D, E Tests used to aid in the diagnosis of lymphoma include CT scan, lymph node biopsy, lymphangiography, and complete blood count. B. Cerebral angiogram is not a test used to diagnose lymphoma.

What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for patients with PAD? (Select all that apply.) a. Ramipril (Altace) b. Cilostazol (Pletal) c. Simvastatin (Zocor) d. Clopidogrel (Plavix) e. Warfarin (Coumadin) f. Aspirin (acetylsalicylic acid)

ANS: A, C, D, F Angiotensin-converting enzyme inhibitors (e.g., ramipril [Altace]) are used to control hypertension. Statins (e.g., simvastatin [Zocor]) are used for lipid management. Aspirin is used as an antiplatelet agent. Clopidogrel may be used if the patient cannot tolerate aspirin. Cilostazol (Pletal) is used for intermittent claudication, but it does not reduce CVD morbidity and mortality risks. Anticoagulants (e.g., warfarin [Coumadin]) are not recommended to prevent cardiovascular disease events in PAD patients.

Which BP regulating mechanism(s) can result in the development of hypertension if defective (select all that apply)? a. release of norepinephrine b. secretion of prostaglandins c. stimulation of the sympathetic nervous system d. stimulation of the parasympathetic nervous system e. activation of the renin-angiotensin-aldosterone system

ANS: A, C, E Norepinephrine (NE) is released from the sympathetic nervous system nerve endings and activates receptors found in the vascular smooth muscle. When the α-adrenergic receptors in smooth muscle of the blood vessels are stimulated by NE, vasoconstriction results. Increased sympathetic nervous system stimulation produces increased vasoconstriction and increased renin release. Increased renin levels activate the renin-angiotensin-aldosterone system, leading to an elevation in BP.

Which assessment finding would the nurse expect in a patient who has been taking oral prednisone several weeks and is experiencing sudden withdrawal? (Select all that apply.) a. BP 80/50 b. Heart rate 54 c. Glucose 63 mg/dL d. Sodium 148 mEq/L e. Potassium 6.3 mEq/L f. Temperature 101.1° F

ANS: A, C, E, F Sudden cessation of corticosteroid therapy can precipitate life-threatening adrenal insufficiency. During acute adrenal insufficiency, the patient exhibits severe manifestations of glucocorticoid and mineralocorticoid deficiencies, including hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, and confusion.

A client on a telemetry unit has a blood pressure (BP) of 88/40 mm Hg, a heart rate of 44 beats per minute, feels faint, and is pale and confused. When caring for this client, which tasks should a registered nurse (RN) delegate to a patient care assistant (PCA)? Select all that apply. a. Paging for the charge nurse b. Paging for a respiratory therapist c. Applying oxygen per protocol d. Securing an automatic BP machine e. Completing a head-to-toe assessment f. Obtaining a cardiac rhythm strip that the nurse has sent for printing at a central location

ANS: A, D, F

A patient with cancer is having chemotherapy treatments and has now developed neutropenia. What care should the nurse expect to provide and teach the patient about? (Select all that apply.) a. Strict hand washing. b. Daily nasal swabs for culture. c. Monitor temperature every hour. d. Daily skin care and oral hygiene. e. Encourage the patient to eat all foods to increase nutrients. f. Private room with a high-efficiency particulate air (HEPA) filter

ANS: A, D, F Strict hand washing and daily skin and oral hygiene must be done with neutropenia, because the patient is predisposed to infection from the normal body flora; other people; and uncooked meats, seafood, and eggs; unwashed fruits and vegetables; and fresh flowers or plants. The private room with HEPA filtration reduces the aerosolized pathogens in the patient's room. Blood cultures and antibiotic treatment are used when the patient has a temperature of 100.4° F or more, but temperature is not monitored every hour.

Leukemic cells have invaded a 16-year-old male's testes and irradiation of the testes is planned. The client asks a nurse if this means he will be sterile. The nurse's best response to the client is based on knowing that (Select all that apply) a. the irradiation to the testes will lead to sterilization b. the irradiation of the testes will decrease sperm production but not cause sterilization c. this is a question only the oncologist and radiologist would be able to answer d. a lead shield will be used to protect the pelvic area and preserve reproductive organs e. if the male is past puberty and is forming sperm, sperm banking may be an option before treatment

ANS: A, E

A 47 year old male patient is admitted to the hospital with a blood pressure of 240/118 accompanied by confusion and stupor. He has been taking clonidine (Catapres) and hydrochlorothiazide (HCTZ) for several years for management of his hypertension. His wife is 32 years old and looks more like 25. In a medication class with the patient and his wife, the nurse was discussing the side effects of antihypertensives. The patient's wife asks, "Is it true that these medications cause impotence?" The nurse's best response is a. They may, but would you prefer to have sex or do you prefer a man with a stroke? b. Most antihypertensives cause impotence, but it is too early to say if that will happen to your husband. c. If your husband becomes impotent, he could always use Viagra. d. If your husband becomes impotent, you could always explore other avenues of sexual satisfaction.

ANS: B

A 50-year-old woman who weighs 95 kg has a history of tobacco use, high blood pressure, high sodium intake, and sedentary lifestyle. Which is the most important risk factor for peripheral artery disease (PAD) to address in the nursing plan of care? a. Salt intake b. Tobacco use c. Excess weight d. Sedentary lifestyle

ANS: B

A client diagnosed with Hodgkin's lymphoma develops radiation pneumonitis 3 months after radiation treatment. For which symptoms of radiation pneumonitis should a nurse observe the client? a. tachypnea, hypotension, and fever b. cough, fever, dyspnea c. bradypnea, cough, and decreased urine output d. cough, tachycardia, and altered mental status

ANS: B

A client diagnosed with acute myeloid leukemia receives a bone marrow transplant. Which medication to prevent graft-versus-host disease (GVHD) should a nurse anticipate receiving an order to administer? a. A cephalosporin antibiotic, such as ceftazidime (Fortaz) b. An immunosuppressant, such as cyclosporine (Neoral) c. A chemotherapeutic agent, such as cisplatin (Platinol A-Q) d. Peginterferon alfa-2a (Pegasys) for prevention and treatment of hepatitis

ANS: B

A client hospitalized with a history of vomiting and diarrhea for 2 days has weakness, lethargy, serum CO2 of 18 mEq/L, and abdominal cramping. The client reports an inability to eat due to nausea. Which should be the nurse's priority nursing diagnosis when caring for the client? a. Altered nutrition less than body requirements related to diarrhea as manifested by inability to eat b. Deficient fluid volume related to vomiting as manifested by weakness and low serum CO2 c. Risk for injury related to weakness and lethargy d. Acute pain related to increased peristalsis as manifested by abdominal cramping

ANS: B

A client is neutropenic following treatment for acute lymphocytic leukemia and is now experiencing hypotension, tachycardia, and an elevated temperature. Because an infection is suspected, a nurse notifies a physician. Which physician order should be the nurse's priority? a. Portable chest x-ray b. Urine and blood cultures c. Vancomycin (Vancocin) 1 gm IV d. Filgrastim (Neupogen) 10 mg/kg subcutaneously daily

ANS: B

A client with Raynaud's disease is seen in a vascular clinic 6 weeks after nifedipine (Procardia) has been prescribed. A nurse evaluates that the medication has been effective when which findings are noted? a. the client's BP is 110/68 mm Hg b. The client states experiencing less pain and numbness c. the client states that tolerance to heat has improved d. the client walks without claudication

ANS: B

A client with leukemia asks a nurse how donor cells are obtained for peripheral blood stem cell transplantation (PBSCT). Which statement by the nurse is correct? a. "A large amount of bone marrow tissue is harvested from a donor's hip bone under general anesthesia in the operating room." b. "Stem cells are collected from the donor's blood, which goes through a machine, removes the stem cells, and then returns the blood back to the donor." c. "Stem cells are collected from a donor through a process called apheresis, which removes the stem cells from the blood. This typically takes 10 to 15 minutes." d. "Stem cells are obtained similar to other blood donations, where the blood is collected and then administered to you immediately following collection."

ANS: B

A female college professor is recently diagnosed with hypertension. Her diet is currently regular; she eats out often at fast food restaurants, and likes salty foods. Her physician has prescribed a 1500 calorie, 2 GM sodium diet. In teaching her about this diet, the nurse should emphasize a. eliminating all alcohol from the diet and replace with fruit juice or milk b. increasing fruits and vegetables and decreasing current snack food items c. avoid fast food restaurants and carry lunch meat sandwiches and soup to work d. replacing junk food snacks with high fiber breads and pasta.

ANS: B

A hospitalized client has protective precautions in place because of severe neutropenia. Which statement by a nurse is correct regarding the use of protective precautions? a. "Caregivers should don gloves as soon as they enter the client's room". b. "The client should minimize the time spent outside the room". c. "The client should be in a private room with negative air pressure." d. "All persons entering the client's room should wear a mask."

ANS: B

A hospitalized client, identified to be at risk for thromboembolic disease, has anti-embolism hose ordered. A nurse discusses the correct use of the stockings. Which direction should the nurse include in teaching this client? a. If ambulating 10 times daily for 5 minutes at a time, wearing the hose in unnecessary b. The most appropriate time to apply the hose is before standing to get out of bed in the morning c. If the hose becomes painful to the skin underneath, notify the nurse and request pain medication d. Only cross the legs while wearing the antiembolism hose; otherwise keep the legs uncrossed

ANS: B

A nurse cares for a client with a venous leg ulcer who undergoes trilayer artificial skin grafting. The nurse understands that grafted skin heals best on venous leg ulcers when which intervention is implemented after grafting? a. applying a gauze dressing b. applying compression bandages c. applying xeroform dressing d. applying petrolatum bandages

ANS: B

A nurse is caring for a male client the night before the client is scheduled for an amputation. The client has a 7 year history of peripheral artery disease. Recent surgeries have failed to revascularize the client's leg. The client tells the nurse that he is a failure and all the efforts of his family and physician have been wasted. The most appropriate intervention by the nurse at this time is to a. explain that the hospital staff will help him through the surgery and recovery b. stay with the client, listen carefully, and encourage him to express his feelings c. offer to contact pastoral care d. offer to contact the primary care provider to obtain an antidepressant

ANS: B

A nursing assistant (NA), who is taking routine vital signs, tells a nurse that the small adult cuff is nowhere to be found and that a client's arm is too small to use an adult-size cuff. In response to the NA's report, which direction should the nurse give to the NA? a. Document the other vital signs and note that proper blood pressure (BP) equipment is not available b. Contact the nursing supervisor, obtain a small, adult BP cuff, and take the client's BP with the small adult-size cuff c. Use the adult BP cuff to obtain the blood pressure, add 10 to both the diastolic and systolic readings, and document on the client's record the BP was obtained with an adult cuff d. Take the client's BP using any available cuff

ANS: B

A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that the aneurysm has ruptured? a. rapid onset of shortness of breath and hemoptysis b. sudden, severe low back pain and bruising along his flank c. gradually increasing substernal chest pain and diaphoresis d. sudden, patchy blue mottling on feet and toes and rest pain

ANS: B

A patient with a history of a 4 centimeter fusiform abdominal aneurysm is admitted to the emergency room with severe back pain and bilateral flank ecchymosis. His vital signs are blood pressure 90/58, pulse 138, respirations 34. The nurse plans interventions for the patient based on the expectation that treatment will include a. a STAT aortogram b. immediate surgery c. ICU admission d. a paracentesis

ANS: B

After seeing a primary care provider for a routine appointment, a 48-year-old client tells a nurse that she experienced pain in the calf of her left leg earlier in the week, but she is pain-free now. The nurse assesses the client and finds the dorsalis pedis pulses palpable and no pain upon dorsiflexion bilaterally. A few varicose veins are visible in each leg. There is very slight swelling in the left foot and none in the right foot. Which is the best action by the nurse? a. Ask the client if she has been walking more lately. b. Notify the primary care provider. c. Ask the client is she has thought about taking a baby aspirin once a day. d. Explain to the client that there are no significant findings but to call the office if the pain returns.

ANS: B

An activated partial prothrombin time (aPTT) test is done on a patient receiving intravenous heparin and the results are: Patient 28 seconds, control: 35 seconds. The nurse should recognize that this result is a. above the desired therapeutic response b. below the desired therapeutic response c. a reading that indicates faculty lab equipment d. within the limits of the desired therapeutic response

ANS: B

An agitated client is admitted to the emergency department (ED) with tachycardia, dyspnea, and intermittent chest palpitations. The client has a blood pressure of 170/110 mm Hg and heart rate of 130 beats per minute. The client's health history reveals thinning hair, recent 10 lb weight loss, increased appetite, fine hand and tongue tremors, hyperreflexic tendon reflexes, and smooth moist skin. A physician writes orders for the client. Which order should the nurse implement first? a. Obtain 12-lead electrocardiogram (ECG) b. Administer propranolol (Inderal) 2 mg intravenously q 10-15 min or until symptoms are controlled c. Administer propylthiouracil (PTU) 600 mg oral loading dose followed by 200 mg orally q4h d. Obtain thyroid-stimulating hormone (TSH), free T4, and cardiac enzyme levels

ANS: B

Elastic support-type stockings (TEDS) are used to prevent venous stasis. They are applied bilaterally a. While the person is standing, flexing at the waist b. while the person is in bed and supine, with legs elevated c. as the person gets out of bed, with legs in dependent position d. from toe to mid-calf with legs extended

ANS: B

Mr. Merlot is admitted to the hospital with the diagnosis of peripheral vascular disease - arterial. One of his orders reads "check peripheral pulses every 2 hours". The nurse cannot palpate Mr. Merlot's left pedal pulse but notes that the left lower extremity looks naturally pink and feels warm to touch. This is most probably due to a. only venous circulation impairment and engorgement leads to diminished pedal pulses b. development of collateral circulation through communicating arterial branches c. pooling of the blood when the extremity is held in a dependent position d. inflammatory processes brought on by continued ischemia of the extremity

ANS: B

Prior to administering L-asparaginase to a 12 year old child with acute lymphocytic leukemia, a nurse reviews the child's laboratory report. Which lab value should prompt the nurse to notify a physician before administering the chemotherapeutic agent? a. Hgb 11.8 mg/dL b. Blood glucose 252 mg/dL c. Total bilirubin 1.2 mg/dL d. Absolute neutrophil count (ANC) 1,078

ANS: B

When taking the BP of a patient who has had a thyroidectomy, the nurse notices the patient is pale and has spasms of the hand and notifies the physician. While awaiting the physician's orders, the nurse should prepare for replacement of a. bicarbonate b. calcium c. magnesium d. potassium chloride

ANS: B

When teaching a patient about rest pain with PAD, what should the nurse explain as the cause of the pain? a. vasospasms of cutaneous arteries in the feet b. decrease in blood flow to the nerves of the feet c. increase in retrograde venous perfusion to the lower legs d. constriction in blood flow to leg muscles during exercise

ANS: B

Which patient is at highest risk for venous thromboembolism (VTE)? a. a 62-year-old man with spider veins who is having arthroscopic knee surgery b. a 32-year-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe c. a 26-year-old woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during her labor d. an active 72-year-old man at home recovering from transurethral resection of the prostate for benign prostatic hyperplasia

ANS: B

An older adult with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide teaching on which type of diet for this patient and his caregiver? a. Low-fat diet b. High-protein diet c. Calorie-restricted diet d. High-carbohydrate diet

ANS: B A patient with a venous ulcer should have a balanced diet with adequate protein, calories, and micronutrients; this type of diet is essential for healing. Nutrients most important for healing include protein, vitamins A and C, and zinc. Foods high in protein (e.g., meat, beans, cheese, tofu), vitamin A (green leafy vegetables), vitamin C (citrus fruits, tomatoes, cantaloupe), and zinc (meat, seafood) must be provided. Restricting fat or calories is not helpful for wound healing or in patients of normal weight. For overweight individuals with no active venous ulcer, a weight-loss diet should be considered.

A 40-year-old patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask? a. "Have you had a recent head injury?" b. "Do you have to wear larger shoes now?" c. "Is there a family history of acromegaly?" d. "Are you experiencing tremors or anxiety?"

ANS: B Acromegaly causes an enlargement of the hands and feet. Head injury and family history are not risk factors for acromegaly. Tremors and anxiety are not clinical manifestations of acromegaly.

While obtaining subjective assessment data from a patient with hypertension, the nurse recognizes that a modifiable risk factor for the development of hypertension is a. a low-calcium diet b. excessive alcohol consumption c. a family history of hypertension d. consumption of a high-protein diet

ANS: B Alcohol intake is a modifiable risk factor for hypertension. Excessive alcohol intake is strongly associated with hypertension. Males with hypertension should limit their daily intake of alcohol to 2 drinks per day, and one drink per day for females with hypertension.

A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/μL. Which action will the nurse include in the plan of care? a. Prepare for platelet transfusion. b. Discontinue the heparin infusion. c. Administer prescribed warfarin (Coumadin). d. Give low-molecular-weight heparin (LMWH).

ANS: B All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/μL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.

An older adult, hospitalized with chest trauma following a motor vehicle accident, has a right femoral arterial line. Because the client has been thrashing about in bed, a physician writes an order for wrist restraints to be applied. Based on this information, which action by a nurse is correct? a. apply the wrist restraints as ordered b. request an order for a right ankle restraint also c. request an order for sedation instead of restraints d. question the order because restraints will increase the client's agitation

ANS: B An ankle restraint will help prevent dislodgement of the arterial catheter and bleeding and injury that can occur from thrashing in bed.

When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? a. Recommend ibuprofen for left upper quadrant pain. b. Schedule immunization with the pneumococcal vaccine. c. Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery. d. Discourage deep breathing and coughing to reduce risk for splenic rupture.

ANS: B Asplenic patients are at high risk for infection with pneumococcal infections and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth, and the patient should be encouraged to take deep breaths.

A patient has been diagnosed with acute myelogenous leukemia (AML). What should the nurse educate the patient that care will focus on? a. Leukapheresis b. Attaining remission c. One chemotherapy agent d. Waiting with active supportive care

ANS: B Attaining remission is the initial goal of care for leukemia. The methods to do this are decided based on age and cytogenetic analysis. The treatments include leukapheresis or hydroxyurea to reduce the white blood cell count and risk of leukemia-cell-induced thrombosis. A combination of chemotherapy agents will be used for aggressive treatment to destroy leukemic cells in tissues, peripheral blood, and bone marrow and minimize drug toxicity. In nonsymptomatic patients with chronic lymphocytic leukemia, waiting may be done to attain remission, but not with AML.

The nurse is caring for a patient with hypertension who is scheduled to receive a dose of metoprolol (Lopressor). The nurse should withhold the dose and consult the prescribing provider for which vital sign taken just before administration? a. O2 saturation 93% b. Pulse 48 beats/min c. Respirations 24 breaths/min d. Blood pressure 118/74 mm Hg

ANS: B Because metoprolol is a β1-adrenergic blocking agent, it can cause hypotension and bradycardia as adverse effects. The nurse should withhold the dose and consult with the health care provider for parameters regarding pulse rate limits.

A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should the nurse take first? a. Tell the patient why a change in drug dosage is needed. b. Ask the patient if the medication is being taken as prescribed. c. Review with the patient any lifestyle changes made to help control BP. d. Teach the patient that multiple drugs are often needed to treat hypertension.

ANS: B Because nonadherence with antihypertensive therapy is common, the nurse's initial action should be to determine whether the patient is taking the atenolol as prescribed. The other actions also may be implemented, but these would be done after assessing patient adherence with the prescribed therapy.

The nurse is admitting a patient newly diagnosed with peripheral artery disease who takes clopidogrel. Which admission order should the nurse question? a. Cilostazol drug therapy b. Omeprazole drug therapy c. Use of treadmill for exercise d. Exercise to the point of discomfort

ANS: B Because the antiplatelet effect of clopidogrel is reduced when it is used with omeprazole, the nurse should clarify this order with the health care provider. The other interventions are appropriate for a patient with peripheral artery disease.

An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which action should the nurse take first? a. Draw blood for laboratory testing. b. Check the patient's blood pressure. c. Assess the patient for an abdominal bruit. d. Determine any family history of heart disease.

ANS: B Because the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions may also be done, but they will not provide information to determine what interventions are needed immediately.

The nurse is evaluating the discharge teaching outcomes for a patient with chronic peripheral artery disease (PAD). Which patient statement indicates a need for further instruction? a. "I will buy loose clothes that do not bind across my legs or waist." b. "I will use a heating pad on my feet at night to increase the circulation." c. "I will walk to the point of pain, rest, and walk again for at least 30 minutes 3 times a week." d. "I will change my position every hour and avoid long periods of sitting with my legs crossed."

ANS: B Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful.

A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. What should the nurse plan to explain to the patient? a. Blood transfusion b. Bone marrow biopsy c. Filgrastim administration d. Erythropoietin administration

ANS: B Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary later if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.

The nurse admits a 73-yr-old male patient with dementia for treatment of uncontrolled hypertension. The nurse will closely monitor for hypokalemia if the patient receives which medication? a. Clonidine (Catapres) b. Bumetanide (Bumex) c. Amiloride (Midamor) d. Spironolactone (Aldactone)

ANS: B Bumetanide is a loop diuretic. Hypokalemia is a common adverse effect of this medication. Amiloride is a potassium-sparing diuretic. Spironolactone is an aldosterone-receptor blocker. Hyperkalemia is an adverse effect of both amiloride and spironolactone. Clonidine is a central-acting α-adrenergic antagonist and does not cause electrolyte abnormalities.

Which patient statement supports a history of intermittent claudication? a. "When I stand too long, my feet start to swell." b. "My legs cramp when I walk more than a block." c. "I get short of breath when I climb a lot of stairs." d. "My fingers hurt when I go outside in cold weather."

ANS: B Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynaud's phenomenon. Shortness of breath that occurs with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease.

The nurse receives a phone call from a patient taking cyclophosphamide for treatment of non-Hodgkin's lymphoma. The patient tells the nurse that she has muscle cramps, weakness, and very little urine output. Which response by the nurse is best? a. "Start taking supplemental potassium, calcium, and magnesium." b. "Stop taking the medication now and call your healthcare provider." c. "These symptoms will decrease with continued use of the medication." d. "Increase your fluid intake to 3000 mL for 24 hours to improve your urine output."

ANS: B Cyclophosphamide may cause syndrome of inappropriate antidiuretic hormone (SIADH). Medications that stimulate the release of ADH should be avoided or discontinued. Treatment may include restriction of fluids to 800 to 1000 mL/day. A loop diuretic such as furosemide (Lasix) is used to promote diuresis, and supplements of potassium, calcium, and magnesium may be needed.

Which finding on a patient's nursing admission assessment is congruent with the initial medical diagnosis of a 6-cm thoracic aortic aneurysm? a. Low back pain b. Trouble swallowing c. Abdominal tenderness d. Changes in bowel habits

ANS: B Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. The other symptoms will be important to assess for in patients with abdominal aortic aneurysms.

The cardiac telemetry unit charge nurse receives status reports from other nursing units about four patients who need cardiac monitoring. Which patient should be transferred to the cardiac unit first? a. Patient with Hashimoto's thyroiditis and a heart rate of 102 b. Patient with tetany who has a new order for IV calcium chloride c. Patient with Cushing syndrome and a blood glucose of 140 mg/dL d. Patient with Addison's disease who takes IV hydrocortisone twice daily

ANS: B Emergency treatment of tetany requires IV administration of calcium; electrocardiographic monitoring will be required because cardiac arrest may occur if high calcium levels result from too-rapid administration. The information about the other patients indicates that they are more stable than the patient with tetany.

Which assessment finding would alert the nurse that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox)? a. Crackles bilaterally in the lung bases b. Pain and swelling in a lower extremity c. Absence of arterial pulse in a lower extremity d. Abdominal pain with decreased bowel sounds

ANS: B Enoxaparin is a low-molecular-weight heparin used to prevent the development of deep vein thromboses (DVTs) in the postoperative period. Pain and swelling in a lower extremity can indicate development of DVT and therefore may signal ineffective medication therapy.

A client diagnosed with acute myeloid leukemia receives a bone marrow transplant. Which medication to prevent graft-versus-host disease (GVHD) should a nurse anticipate receiving an order to administer? a. A cephalosporin antibiotic, such as ceftazidime b. An immunosuppressant, such as cyclosporine (Neoral) c. A chemotherapeutic agent, such as cisplatin (Platinol-A-Q) d. Peginterferon alfa-2a (Pegasys) for prevention and treatment of hepatitis

ANS: B GVHD occurs when the T lymphocytes proliferate from the transplanted donor marrow and mount an immune response against the recipient's tissues. An immunosuppressant prevents the immune response.

Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? a. Patient reports severe back pain. b. Serum calcium level is 15 mg/dL. c. Patient reports no stool for 5 days. d. Urine sample has Bence-Jones protein.

ANS: B Hypercalcemia may lead to complications such as dysrhythmias or seizures and should be addressed quickly. The other patient findings will also be discussed with the health care provider but are not life threatening.

Which assessment finding for a patient receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider? a. Blood glucose level of 175 mg/dL b. Serum potassium level of 3.0 mEq/L c. Orthostatic systolic BP decrease of 12 mm Hg d. Current blood pressure (BP) reading of 168/94 mm Hg

ANS: B Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider should be notified of the potassium level immediately and administration of potassium supplements initiated. The elevated blood glucose and BP also need collaborative intervention but will not require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg will require intervention only if the patient is symptomatic.

Which nursing assessment of a 70-year-old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)? a. Fluid balance b. Apical pulse rate c. Nutritional intake d. Orientation and alertness

ANS: B In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina or dysrhythmias. The medication also is expected to improve mental status and fluid balance and will increase metabolic rate and nutritional needs, but these changes will not result in potentially life-threatening complications.

An older patient has been diagnosed with possible white coat hypertension. Which planned action by the nurse addresses that suspected cause of the hypertension? Instruct the patient about the need to decrease stress levels. Teach the patient how to self-monitor and record BPs at home. Tell the patient and caregiver that major dietary changes are needed. Schedule the patient for regular blood pressure (BP) checks in the clinic.

ANS: B In the phenomenon of "white coat" hypertension, patients have elevated BP readings in a clinical setting and normal readings when BP is measured elsewhere. Having the patient self-monitor BPs at home will provide a reliable indication about whether the patient has hypertension. Regular BP checks in the clinic are likely to be high in a patient with white coat hypertension. There is no evidence that this patient has elevated stress levels or a poor diet, and those factors do not cause white coat hypertension.

After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. A 31-year-old female patient with Cushing syndrome and a blood glucose level of 244 mg/dL b. A 70-year-old female patient taking levothyroxine (Synthroid) who has an irregular pulse of 134 c. A 53-year-old male patient who has Addison's disease and is due for a prescribed dose of hydrocortisone (Solu-Cortef). d. A 22-year-old male patient admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mEq/L

ANS: B Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias. The patient's high pulse rate needs rapid investigation by the nurse to assess for and intervene with any cardiac problems. The other patients also require nursing assessment and/or actions but are not at risk for life-threatening complications.

A patient with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? a. Patient reports chest pain with strenuous activity. b. Patient says muscle leg pain occurs with continued exercise. c. Patient has numbness and tingling of all their toes and both feet. d. Patient states the feet become red when they are in a dependent position.

ANS: B Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain with exertion. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position, the term is dependent rubor.

The nurse is caring for a patient recently started on levothyroxine for hypothyroidism. What information reported by the patient requires immediate action? a. Weight gain or weight loss b. Chest pain and palpitations c. Muscle weakness and fatigue d. Decreased appetite and constipation

ANS: B Levothyroxine is used to treat hypothyroidism. With replacement, the patient can be overmedicated, causing hyperthyroidism. Any chest pain, heart palpitations, or heart rate greater than 100 beats/min experienced by a patient starting thyroid replacement should be reported immediately, and electrocardiography and serum cardiac enzyme tests should be performed.

The provider was unable to spare a patient's parathyroid gland during a thyroidectomy. Which assessments should the nurse prioritize when providing postoperative care for this patient? a. White blood cell levels and signs of infection b. Serum calcium levels and signs of hypocalcemia c. Hemoglobin, hematocrit, and red blood cell levels d. Level of consciousness and signs of acute delirium

ANS: B Loss of the parathyroid gland is associated with hypocalcemia. Whereas infection and anemia are not associated with loss of the parathyroid gland, cognitive changes are less pronounced than the signs and symptoms of hypocalcemia.

A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate? a. "Taking both blood thinners greatly reduces the risk for another clot to form." b. "Enoxaparin will work right away, but warfarin takes several days to begin preventing clots." c. "Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from forming." d. "Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner."

ANS: B Low-molecular-weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another VTE. Anticoagulants do not thin the blood.

The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? a. Wrap both legs in a warming blanket. b. Notify the surgeon and anesthesiologist. c. Document the findings and recheck in 15 minutes. d. Compare findings to the preoperative assessment of the pulses.

ANS: B Lower extremity pulses may be absent for a short time after surgery because of vasospasm and hypothermia. Decreased or absent pulses together with a cool and mottled extremity may indicate embolization or graft occlusion. These findings should be reported to the surgeon immediately because this is an emergency situation. Because pulses are marked before surgery, the nurse would know whether pulses were present before surgery before notifying the health care providers about the absent pulses. Because the patient's symptoms may indicate graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 15 minutes before taking action. A warming blanket will not improve the circulation to the patient's legs.

Which question will the nurse in the endocrine clinic ask to help determine a patient's risk factors for goiter? a. "How much milk do you drink?" b. "What medications are you taking?" c. "Have you had a recent neck injury?" d. "Are your immunizations up to date?"

ANS: B Medications that contain thyroid-inhibiting substances can cause goiter. Milk intake, neck injury, and immunization history are not risk factors for goiter.

A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). What is the best approach for the nurse to assist the patient with this treatment decision? a. Discuss the need for insurance to cover post-HSCT care. b. Inquire whether there are questions or concerns about HSCT. c. Emphasize the positive outcomes of a bone marrow transplant. d. Explain that a cure is not possible with any treatment except HSCT.

ANS: B Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.

Which patient statement indicates to the nurse that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH)? a. "I should weigh myself daily and report sudden weight loss or gain." b. "I need to shop for foods low in sodium and avoid adding salt to food." c. "I need to limit my fluid intake to no more than 1 quart of liquids a day." d. "I should eat foods high in potassium because diuretics cause potassium loss."

ANS: B Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other patient statements are correct and indicate successful teaching has occurred.

When providing dietary teaching to a patient with hypertension, the nurse would teach the patient to restrict intake of which meat? a. Broiled fish b. Roasted duck c. Roasted turkey d. Baked chicken breast

ANS: B Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall cardiovascular disease risk. The other meats are lower in fat and are therefore acceptable in the diet.

Which instructions should the nurse include in a teaching plan for an older adult patient newly diagnosed with peripheral artery disease (PAD)? a. "Exercise only if you do not experience any pain." b. "It is very important that you stop smoking cigarettes." c. "Try to keep your legs elevated whenever you are sitting." d. "Put elastic compression stockings on early in the morning."

ANS: B Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.

A 62-yr-old Hispanic male patient with diabetes has been diagnosed with peripheral artery disease (PAD). The patient smokes and has a history of gout. To prevent complications, which factor is priority in patient teaching? a. Gender b. Smoking c. Ethnicity d. Comorbidities

ANS: B Smoking is the most significant factor for this patient. PAD is a marker of advanced systemic atherosclerosis. Therefore, tobacco cessation is essential to reduce PAD progression, CVD events, and mortality. Diabetes and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD.

A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department. The patient reports a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings? a. "Have you recently taken any antihistamines?" b. "Have you consistently taken your medications?" c. "Did you take any acetaminophen (Tylenol) today?" d. "Have there been recent stressful events in your life?"

ANS: B Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.

The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) after hospitalization for venous thromboembolism (VTE). Which patient statement indicates a need for additional teaching? a. "I should get a Medic Alert device stating that I take warfarin." b. "I should reduce the amount of green, leafy vegetables that I eat." c. "I will need routine blood tests to monitor the effects of the warfarin." d. "I will check with my health care provider before I begin any new drugs."

ANS: B Teach patients taking warfarin to follow a consistent diet regarding foods that are high in vitamin K, such as green, leafy vegetables. The other patient statements are accurate.

Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 48-yr-old patient with newly diagnosed hypertension? a. 98/56 mm Hg b. 128/76 mm Hg c. 128/92 mm Hg d. 142/78 mm Hg

ANS: B The 8th Joint National Committee's recommended goal for antihypertensive therapy for a 30- to 59-yr-old patient with hypertension is a BP below 130/80 mm Hg. The BP of 98/56 mm Hg may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient's treatment.

The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (Vasotec). Which statement by the new nurse to the patient would require the charge nurse's intervention? a. "Make an appointment with the dietitian for teaching." b. "Increase your dietary intake of high-potassium foods." c. "Check your blood pressure at home at least once a day." d. "Move slowly when moving from lying to sitting to standing."

ANS: B The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril.

Several hours after a patient had an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 45 mL. What should the nurse anticipate will be prescribed? a. Hemoglobin count b. Increased IV fluids c. Additional antibiotics d. Serum creatinine level

ANS: B The decreased urine output suggests decreased renal perfusion and monitoring of renal function is needed. There is no indication that infection is a concern, so antibiotic therapy and a WBC count are not needed. The IV rate may be increased because hypovolemia may be contributing to the patient's decreased urinary output.

Which action will the admitting nurse include in the care plan for a patient who has neutropenia? a. Avoid intramuscular injections. b. Check temperature every 4 hours. c. Place a "No Visitors" sign on the door. d. Omit fruits and vegetables from the diet.

ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. While unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed.

A patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon? a. Difficult to awaken. b. Increasing neck swelling. c. Reports 7/10 incisional pain. d. Cardiac rate 112 beats/min.

ANS: B The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 beats/min is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Sleepiness in the immediate postoperative period is expected.

The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to correctly administer this medication? a. Spread the skin before inserting the needle. b. Leave the air bubble in the prefilled syringe. c. Use the back of the arm as the preferred site. d. Sit the patient at a 30-degree angle before administration.

ANS: B The nurse should not expel the air bubble from the prefilled syringe because it should be injected to clear the needle of medication and avoid leaving medication in the needle track in the tissue.

A patient receiving outpatient chemotherapy for myelogenous leukemia develops an absolute neutrophil count of 850/μL. Which collaborative action should the outpatient clinic nurse anticipate? a. Discuss the need for hospital admission to treat the neutropenia. b. Teach the patient to administer filgrastim (Neupogen) injections. c. Plan to discontinue the chemotherapy until the neutropenia resolves. d. Order a high-efficiency particulate air (HEPA) filter for the patient's home.

ANS: B The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count <500/μL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient's home environment.

Which action should the nurse in the hypertension clinic take to obtain an accurate baseline blood pressure (BP) for a new patient? a. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. b. Have the patient sit in a chair with the feet flat on the floor. c. Assist the patient to the supine position for BP measurements. d. Obtain two BP readings in the dominant arm and average the results.

ANS: B The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, and the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.

When teaching a patient about dietary management of stage 1 hypertension, which instruction is appropriate? a. Increase water intake. b. Restrict sodium intake. c. Increase protein intake. d. Use calcium supplements.

ANS: B The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Protein intake does not affect hypertension. Calcium supplements are not recommended to lower blood pressure.

Which nursing action will be included in the plan of care for a patient with Graves' disease who has exophthalmos? a. Place cold packs on the eyes to relieve pain and swelling. b. Elevate the head of the patient's bed to reduce periorbital fluid. c. Apply alternating eye patches to protect the corneas from irritation. d. Teach the patient to blink every few seconds to lubricate the corneas.

ANS: B The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos, the patient is unable to close the eyes completely to blink. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring. The swelling of the eye is not caused by excessive blood flow to the eye, so cold packs will not be helpful.

The patient in the emergency department after a car accident is wearing medical identification listing Addison's disease. What should the nurse expect to be included in the care of this patient? a. Low-sodium diet b. Increased glucocorticoid replacement c. Limiting IV fluid replacement therapy d. Withholding mineralocorticoid replacement

ANS: B The patient with Addison's disease needs lifelong glucocorticoid and mineralocorticoid replacement and has an increased need with illness, injury, or stress, as this patient is experiencing. The patient with Addison's may need large volumes of IV fluid replacement and a high-sodium diet. Withholding mineralocorticoid replacement cannot be done for patients with Addison's disease.

A patient has been diagnosed with stage 1A Hodgkin's lymphoma. The nurse knows that which chemotherapy regimen is most likely to be prescribed for this patient? a. Brentuximab vedotin (Adcetris) b. Two to four cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine c. Four to six cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine d. BEACOPP: bleomycin, etoposide, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), procarbazine, and prednisone

ANS: B The patient with a favorable prognosis early-stage Hodgkin's lymphoma (stage 1A) will receive two to four cycles of ABVD. The unfavorable prognostic featured (stage 1B) Hodgkin's lymphoma would be treated with four to six cycles of chemotherapy. Advanced-stage Hodgkin's lymphoma is treated more aggressively with more cycles or with BEACOPP. Brentuximab vedotin (Adcetris) is a newer agent that will be used to treat patients who have relapsed or refractory disease.Note: Some of acronyms for drug protocols use the brand/trade name of drugs (Adriamycin, Oncovin). These brand/trade names have been discontinued but the drugs are still available as generic drugs.

A patient with varicose veins has been prescribed compression stockings. Which nursing instruction would be appropriate? a. "Try to keep your stockings on 24 hours a day, as much as possible." b. "While you're still lying in bed in the morning, put on your stockings." c. "Dangle your feet at your bedside for 5 minutes before putting on your stockings." d. "Your stockings will be most effective if you can remove them several times a day."

ANS: B The patient with varicose veins should apply stockings in bed before rising in the morning. Stockings should not be worn continuously and should not be removed several times daily. Dangling at the bedside before application is likely to decrease their effectiveness.

Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? a. A 44-yr-old with sickle cell anemia who says his eyes always look yellow b. A 23-yr-old with no previous health problems who has a nontender axillary lump c. A 50-yr-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue d. A 19-yr-old with hemophilia who wants to learn to self-administer factor VII replacement

ANS: B The patient's age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently.

After receiving change-of-shift report, which patient admitted to the emergency department should the nurse assess first? a. A 67-yr-old patient who has a gangrenous foot ulcer with a weak pedal pulse b. A 50-yr-old patient who is reporting sudden sharp and severe upper back pain c. A 39-yr-old patient who has right calf tenderness and swelling after a plane ride d. A 58-yr-old patient taking anticoagulants for atrial fibrillation who has black stools

ANS: B The patient's presentation of sudden sharp and severe upper back pain is consistent with dissecting thoracic aneurysm, which will require the most rapid intervention. The other patients also require rapid intervention but not before the patient with severe pain.

The patient had aortic aneurysm repair 6 hours ago. What priority nursing action will maintain graft patency? a. Assess output for renal dysfunction. b. Use IV fluids to maintain adequate BP. c. Use oral antihypertensives to maintain cardiac output. d. Maintain a low BP to prevent pressure on surgical site.

ANS: B The priority is to maintain an adequate blood pressure (BP) (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it.

The nurse obtains the following information from a patient newly diagnosed with elevated blood pressure. Which finding is most important to address with the patient? a. Low dietary fiber intake b. No regular physical exercise c. Drinks a beer with dinner every night d. Weight is 5 pounds above ideal weight

ANS: B The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber but increasing fiber alone will not prevent hypertension from developing. The patient's alcohol intake is within guidelines and will not increase the hypertension risk.

The nurse is reviewing the laboratory test results for a patient whose warfarin (Coumadin) therapy was stopped before surgery. On postoperative day 2, the international normalized ratio (INR) result is 2.7. Which action by the nurse is most appropriate? a. Hold the daily dose of warfarin. b. Administer the daily dose of warfarin. c. Teach the patient signs and symptoms of bleeding. d. Call the health care provider to request an increased dose of warfarin.

ANS: B The therapeutic range for INR is 2.0 to 3.0 for many clinical diagnoses. To maintain therapeutic values, the nurse will administer the medication as ordered. Holding the medication would lower the INR, which would increase the risk of clot formation. Conversely, the higher the INR is, the more prolonged the clotting time. Calling the health care provider is not indicated. Although teaching is important, administering the medication is a higher priority at this time.

A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? a. "If you do not want to have chemotherapy, other treatment options include stem cell transplantation." b. "The side effects of chemotherapy are difficult, but AML often goes into remission with chemotherapy." c. "The decision about treatment is one that you and the doctor need to make rather than asking what I would do." d. "You don't need to make a decision about treatment right now because leukemias in adults tend to progress slowly."

ANS: B This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information.

A patient with critical limb ischemia had peripheral artery bypass surgery to improve circulation. What nursing care should be provided on the first postoperative day? a. Keep patient on bed rest. b. Assist patient to walk several times. c. Have patient sit in the chair several times. d. Place patient on their side with knees flexed.

ANS: B To avoid blockage of the graft or stent, the patient should walk several times on postoperative day one and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines.

The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT) who is scheduled for an emergency appendectomy. Vitamin K is ordered for immediate administration. The international normalized ratio (INR) value is 1.0. Which nursing action is most appropriate? a. Administer the medication as ordered. b. Hold the medication and record in the electronic medical record. c. Hold the medication until the lab result is repeated to verify results. d. Administer the medication and seek an increased dose from the health care provider.

ANS: B Vitamin K is the antidote to warfarin (Coumadin), which the patient has likely been taking before admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore, it may be necessary to give vitamin K before surgery to reduce the risk of hemorrhage. However, the INR value is normal, and vitamin K is not required, so the medication would be held and recorded in the electronic medical record.

A 56-year-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with syndrome of inappropriate antidiuretic hormone (SIADH). Which initial laboratory result should the nurse expect? a. Elevated hematocrit b. Decreased serum sodium c. Increased serum chloride d. Low urine specific gravity

ANS: B When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient. The hematocrit will decrease because of the dilution caused by water retention. Urine will be more concentrated with a higher specific gravity. The serum chloride level will usually decrease along with the sodium level.

The nurse is collaborating on discharge teaching needed for a patient recovering from a splenectomy. What follow-up care is most important for the nurse to emphasize with this patient? a. Monthly coagulation studies b. Yearly influenza vaccination c. Oral analgesics for pain control d. Routine transfusion of packed RBCs to prevent anemia

ANS: B Without a spleen to assist in the immune response, the patient is at risk for infection, making flu vaccination important. A. D. Coagulation studies and transfusions are not necessary. C. Oral analgesics may be needed for a short time but are not as essential as preventing infection.

A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving. Discharge is expected to occur in 2 days. Which teaching strategy is likely to result in effective patient self-management at home? a. Delay teaching until closer to discharge date. b. Provide written reminders of information taught. c. Offer multiple options for management of therapies. d. Ensure privacy for teaching by asking the family to leave.

ANS: B Written instructions will be helpful to the patient because initially the hypothyroid patient may be unable to remember to take medications and other aspects of self-care. Because the treatment regimen is complex, teaching should be started well before discharge. Family members or friends should be included in teaching because the hypothyroid patient is likely to forget some aspects of the treatment plan. A simpler regimen will be easier to understand until the patient is euthyroid.

Which assessment findings of the left lower extremity would the nurse identify as consistent with arterial occlusion? (Select all that apply.) a. Edematous b. Cold and mottled c. Reports of paresthesia d. Pulse not palpable with Doppler e. Warmer than right lower extremity f. Capillary refill less than 3 seconds

ANS: B, C, D Arterial occlusion may result in loss of limb if not timely revascularized. When an artery is occluded, perfusion to the extremity is impaired or absent. On assessment, the nurse would note a cold, mottled extremity with impaired sensation or numbness. The pulse would not be identified, even with a Doppler. In contrast, the nurse would find edema, erythema, and increased warmth in the presence of a venous occlusion (deep vein thrombosis). Capillary refill would be greater than 3 seconds in an arterial occlusion and less than 3 seconds with a venous occlusion.

A nurse is discussing healthy lifestyle practices with a client who has chronic venous insufficiency. Which practices should be emphasized with this client? Select all that apply. a. avoid eating an excess of dark green vegetables b. elevate the legs while sitting c. wear elastic stockings (TEDS) daily, applying them before getting out of bed d. increase standing time and shift weight from one leg to the other when standing in one place e. sleep with legs elevated above the level of the heart

ANS: B, C, E

A nurse is assessing a 6-year-old child newly diagnosed with acute lymphocytic leukemia (ALL). Which assessment findings should the nurse expect based on the child's diagnosis? Select all that apply. a. Alopecia b. Petechia c. Anorexia d. Insomnia e. Bleeding gums f. Pallor

ANS: B, C, E, F

Which clinical finding should the nurse expect in a person with an acute lower extremity VTE? (Select all that apply) a. pallor and coolness of foot and calf b. mild to moderate calf pain and tenderness c. grossly decreased or absent pedal pulses d. unilateral edema and induration of the thigh e. palpable cord along a superficial varicose vein

ANS: B, D

The nurse suspects a patient is experiencing manifestations of Hodgkin's disease. Which are characteristics of this health disorder? (Select all that apply.) a. Visual changes occur. b. It is the most curable of all lymphomas. c. Skeletal pain is a common symptom. d. It is distinguished by the presence of Reed-Sternberg cells. e. Painless swelling of cervical, axillary, or inguinal nodes occurs. f. It is distinguished by the presence of Philadelphia chromosome.

ANS: B, D, E Hodgkin's disease is a lymphoma, which is a cancer of the lymph system. Its distinguishing feature is Reed-Sternberg cells, which make it different from all the other forms of lymphoma. Of all the lymphomas, Hodgkin's disease is the most curable type, even when the disease is widely spread at the time of diagnosis. Painless swelling in one or more of the common lymph node chains is a usual presentation. Swelling can range from barely perceptible to the size of a softball, occasionally even larger. F. Chronic myelogenous leukemia is characterized by the Philadelphia chromosome. C. Skeletal pain is a symptom of leukemias and multiple myeloma. A. Visual changes are associated with PV.

A client with leukemia asks a nurse to explain how donor cells are obtained for peripheral blood stem cell transplantation (PBSCT). Which statement by the nurse is correct? a. "A large amount of bone marrow tissue is harvested from a donor's hip bone under general anesthesia in the operating room." b. "Stem cells are collected from the donor's blood, which goes through a machine, removes the stem cells, and then returns the blood back to the donor." c. "Stem cells are collected from a donor through a process called apheresis, which removes the stem cells from the blood. This typically takes 10 to 15 minutes. d. "Stem cells are obtained similar to other blood donations, where the blood is collected and then administered to you immediately following collection."

ANS: Bq

A 31-year-old male client seeks care at a vascular clinic because of painful fingers and toes. He is diagnosed with Buerger's disease (thromboangiitis obliterans). A nurse is teaching the client ways to prevent progression of the disease. Which prevention measure should be the nurse's initial focus when teaching the client? a. avoiding exposure to cold b. maintaining meticulous hygiene practices c. abstaining from all tobacco products in all forms d. following a low-fat diet

ANS: C

A 47 year old male patient is admitted to the hospital with a blood pressure of 240/118 accompanied by confusion and stupor. He has been taking clonidine (Catapres) and hydrochlorothiazide (HCTZ) for several years for management of his hypertension. His wife is 32 years old and looks more like 25. The patient is to be started on amlodipine (Norvasc). The patient is taught not to consume _________ while he is on this drug because of significant interactions. a. apple juice b. orange juice c. grapefruit juice d. cranberry juice

ANS: C

A 47 year old male patient is admitted to the hospital with a blood pressure of 240/118 accompanied by confusion and stupor. He has been taking clonidine (Catapres) and hydrochlorothiazide (HCTZ) for several years for management of his hypertension. His wife is 32 years old and looks more like 25. The patient needs a more potent diuretic because of increased intravascular fluid accumulation and is placed on furosemide (Lasix) instead of the HCTZ. In order to monitor the effectiveness of this therapy, the nurse initiates a. blood pressure every hour b. a high sodium diet for patient c. intake and output d. weekly weight

ANS: C

A 62-year-old woman weighs 92 kg and has a history of daily alcohol intake, smoking, HTN, high Na+ intake, and sedentary lifestyle. The nurse identifies the risk factors most highly related to peripheral atherosclerosis in this patient as a. sex and age b. weight and alcohol intake c. cigarette smoking and HTN d. sedentary lifestyle and high Na+ diet

ANS: C

A 77-year-old client is diagnosed with an abdominal aortic aneurysm measuring 3.5 cm, which was discovered on a routine health physical. The client has a 30 pack-year history of cigarette smoking. Which learning need should a nurse identify as most important for this client? a. Understand the importance and begin the process of smoking cessation b. Understand and follow a reduced-sodium and low-saturated fat diet c. Follow through with medical supervision so the size of the aneurysm can be monitored at regular intervals d. Verbalize understanding of preoperative and postoperative care following surgical repair of the aneurysm

ANS: C

A client has an automatic blood pressure cuff and the same number is displayed for 11 hours of a 12-hour shift. A nurse documents the reading, thinking it is a new blood pressure measurement each hour. When the nurse working the next shift takes the client's blood pressure, the client is hypotensive. The nurse manager speaks with the nurse about the event and concludes that the nurse failed to assess the client's blood pressure (BP) for 11 hours of a 12-hour shift. Due to a similar event with a new nurse, the standards and protocols were reviewed with all nurses at a required department meeting the previous week. Which intervention by the nurse manager with the involved nurse is most appropriate? a. Terminating the nurse's employment immediately b. Reviewing the operation of the blood pressure machine with the nurse c. Providing the nurse with a notice of intent to terminate if further incidents occur d. Informing the nurse of the unsafe action and expectations related to BP assessment

ANS: C

A client is taking metolazone (Zaroxolyn) and diltiazem (Cardizem) for treatment of hypertension. A home health nurse is reviewing the medications with the client. Which client statement indicates that the client needs teaching about these medications? a. "I make sure that I eat foods high in potassium every day." b. "Because metolazone makes me urinate more, I take my last dose at suppertime." c. "I take my medications with a healthy breakfast of eggs, toast, grapefruit juice, and milk." d. "Because ibuprofen (Motrin) seems to affect my urine output, I prefer to take acetaminophen (Tylenol) for pain."

ANS: C

A client, following a total hip replacement, asks a nurse why she is receiving enoxaparin (Lovenox) for prevention of deep vein thrombosis (DVT) when, with her last hip surgery, she received heparin subcutaneously. What is the nurse's best response? a. "Enoxaparin is less expensive and easier to administer than heparin." b. "There is less risk of bleeding with enoxaparin, and it doesn't affect your laboratory results." c. "Enoxaparin is a low-molecular-weight heparin that lasts twice as long as regular heparin." d. "Enoxaparin can be administered orally whereas heparin is only administered by injection."

ANS: C

A hospitalized client has been receiving clonidine (Catapres) 0.1 mg via transdermal patch once every 7 days. When bathing the client, a nursing assistant removes the patch thinking it is tape. Eight hours later, an oncoming nurse discovers that the transdermal patch is no longer on the client as prescribed. Based on this information, which assessment finding should be most concerning to the nurse? a. Skin tear noted on the client's upper chest b. Excruciating headache reported c. Blood pressure is 182/100 mm Hg d. Electrocardiogram shows a heart rate of 120 beats per minute

ANS: C

A nurse in the postanesthesia care unit (PACU) is monitoring a client who has had a repair of an aortic aneurysm with graft surgery. The nurse is unable to palpate the posterior tibial pulse of one leg that was palpable 15 minutes earlier. The most appropriate initial action for the nurse is to a. recheck the pulse in 15 minutes b. reposition the leg c. notify the surgeron d. remove the surgical dressing

ANS: C

A nurse is caring for a client who has 0.9% NaCl infusing intravenously (IV). An order had been written the previous day to change the IV solution to 0.9% NaCl with 10 mEq KCL. Which action should the nurse initiate first? a. Notify the client's physician b. Complete an incident report c. Check the client's serum potassium level d. Replace 0.9% NaCl with the ordered solution

ANS: C

A nurse is observing a nursing student administer a clonidine (Catapres) transdermal patch to a client diagnosed with hypertension. Which action requires the nurse to intervene? a. Applies gloves b. Asks the client to state name and also checks the client's name band c. Applies patch, rubbing the patch against the skin, and then securing in place d. Folds old patch with medication to the inside and discards in a medication disposal receptacle

ANS: C

A nurse is observing a nursing student administering a clonidine (Catapres) transdermal patch to a client diagnosed with hypertension. Which action requires the nurse to intervene? a. Applies gloves b. Asks the client to state name and also checks the client's name band c. Applies patch, rubbing the patch against the skin, and then securing it in place d. Folds old patch with medication to the inside and discards in a medication disposal receptacle

ANS: C

A nurse notes the illustrated skin changes on the arm of a client who is 19 days post autologous peripheral blood stem-cell transplantation (PBSCT) for treatment of non-Hodgkin's lymphoma (NHL). A nurse notifies the physician, suspecting that the client is most likely experiencing a. Herpes zoster b. A peripherally inserted central catheter (PICC) line infection c. Graft-versus-host disease (GVHD) d. An allergic reaction to a medication

ANS: C

A patient has been receiving warfarin (Coumadin) 5 mg for 6 days; the patient's protime (PT) is 16.4 with a control of 12.5. The physician orders an increase to 10 mg of warfarin (Coumadin) daily, when would you expect to see a change in the patient's protime (PT)? a. the day following the increase b. the 2nd day following the increase c. the 3rd day following the increase d. the 4th day following the increase

ANS: C

A patient is taking four antihypertensives. Which of the following instructions is significant for the nurse to instruct a. expect urine color changes b. avoid cold temperatures c. change position slowly d. avoid eating aged cheese

ANS: C

A patient with a head injury develops SIADH. Manifestations the nurse would expect to find include a. hypernatremia and edema b. muscle spasticity and hypertension c. low urine output and hyponatremia d. weight gain and decreased glomerular filtration rate

ANS: C

An EKG is ordered for a long-standing hypertensive patient. The most important reason behind the ordering of this test is to a. put a copy on the chart b. detect valvular disease c. detect left ventricular hypertrophy or ischemia d. detect the length of time the patient has been off medications

ANS: C

An EKG is ordered for a long-standing hypertensive patient. The most important reason behind the ordering of this test is to a. put a copy on the chart b. detect valvular diseases c. detect left hypertrophy or ischemia d. detect the length of time the patient has been off medications

ANS: C

An EKG is ordered for a long-standing hypertensive patient. The most important reason behind the ordering of this test is to a. put a copy on the chart b. detect valvular diseases c. detect left ventricular hypertrophy or ischemia d. detect the length of time the patient has been off medications

ANS: C

An error occurs and an admission order for a client to be on a venous thromboembolic protocol is not processed. Two days later, a nurse notices the omitted order for heparin 5,000 units subcutaneous every 8 hours. Which statement describes appropriate follow-up? a. "I am so glad I didn't make that mistake, that other nurse is going to be in trouble." b. "I am too busy to complete a variance report. I'll do it next week." c. "I need to contact the physician and complete a variance report." d. "I will contact the supervisor immediately about this error."

ANS: C

An important preoperative nursing intervention before an adrenalectomy for hyperaldosteronism is to a. monitor blood glucose levels b. restrict fluid and sodium intake c. administer potassium-sparing diuretics d. advise the patient to make postural changes slowly

ANS: C

Idiopathic Thrombocytopenic Purpura (ITP) is the most common form of thrombocytopenia. It is the result of: a. decreased vitamin K absorption b. deficiency of factor IX c. decreased platelet count d. deficiency of factor VIII

ANS: C

Mr. Zinfandel, a 72-year-old retired banker, found a pulsating mass in his abdomen. An x-ray revealed an abdominal aortic aneurysm and he was admitted for surgery. A graft was inserted and he was transferred to ICU post-operatively. The nurse assess him for maintenance of optimal circulation. Which one of the following findings during a post-surgical physical assessment is significant? a. Warm, blanching toes b. Blood pressure of 110/60 c. Absence of popliteal pulse d. Urine output of 50 mL/hour

ANS: C

One of the interventions the nurse can utilize in the management of Buerger's disease is to a. immerse the patient's hands in cold water for 10-15 minutes every morning b. instruct the patient to perform Range of Motion exercises TID c. encourage the patient to stop smoking d. encourage the

ANS: C

The effects of warfarin (Coumadin) can be reversed with a. prothrombin b. platelets c. vitamin K d. protamine sulfate

ANS: C

The home healthcare nurse is talking on the telephone to a male client diagnosed with hypertension and hears the client sneezing. The client tells the nurse that he has been blowing his nose frequently. Which question should the nurse ask the client? a. "Have you had the flu shot in the last two (2) weeks?" b. "Are there any small children in the home?" c. "Are you taking over-the-counter medicine for these symptoms?" d. "Do you have any cold sores associated with your sneezing?"

ANS: C

The most common initial symptom associated with pulmonary embolism is a. cyanosis b. agitation c. chest pain d. bradycardia

ANS: C

The patient has acute myelogenous leukemia (AML). Both she and her family are fearful over the potential of her death. The nurse selects a nursing diagnosis of anticipatory grieving. The nursing intervention that will support the patient's and her family in their grieving process is to a. avoid discussing their feelings with them until they have had time to adjust to the diagnosis b. encourage them to keep themselves busy with unrelated activities c. encourage them to talk about the meaning of loss for each person d. point out their behaviors to them and explain the grief process

ANS: C

What are the priority nursing interventions 8 hours after an abdominal aortic aneurysm repair? a. assessing nutritional status and dietary preferences b. initiating IV heparin and monitoring anticoagulation c. administering IV fluids and watching kidney function d. elevating the legs and applying compression stockings

ANS: C

What is the first priority of interprofessional care for a patient with a suspected acute aortic dissection? a. reduce anxiety b. monitor chest pain c. control blood pressure d. increase myocardial contractility

ANS: C

When teaching a patient with hypoparathyroidism about the disorder, the nurse explains that blood calcium levels are altered because the role of parathyroid hormone is to a. block phosphorus excretion by the kidneys, which decreases the blood calcium level because calcium and phosphorus are reciprocal b. promote magnesium excretion by the kidney, which raises blood calcium levels c. stimulate bone reabsorption and increase the calcium in the blood when blood calcium levels fall d. stimulate the cells of the gastrointestinal tract to absorb dietary calcium, raising the blood leve;

ANS: C

The nurse is assigned to care for several patients on a medical unit. Which patient should the nurse assess first? a. A 60-yr-old patient with a blood pressure of 92/64 mm Hg and hemoglobin of 9.8 g/dL b. A 50-yr-old patient with a respiratory rate of 26 breaths/minute and an elevated D-dimer c. A 40-yr-old patient with a temperature of 100.8°F (38.2°C) and a neutrophil count of 256/µL d. A 30-yr-old patient with a pulse of 112 beats/min and a white blood cell count of 14,000/µL

ANS: C A low-grade fever greater than 100.4° F (38° C) in a patient with a neutrophil count below 500/µL is a medical emergency and may indicate an infection. An infection in a neutropenic patient could lead to septic shock and possible death if not treated immediately.

A 62-yr-old patient who has no history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that: a. a BP recheck should be scheduled in a few weeks. b. dietary sodium and fat content should be decreased. c. diagnosis, treatment, and monitoring will be needed. d. there is danger of a stroke, requiring hospitalization.

ANS: C A sudden increase in BP in a patient older than age 50 years with no hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP. Reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.

Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/VN)? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Administering subcutaneous filgrastim (Neupogen) injection d. Developing a discharge teaching plan for the patient and family

ANS: C Administration of subcutaneous medications is included in LPN/VN education and scope of practice. Patient teaching, assessment, and developing the plan of care require RN level education and scope of practice.

A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first? a. Observe the dressing for bleeding. b. Check the blood pressure and pulse. c. Assess the patient's respiratory effort. d. Support the patient's head with pillows.

ANS: C Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany. The priority nursing action is to assess the airway. The other actions are also part of the standard nursing care post thyroidectomy but are not as high of a priority.

A patient is being tested for possible leukemia. With which diagnostic test should the nurse anticipate assisting? a. Liver biopsy b. Thoracentesis c. Bone marrow biopsy d. Arterial blood gas analysis

ANS: C Although a simple complete blood count (CBC) often points toward the diagnosis, only bone marrow aspiration can show the extent of proliferation of the malignant WBCs and confirm the diagnosis of leukemia. B. D. Thoracentesis and arterial blood gases diagnose pulmonary problems A. Liver biopsy is used to detect liver cancer.

A nurse is reviewing serum laboratory data for four female clients. Which client would require the most immediate assessment? Client A TSH 5.2 mIU/L, normal 0/4-4.2 mIU/L Client B Growth hormone 23 ug/L, normal 8-18 ug/L Client C Free T4 (thyroxin) 7.0 ng/dL, normal 0.8-2.7 ng/dL Client D Glucose 140 mg/dL, normal 70-110 mg/dL a. Client A b. Client B c. Client C d. Client D

ANS: C An excess of thyroid hormone is the most life-threatening of the findings listed.

After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? a. A 23-yr-old who reports severe fatigue b. A 56-yr-old with frequent explosive diarrhea c. A 33-yr-old with a fever of 100.8° F (38.2° C) d. A 66-yr-old who has white pharyngeal lesions

ANS: C Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not have symptoms of potentially life-threatening problems.

The nurse is caring for a patient admitted with chronic obstructive pulmonary disease (COPD), angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assesses the patient carefully. Which adverse effect is this patient at risk for given the patient's health history? a. Hypocapnia b. Tachycardia c. Bronchospasm d. Nausea and vomiting

ANS: C Atenolol is a cardioselective β1-adrenergic blocker that reduces blood pressure and could affect the β2-receptors in the lungs with larger doses or with drug accumulation. Although the risk of bronchospasm is less with cardioselective β-blockers than nonselective β-blockers, atenolol should be used cautiously in patients with COPD.

A patient with multiple myeloma becomes confused and lethargic. The nurse would expect that these clinical manifestations may be explained by diagnostic results that indicate: A. hyperkalemia B. hyperuricemia C. hypercalcemia D. CNS myeloma

ANS: C Bone degeneration in multiple myeloma causes calcium loss from bones, which eventually results in hypercalcemia. Hypercalcemia may cause renal, gastrointestinal, or neurologic manifestations, such as polyuria, anorexia, or confusion, and heart problems.

A patient has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe. What should the nurse expect to find on assessment? a. Dilated superficial veins. b. Swollen, dry, scaly ankles. c. Prolonged capillary refill in all the toes. d. Serosanguineous drainage from the ulcer.

ANS: C Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease.

The nurse is providing care for a patient who has had a splenectomy. Which nursing action has the highest priority? a. Assess pain every shift. b. Provide a diet rich in fruits and vegetables. c. Teach the patient to cough and deep breathe every hour. d. Encourage the patient to look at the incision during dressing changes.

ANS: C Coughing and deep breathing will mobilize secretions and help prevent respiratory infection. Patients are at risk for serious infection following splenectomy. A. Pain should be assessed more frequently than every shift. D. Body image changes are considered a lower priority than the physical risk of respiratory infection. B. Fruits and vegetables are a good idea but will not directly prevent infection.

A 54-year-old patient is admitted to the hospital in the final stage of chronic lymphocytic leukemia (CLL). Which manifestations of CLL should the nurse expect to find while collecting admission data? a. Nausea and vomiting b. Hypotension and alopecia c. Fever and abnormal bleeding d. Cervical lymphadenopathy and chest pain

ANS: C During the acute phase of CLL, the patient may exhibit high fevers from infection and ecchymosis or petechiae from thrombocytopenia. A. B. Nausea, vomiting, and alopecia are side effects of chemotherapy. D. Lymphadenopathy and chest pain are not generally associated with leukemia.

A 46-yr-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions should the nurse provide to the patient before discharge? a. Sitting at the work counter, rather than standing, is recommended. b. Exercise, such as walking or jogging, can cause recurrence of varicosities. c. Elastic compression stockings should be applied before getting out of bed. d. Taking an aspirin daily will help prevent clots from forming around venous valves.

ANS: C Elastic compression stockings are applied with the legs elevated to reduce pressure in the lower legs. Walking is recommended to prevent recurrent varicosities. Sitting and standing are both risk factors for varicose veins and venous insufficiency. An aspirin a day is not adequate to prevent venous thrombosis and would not be recommended for a patient who had just had sclerotherapy.

What should be included in the interprofessional plan of care for a patient with Cushing disease? a. Lab monitoring for hyperkalemia b. Vital sign monitoring for hypotension c. Counseling related to body image changes d. Diet consultation to determine low protein choices

ANS: C Elevated corticosteroid levels can cause body changes, including truncal obesity, moon face, and hirsutism in women and gynecomastia in men. Counseling and support should be offered because of the changes in body image. Hypokalemia and hypertension are consistent with Cushing disease. Sodium restriction and potassium supplementation are indicated. High-protein choices are necessary to counteract catabolic processes and assist with wound healing.

A postoperative patient asks the nurse why the provider ordered daily administration of enoxaparin (Lovenox). Which reply by the nurse is accurate? a. "This medication will help prevent breathing problems after surgery, such as pneumonia." b. "This medication will help lower your blood pressure to a safer level, which is very important after surgery." c. "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." d. "This medication is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table."

ANS: C Enoxaparin is an anticoagulant that is used to prevent DVTs postoperatively. All other options do not describe the action or purpose of enoxaparin.

After the nurse teaches the patient with stage 1 hypertension about diet modifications, which diet choice indicates that the teaching has been most effective? a. The patient avoids eating nuts or nut butters. b. The patient restricts intake of chicken and fish. c. The patient drinks low-fat milk with each meal. d. The patient has two cups of coffee in the morning.

ANS: C For the prevention of hypertension, the Dietary Approaches to Stop Hypertension (DASH) recommendations include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not part of the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.

A college health nurse is providing education to a student athlete who is diagnosed with infectious mononucleosis. The student asks, "Will I be able to play soccer after I rest up for a few weeks?" Which should be the best response by the nurse? a. "You may not be physically active for 2 to 3 months." b. "You may be as active as you wish as long as you are not feeling fatigued." c. "You should not engage in activities in which you may receive a blow to the abdomen." d. "There are no limitations on activity with this diagnosis."

ANS: C Hepatosplenomegaly is a potential complication of infectious mononucleosis, which is caused by the Epstein-Barr virus (EBV).

Which information is most important for the nurse to include when teaching a patient newly diagnosed with hypertension? a. Most people are able to control BP through dietary changes. b. Annual BP checks are needed to monitor treatment effectiveness. c. Hypertension is usually asymptomatic until target organ damage occurs. d. Increasing physical activity controls blood pressure (BP) for most people.

ANS: C Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes (e.g., physical activity, dietary changes) are used to help manage BP, but drugs are needed for most patients. Home BP monitoring should be taught to the patient and findings checked by the health care provider frequently when starting treatment for hypertension and then every 3 months when stable.

The health care provider prescribes an infusion of heparin and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). Which action should the nurse include in the plan of care? a. Obtain a Doppler for monitoring bilateral pedal pulses. b. Decrease the infusion when the PTT value is 65 seconds. c. Avoid giving IM medications to prevent localized bleeding. d. Have vitamin K available in case reversal of the heparin is needed.

ANS: C Intramuscular injections are avoided in patients receiving anticoagulation to prevent hematoma formation and bleeding from the site. A PTT of 65 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE.

The nurse who works in the vascular clinic has several patients with venous insufficiency. Which patient should the nurse assign to an experienced licensed practical/vocational nurse (LPN/VN)? a. Patient who has a history of venous thromboembolism and reports dyspnea. b. Patient who has been reporting increased edema and skin changes in the legs. c. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg. d. Patient who needs teaching about compression stockings for venous insufficiency

ANS: C LPN education and scope of practice includes wound care. The other patients, which require more complex assessments or education, should be managed by the RN.

When teaching how lisinopril (Zestril) will help lower the patient's blood pressure, which mechanism of action should the nurse explain? a. Blocks β-adrenergic effects. b. Relaxes arterial and venous smooth muscle. c. Inhibits conversion of angiotensin I to angiotensin II. d. Reduces sympathetic outflow from central nervous system

ANS: C Lisinopril is an angiotensin-converting enzyme inhibitor that inhibits the conversion of angiotensin I to angiotensin II, which reduces angiotensin II-mediated vasoconstriction and sodium and water retention. β-Blockers result in vasodilation and decreased heart rate. Direct vasodilators relax arterial and venous smooth muscle. Central-acting α-adrenergic antagonists reduce sympathetic outflow from the central nervous system to produce vasodilation and decreased systemic vascular resistance and blood pressure.

When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider? a. Presence of flatus b. Hypoactive bowel sounds c. Maroon-colored liquid stool d. Abdominal pain with palpation

ANS: C Loose, bloody (maroon-colored) stools at this time may indicate intestinal ischemia or infarction and should be reported immediately because the patient may need an emergency bowel resection. The other findings are normal on the first postoperative day after abdominal surgery.

Which information will the nurse teach a patient who has been newly diagnosed with Graves' disease? a. Exercise is contraindicated to avoid increasing metabolic rate. b. Restriction of iodine intake is needed to reduce thyroid activity. c. Antithyroid medications may take several months for full effect. d. Surgery will eventually be required to remove the thyroid gland.

ANS: C Medications used to block the synthesis of thyroid hormones may take 2 to 3 months before the full effect is seen. Large doses of iodine are used to inhibit the synthesis of thyroid hormones. Exercise using large muscle groups is encouraged to decrease the irritability and hyperactivity associated with high levels of thyroid hormones. Radioactive iodine is the most common treatment for Graves' disease, although surgery may be used.

The nurse is aware that a major difference between Hodgkin's lymphoma and non-Hodgkin's lymphoma is that a. Hodgkin's lymphoma occurs only in young adults b. Hodgkin's lymphoma is considered potentially curable c. Non-Hodgkin's lymphoma can manifest in multiple areas d. Non-Hodgkin's lymphoma is treated only with radiation therapy

ANS: C Most patients with Non-Hodgkin's have widely disseminated disease at the time of diagnosis.

Which assessment findings for a client who is status post-thyroidectomy should direct a nurse to check the client's serum calcium level? a. fatigue, decreased cardiac function, and tetany b. weakness, tachycardia, and disorientation c. muscle cramps, paresthesia, and trousseau's sign d. weakness, edema, and orthostatic hypotension

ANS: C Muscle cramps, paresthesia, and a positive trousseau's sign are common manifestations of hypo- or hypercalcemia because of the irritation to the neuromuscular system.

Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a. Report of right calf pain b. Erythema of right lower leg c. New onset shortness of breath d. Temperature of 100.4° F (38° C)

ANS: C New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as O2 administration and notification of the health care provider. The other findings are typical of VTE.

The nurse teaches a 28-yr-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which patient statement requires reinforcement of teaching? a. "I will avoid adding salt to my food during or after cooking." b. "If I lose weight, I might not need to continue taking medications." c. "I can lower my blood pressure by switching to smokeless tobacco." d. "Diet changes can be as effective as taking blood pressure medications."

ANS: C Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (e.g., the DASH diet) lowers blood pressure, and these decreases compare with those achieved with blood pressure-lowering medication.

A patient is being admitted with a diagnosis of Cushing syndrome. Which finding will the nurse expect during the assessment? a. Chronically low blood pressure b. Bronzed appearance of the skin c. Purplish streaks on the abdomen d. Decreased axillary and pubic hair

ANS: C Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison's disease. Decreased axillary and pubic hair occur with androgen deficiency.

A patient is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. Which assessment finding would indicate to the nurse that the medication is effective? a. Improved skin turgor b. Decreased cardiac rate c. Improved finger perfusion d. Decreased mean arterial pressure

ANS: C Raynaud's phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes. Diltiazem (Cardizem) is a calcium channel blocker that relaxes smooth muscles of the arterioles by blocking the influx of calcium into the cells, thus reducing the frequency and severity of vasospastic attacks. Perfusion to the fingertips is improved, and vasospastic attacks are reduced. Diltiazem may decrease heart rate and blood pressure, but that is not the purpose in Raynaud's phenomenon. Skin turgor is most often a reflection of hydration status.

A young adult patient tells the health care provider about experiencing cold, numb fingers and Raynaud's phenomenon is suspected. What type of testing should the nurse anticipate explaining to the patient? a. Hyperglycemia b. Hyperlipidemia c. Autoimmune disorders d. Coronary artery disease

ANS: C Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis. Patients should be screened for autoimmune disorders. Raynaud's phenomenon is not associated with hyperlipidemia, hyperglycemia, or coronary artery disease.

A patient with Hodgkin's disease has cervical lymph node enlargement. Which symptom should the nurse attend to first? a. Pain b. Fever c. Stridor d. Fatigue

ANS: C Stridor indicates airway involvement due to enlarged lymph nodes. Airway is always a priority, as airway compromise is life-threatening. A. B. D. Fever, fatigue, and pain are important but should be addressed only once the airway is open

A patient with Hodgkin's disease has cervical lymph node enlargement. Which symptom should the nurse attend to first? A pain B fever C stridor D. fatigue

ANS: C Stridor indicates airway involvement due to enlarged lymph nodes. Airway is always a priority, as airway compromise is life-threatening. A. B. D. Fever, fatigue, and pain are important but should be addressed only once the airway is open.

Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE) indicates that the nurse needs further education about the drug? a. The nurse avoids rubbing the site after giving the injection. b. The nurse injects the drug into the abdominal subcutaneous tissue. c. The nurse ejects the air bubble from the syringe before giving the drug. d. The nurse does not check partial thromboplastin time (PTT) before giving the drug.

ANS: C The air bubble is not ejected before giving fondaparinux to avoid loss of drug. The other actions by the nurse are appropriate for subcutaneous administration of a low-molecular-weight heparin (LMWH). LMWHs typically do not require ongoing PTT monitoring and dose adjustment.

A patient diagnosed with hypertension has been prescribed captopril. Which information is most important to teach the patient about this drug? a. Include high-potassium foods such as bananas in the diet. b. Increase fluid intake if dryness of the mouth is a problem. c. Change position slowly to help prevent dizziness and falls. d. Check the blood pressure in both arms before taking the drug.

ANS: C The angiotensin-converting enzyme (ACE) inhibitors often cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the drug. The patient is taught to use gum or hard candy to relieve dry mouth. The BP should be taken in the nondominant arm by newly diagnosed patients in the morning, before taking the drug, and in the evening. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.

The client in the intensive care department is receiving 2 mcg/kg/min of dopamine, an inotropic vasopressor. Which intervention should the nurse include in the plan of care? a. monitor the client's blood pressure every two (2) hours b. assess the client's peripheral pulses every shift c. use a urometer to assess hourly output d. ensure that the IV tubing is not exposed to the light

ANS: C The client's urine output should be monitored because low-dose dopamine is administered to maintain renal perfusion; higher doses can cause vasoconstriction of the renal arteries.

A patient who smokes reports having significant stress and has some eye problems. On assessment, the nurse notes exophthalmos. What additional abnormal findings should the nurse assess for? a. Muscle weakness and slow movements b. Puffy face, decreased sweating, and dry hair c. Systolic hypertension and increased heart rate d. Decreased appetite, increased thirst, and pallor

ANS: C The manifestations are consistent with Graves' disease or hyperthyroidism. Systolic hypertension, increased heart rate, and increased thirst are associated with hyperthyroidism. Cigarette smoking places the patient at increased risk for Graves' disease. The inhaled cigarette toxins may absorb via the eye orbits, causing exophthalmos. A puffy face; decreased sweating; dry, coarse hair; muscle weakness and slow movements; decreased appetite; and pallor are all manifestations of hypothyroidism.

During change-of-shift report, the nurse obtains the following information about a hypertensive patient who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention? a. The patient's pulse has dropped from 68 to 57 beats/min. b. The patient reports that the fingers and toes feel quite cold. c. The patient has developed wheezes throughout the lung fields. d. The patient's blood pressure (BP) reading is now 158/92 mm Hg.

ANS: C The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the noncardioselective B-blockers) is occurring. The nurse should immediately obtain an O2 saturation measurement, apply supplemental O2, and notify the health care provider. The mild decrease in heart rate and cold fingers and toes are associated with B-receptor blockade but do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated. However, this is not as urgently needed as addressing the bronchospasm.

A patient with a history of chronic hypertension is being evaluated in the emergency department for a blood pressure of 200/140 mm Hg. Which patient assessment question is the priority? a. Is the patient pregnant? b. Does the patient need to urinate? c. Does the patient have a headache or confusion? d. Is the patient taking antiseizure medications as prescribed?

ANS: C The nurse's priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensive encephalopathy from increased cerebral capillary permeability leading to cerebral edema. In addition, headache or confusion could represent signs and symptoms of a hemorrhagic stroke. Pregnancy can lead to secondary hypertension. Needing to urinate and taking anti seizure medication do not support a hypertensive emergency.

A patient is being treated for non-Hodgkin's lymphoma (NHL). What should the nurse first teach the patient about the treatment? a. Skin care that will be needed b. Method of obtaining the treatment c. Treatment type and expected side effects d. Gastrointestinal tract effects of treatment

ANS: C The patient should first be taught about the type of treatment and the expected and potential side effects. Nursing care is related to the area affected by the disease and treatment. Skin care will be affected if radiation is used. Not all patients will have gastrointestinal tract effects of NHL or treatment. The method of obtaining treatment will be included in the teaching about the type of treatment.

A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the provider to save the patient's limb? a. Paralysis b. Cramping c. Paresthesia d. Referred pain

ANS: C The provider must be notified immediately if any of the six Ps of acute arterial ischemia occur to prevent ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being a very late sign indicating the death of nerves to the extremity. Crampy leg sensation is more common with varicose veins. The pain is not referred. Paresthesia refers to a burning or prickling sensation that is usually felt in the hands, arms, legs, or feet, but can also occur in other parts of the body.

The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose? a. Hematocrit (Hct) b. Hemoglobin (Hgb) c. Prothrombin time (PT) d. Activated partial thromboplastin time (aPTT)

ANS: C Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of warfarin (Coumadin) and thus decreases the risk of bleeding. High values for either the PT or the international normalized ratio demonstrate the need for this medication.

The nurse is caring for a patient who has been receiving warfarin (Coumadin) and diltiazem (Cardizem) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? a. Decreased cardiac output b. Increased blood pressure c. Cerebral or pulmonary emboli d. Excessive bleeding from incision or IV sites

ANS: C Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. When the medication is terminated, thrombi could again form. If one or more thrombi detach from the atrial wall, they could travel as cerebral emboli from the left atrium or pulmonary emboli from the right atrium.

A patient is planning to have an allogeneic bone marrow transplant. What will the patient most likely have completed before this transplant occurs? (Select all that apply.) a. Electrophoresis b. Peritoneal dialysis c. Total body irradiation d. High-dose chemotherapy e. Massive blood transfusions

ANS: C, D Preparation for bone marrow transplant includes high-dose chemotherapy and/or total body irradiation. The goal is to destroy all of the patients malignant bone marrow and then, at the last possible moment, replace it with a donors clean and healthy bone marrow. A. Electrophoresis is a treatment to remove impurities from the bloodstream. B. Peritoneal dialysis is a treatment for chronic renal failure. E. Massive blood transfusions are not indicated prior to bone marrow transplant.

A client had a PTCA with stent placement. Nursing care that can be delegated to the unlicensed assistive personnel (UAP) after the procedure includes (Select all that apply) a. assessing the distal pulses every 15-30 minutes. b. calling for an ECG immediately if the client has angina. c. monitoring vital signs every 15-30 minutes. d. providing the client with plenty of fluids to drink. e. reminding the client to remain flat in bed.

ANS: C, D, E

A 47 year old male patient is admitted to the hospital with a blood pressure of 240/118 accompanied by confusion and stupor. He has been taking clonidine (Catapres) and hydrochlorothiazide (HCTZ) for several years for management of his hypertension. His wife is 32 years old and looks more like 25. In order to control his blood pressure, the patient has control of all of the following risk factors for HTN except: a. sedentary lifestyle b. stress c. obesity d. race

ANS: D

A client has an appointment at a vascular clinic after being treated with pentoxifylline (Trental) for 6 weeks. A nurse determines the pentoxifylline has been effective by noting that the client a. has a decrease in lower extremity edema b. is experiencing less symptoms of withdrawal after quitting smoking c. has a venous ulcer on the ankle that has decreased in size and depth d. is able to walk a greater distance without claudication

ANS: D

A client seeks medical attention because of pain that develops while walking. An ankle-brachial index (ABI) test is ordered; and the results show that the client has ratios of 1.4 and 1.3 bilaterally. Based on these results, a nurse determines that the client a. has severe peripheral arterial disease b. would benefit from the medication ticlopidine hydrochloride (Ticlid) c. is experiencing pain that is psychological in origin d. needs further medical consultation to determine the cause of pain

ANS: D

A client taking medication for treatment of essential hypertension has a serum potassium level of 3.2 mEq/L. A nurse is reviewing the list of medications being taken by the client. Which medication on the list should the nurse conclude to be the causative factor for this serum potassium level? a. Spironolactone b. Potassium chloride c. Enalapril d. Hydrochlorothiazide

ANS: D

A client tests positive for factor V Leiden (FVL). A nurse recognizes that because the genetic trait is associated with venous thromboembolism (VTE) the client is a. also at a greater risk for myocardial infarction b. more likely to be of African American heritage c. at risk for premature death d. at risk for VTE is taking estrogen as an oral contraceptive or hormone replacement

ANS: D

A hospitalized child diagnosed with leukemia is being discharged after an initial treatment with chemotherapy. A nurse is teaching the parents about the allopurinol (Zyloprim), which the child will continue to take at home. The nurse explains that the purpose of this medication is to a. help promote the child's sleep b. treat the joint pain and swelling caused by the child's gout c. prevent the child from developing gouty arthritis d. protect the child's kidneys by reducing the formation of uric acid

ANS: D

A nurse admits a client to a hospital and obtains a nursing history. The client tells the nurse that he had an endovascular repair of an abdominal aortic aneurysm found 1 year earlier during a routine screening. The nurse understands that this procedure consists of a. excision of the aneurysm and placement of a graft percutaneously b. an angioplasty with placement of a stent around the outside of the aorta c. placement of a filter within the aneurysm to block clots from becoming emboli d. placement of a stent graft inside the aorta that excludes the aneurysm from circulation

ANS: D

A nurse is administering medications to a pediatric client with hypertension. Which oral antihypertensive medication ordered for a child should the nurse question? a. ACE inhibitor b. Calcium channel blocker c. Diuretic d. Nitrate

ANS: D

A nurse is caring for a client who has been repeatedly hospitalized in hypertensive crisis for failing to take prescribed antihypertensive medications. The client states, "I stop taking the blood pressure medication when my blood pressure is okay because I can't afford the medications." Which nursing diagnosis is the best for the nurse to include in the client's plan of care? a. Knowledge deficit related to medication actions b. Ineffective health maintenance related to repeated hospital admissions c. Ineffective therapeutic regimen management related to poor blood pressure control d. Noncompliance related to the cost of medications

ANS: D

A nurse suspects that a 10-year-old client diagnosed with non-Hodgkin's lymphoma (NHL) has superior vena cava syndrome when assessing that the client has a. thrombocytopenia and leukocytosis b. hyperuricemia, hypocalcemia, and hyperphosphatemia c. tingling and paresthesias of the lower extremities and pain on light touch d. cyanosis of the upper chest, neck, face, upper extremity edema, and distended neck veins

ANS: D

A patient is admitted with pulmonary emboli. The most common source of the emboli arises from thrombi in the a. bifurcation of the femoral arteries b. bronchial veins c. left ventricle wall following an MI d. deep veins of the lower legs

ANS: D

A patient who has leukemia was found to have the Philadelphia chromosome present in his genetic studies. Which type of leukemia does this patient have? a. Acute lymphocytic leukemia b. Acute myelogenous leukemia c. Chronic lymphocytic leukemia d. Chronic myelogenous leukemia

ANS: D

A patient, age 40, was admitted with a deep vein thrombophlebitis two days ago. This morning she is complaining of sudden chest pain and difficulty breathing. The nurse finds on assessment - pulse 142, blood pressure 100/50, and respirations of 44. The patient is coughing bloody sputum. Which action by the nurse is most appropriate initially? a. Calm her with emotional support b. Draw arterial blood gasses for immediate analysis c. Administer 10 mg of morphine sulfate IM for the pain d. Elevate the head of the bed, start oxygen, and call the doctor

ANS: D

A physician documents that a client with stage III non-Hodgkin's lymphoma (NHL) is experiencing "B Symptoms". A nurse interprets this to mean that the client has a. bleeding associated with low platelet counts b. a b lymphocyte malignancy and has progressed to an untreatable stage c. symptoms from exposure to a viral infection, such as Epstein-Barr virus d. recurrent fever, drenching night sweats, and an unintentional weight loss of 10% or more

ANS: D

After thyroid surgery, the nurse suspects damage or removal of the parathyroid glands when the patient develops a. muscle weakness and weight loss. b. hyperthermia and severe tachycardia. c. hypertension and difficulty swallowing. d. laryngospasms and tingling in the hands and feet.

ANS: D

An 85-year-old female client seeks medical attention in an emergency department because of her chest pain. She tells a nurse that the chest pain is stabbing through the chest into her back. Her blood pressure is 230/130 mm Hg. The nurse realizes that these findings are most suggestive of a. pulmonary embolism b. subclavian steal syndrome c. acute arterial occlusion d. aortic dissection

ANS: D

During a physical examination, the nurse finds that a patient's thyroid gland cannot be palpated. The nurse interprets this finding as a. insignificant in a patient with elevated T3 and T4 levels b. evidence of an atrophied thyroid gland c. abnormal, and confirmation of the finding by another experienced healthcare professional is necessary d. a normal finding

ANS: D

During the patient's education session, a newly diagnosed hypertensive patient is informed that long term complications of hypertension include all of the following, except: a. retinopathy b. nephropathy c. myocardial hypertrophy d. diabetic neuropathy

ANS: D

If a diabetic hypertensive patient likes the following foods, which group of foods will the nurse encourage the patient to have? a. apples, bacon, sausages, and oranges b. bacon, sausage, cheese, and milk c. bananas, apples, pretzels, canned soups d. bananas, grapes, rice, and pork

ANS: D

Mononucleosis has pathophysiology related to the a. philadelphia chromosome b. Reed-Sternberg cell c. human immunodeficiency virus d. Epstein-Barr virus

ANS: D

Patient had arterial reconstructive surgery and her nurse has selected a nursing diagnosis of Altered Peripheral Tissue Perfusion. What nursing intervention would promote tissue perfusion? a. elevate the foot of the bed 30 degrees if the lower extremity is edematous b. encourage her to perform active ankle and leg exercises every 1-2 hours c. keep the room environment cool at about 70 degrees d. place a pillow under the knee with the arterial reconstruction

ANS: D

Patients with deep vein thrombosis have an increased risk of developing a. thrombophlebitis b. vein rupture c. abdominal bleeding d. pulmonary emboli

ANS: D

Probably the most common reason that patients stop taking antihypertensive medication is a. cost of the medication b. appearance of adverse effects associated with the medication c. loss of contact with the physician d. belief that control of blood pressure means cure

ANS: D

Severe underproduction of thyroxine produces the condition known as a. graves' disease b. cushing's disease c. acromegaly d. myxedema

ANS: D

The characteristic chest pain that accompanies a dissecting aortic aneurysm is a. sharp and intermittent b. dull and constant c. radiates down both arms d. tearing and excruciating

ANS: D

The effects of heparin sodium (Heparin) can be reversed with a. platelets b. prothrombin c. vitamin K d. protamine sulfate

ANS: D

The most common site for formation of thrombi seen in deep vein thrombosis are the deep veins of the a. thigh b. groin area c. abdominal cavity d. calf

ANS: D

The nurse identifies a nursing diagnosis of Risk for Altered Tissue Perfusion related to bypass graft thrombosis for a patient following an abdominal aneurysm repair. An appropriate intervention to prevent this problem in the immediate postoperative period is to a. promote hypotension in the patient to prevent leaking of blood or rupture at the suture site. b. administer IV fluids at a rate to keep the blood pressure within the patient's normal limits. c. maintain the patient's temperature within a normal range to prevent hypermetabolism. d. perform passive range of motion exercises to the lower limbs every hour to promote venous return.

ANS: D

The nurse is planning care and teaching for a patient with venous leg ulcers. What is the most important patient action in healing and control of this condition? a. following activity guidelines b. using moist environment dressings c. taking horse chestnut seed extract daily d. applying graduated compression stockings

ANS: D

The nurse suspects the development of heparin-induced thrombocytopenia and thrombosis syndrome (HITTS) when a patient receiving heparin a. develops a pancytopenia b. has a platelet count of 200,000/mL c. develops a spiking temperature and chills d. has decreasing activated partial thromboplastin times

ANS: D

The patient arrives in the emergency department with a dissecting thoracic aneurysm. The typical clinical manifestations of this emergency situation are a. neck pain that is throbbing and sharp, hoarseness, and stridor b. distended neck veins, edema of the head and neck, and dull throbbing pain c. dull pain with insidious onset with initial blood pressure in the normal ranges d. abrupt, tearing-like pain, syncope, and peripheral pulses diminished or absent

ANS: D

The patient will undergo an arterial graft for an occlusion of his left femoral artery, which is causing intermittent claudication. He is experiencing pain caused by the deprivation of oxygen to the tissues in his left lower leg. What nursing intervention can reduce his pain and prevent vasospasms? a. encourage him to ambulate frequently to keep the blood circulating b. use warm to hot water bottles or electric blankets to keep extremities warm c. allow him to dangle his legs as he feels necessary to improve circulations d. provide him with lightweight socks and cover him with a lightweight blanket

ANS: D

To prevent thrombophlebitis in a patient on complete bed rest, the nursing care plan should include a. dangling the patient's legs over the side of the bed every shift b. massaging the patient's calves briskly every shift c. keep the patient's legs extended and discourage movement d. have the patient tighten and relax leg muscles several times daily

ANS: D

While monitoring a patient's response to heparin therapy, the nurse recalls that anticoagulation therapy CANNOT a. delay the clotting time of the blood b. forestalls the extension of a thrombus once it has formed c. prevent the formation of the thrombus that is already formed d. dissolve the thrombus that has already formed

ANS: D

A patient with leukemia is admitted for severe hypovolemia after prolonged diarrhea. The platelet count is 43,000/µL. It is most important for the nurse to take which action? a. Insert two 18-gauge IV catheters. b. Administer prescribed enoxaparin. c. Monitor the patient's temperature every 2 hours. d. Check stools for presence of frank or occult blood.

ANS: D A platelet count below 150,000/µL indicates thrombocytopenia. Prolonged bleeding from trauma or injury does not usually occur until the platelet counts are below 50,000/µL. Bleeding precautions (e.g., check all secretions for frank and occult blood) are indicated for patients with thrombocytopenia. Injections (including IVs) should be avoided; however, when needed for critical fluids and medications, IV access should be provided through the smallest bore devices that are feasible. Enoxaparin, an anticoagulant administered subcutaneously, is contraindicated in patients with thrombocytopenia. Monitoring temperature would be indicated in a patient with leukopenia.

A nurse is evaluating a client's understanding of teaching about changes to expect following a bone marrow transplant (BMT). Which statement by the client indicates the client misunderstood the expected changes? a. "You can have weight gain from the side effects of your steroid immunosuppressant medications." b. "Sterility can occur from the destruction of your own stem cells with chemotherapy and radiation." c. "Cataracts may develop after total body irradiation." d. "Changes to the mouth include a white, patchy tongue."

ANS: D A white, patchy tongue is a sign of a fungal infection with Candidiasis albicans, and would not be an expected change.

Which risk factor should the nurse focus on when teaching a patient who has a 5-cm abdominal aortic aneurysm? a. Male gender b. Turner syndrome c. Abdominal trauma history d. Uncontrolled hypertension

ANS: D All the factors contribute to the patient's risk, but only hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm.

Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Monitor the quality and presence of the pedal pulses. b. Teach the patient the signs of possible wound infection. c. Check the lower extremities for strength and movement. d. Help the patient to use a pillow to splint while coughing.

ANS: D Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for UAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement should be done by RNs.

Which prescribed medication should the nurse expect will have rapid effects on a patient admitted to the emergency department in thyroid storm? a. Iodine b. Methimazole c. Propylthiouracil d. Propranolol (Inderal)

ANS: D B-Adrenergic blockers work rapidly to decrease the cardiovascular manifestations of thyroid storm. The other medications take days to weeks to have an impact on thyroid function.

A 44-yr-old man is diagnosed with hypertension and receives a prescription for benazepril (Lotensin). After providing teaching, which statement by the patient indicates correct understanding? a. "If I take this medication, I will not need to follow a special diet." b. "It is normal to have some swelling in my face while taking this medication." c. "I will need to eat foods such as bananas and potatoes that are high in potassium." d. "If I develop a dry cough while taking this medication, I should notify my doctor."

ANS: D Benazepril is an angiotensin-converting enzyme inhibitor. The medication inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indicate angioedema and should be reported immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modifications to lower blood pressure such as a reduced sodium diet.

Complications of transfusions that can be decreased by using leukocyte depletion or reduction of RBC transfusion are a. chills and hemolysis b. leukostasis and neutrophilia c. fluid overload and pulmonary edema d. transmission of cytomegalovirus and fever

ANS: D Blood transfusions can transmit infectious viruses, such as human immunodeficiency virus (HIV), human herpesvirus, hepatitis B and C type 6 (HCV-6), Epstein-Barr virus (EBV), human T-cell leukemia virus type 1 (HTLV-1), cytomegalovirus (CMV), and other agents, such as the agent that causes malaria. Leukocyte-reduced blood products reduce the risk for viral infections associated with blood transfusions, including CMV.

What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? a. Applying topical antibiotics to venous ulcers b. Maintaining the patient's legs in a dependent position c. Administering oral and/or subcutaneous anticoagulants d. Teaching the patient the correct use of compression stockings

ANS: D CVI requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent position.

A priority consideration in the management of the older adult with hypertension is to a. prevent primary hypertension from converting to secondary hypertension. b. recognize that the older adult is less likely to adhere to the drug therapy regimen than a younger adult. c. ensure that the patient receives larger initial doses of antihypertensive drugs because of impaired absorption. d. use careful technique in assessing the BP of the patient because of the possible presence of an auscultatory gap.

ANS: D Careful technique is important in assessing BP in older adults. In some older people, there is a wide gap between the first Korotkoff sound and subsequent beats. This wide interval is called an auscultatory gap. Failure to inflate the cuff high enough may result in an inaccurate systolic BP, one that is too low for the patient.

A patient is being evaluated for postthrombotic syndrome. Which assessment will the nurse perform? a. Ask about leg pain with exercise. b. Determine the ankle-brachial index. c. Assess capillary refill in the patient's toes. d. Inspect for presence of lipodermatosclerosis.

ANS: D Clinical signs of postthrombotic syndrome include lipodermatosclerosis. In this situation, the skin on the lower leg becomes scarred, and the leg becomes tapered like an "inverted bottle." The other assessments would be done for patients with peripheral arterial disease.

Which topic should the nurse include in teaching for a patient with a venous stasis ulcer on the lower leg? a. Need to increase carbohydrate intake b. Methods of keeping the wound area dry c. Purpose of prophylactic antibiotic therapy d. Application of elastic compression stockings

ANS: D Compression of the leg is essential to healing of venous stasis ulcers. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used for venous ulcers. Moist dressings are used to hasten wound healing.

A client who has been sick for several days is being seen in a clinic with a tentative diagnosis of mononucleosis. Which findings should a nurse expect when assessing the client? a. Weakness, loss of appetite, and extreme constipation b. Fever, an enlarged spleen, and a rash similar to chickenpox c. White coating on the throat and depressed lymphocyte levels d. Extreme fatigue and enlarged lymph nodes in the neck and axilla

ANS: D During the first 3 days, extreme fatigue, loss of appetite, and chills are present.

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? a. Platelet count b. Reticulocyte count c. Total lymphocyte count d. Absolute neutrophil count

ANS: D Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.

Which action will be included in the plan of care for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency? a. Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting. b. Organize nursing activities so that the patient has 8 hours of undisturbed sleep at night. c. Assist the patient up in the chair for meals to avoid complications associated with immobility. d. Use an automated noninvasive blood pressure machine to obtain frequent measurements.

ANS: D Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments, so allowing 8 hours of undisturbed sleep is not reasonable. When patients are receiving IV vasodilators, bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at risk for aspiration, so an NPO status is unnecessary.

The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside. Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse (LPN/VN)? a. Evaluate effectiveness of nitroprusside therapy on blood pressure (BP). b. Assess the patient's environment for adverse stimuli that might increase BP. c. Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg. d. Set up the automatic noninvasive BP machine to take readings every 15 minutes.

ANS: D LPN/VN education and scope of practice include the correct use of common equipment such as automatic noninvasive blood pressure machines. Assessment, evaluation, and medication titration require advanced nursing judgment and education, and should be done by RNs.

Which action should the nurse take when giving the first dose of oral labetalol to a patient with hypertension? a. Encourage the use of hard candy to prevent dry mouth. b. Teach the patient that headaches often occur with this drug. c. Instruct the patient to call for help if heart palpitations occur. d. Ask the patient to request assistance before getting out of bed.

ANS: D Labetalol decreases sympathetic nervous system activity by blocking both A- and B-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dry mouth, dehydration, and headaches are possible side effects of other antihypertensives.

The nurse is identifying approaches to reduce the risk of infection in a patient with leukemia. Why is it important for the nurse to institute infection control measures for this patient? a. Infection can precipitate hemorrhage in the patient with leukemia. b. The drugs needed to fight infection have life-threatening side effects. c. Infection in the patient with leukemia can lead to permanent neurological damage. d. Leukemia seriously impairs the leukocytes and the body's ability to fight infection.

ANS: D Leukemia is a malignant disease of the WBCs. The immature WBCs are abnormal and unable to effectively fight infection. A. C. Infection does not precipitate hemorrhage and does not typically lead to neurological damage. B. Chemotherapy, not antibiotics, has serious side effects.

In teaching a patient with hypertension about controlling the illness, the nurse recognizes that a. All patients with elevated BP need drug therapy. b. Obese persons must achieve a normal weight to lower BP. c. It is not necessary to limit salt in the diet if taking a diuretic. d. Lifestyle modifications are needed for all persons with elevated BP.

ANS: D Lifestyle modifications are needed for all patients with prehypertension and hypertension.

Because myelodysplastic syndrome arises from the pluripotent hematopoietic stem cell in the bone marrow, laboratory results the nurse would expect to find include a(n): a. excess of T cells b. excess of platelets c. deficiency of granulocytes d. deficiency of all cellular blood components

ANS: D Myelodysplastic syndrome (MDS) often presents as infection and bleeding. It is caused by inadequate numbers of ineffective functioning circulating granulocytes or platelets.

A 67-yr-old woman with hypertension is admitted to the emergency department with a blood pressure of 234/148 mm Hg and was started on nitroprusside (Nitropress). After 1 hour of treatment, the mean arterial blood pressure (MAP) is 55 mm Hg. Which nursing action is a priority? a. Start an infusion of 0.9% normal saline at 100 mL/hr. b. Maintain the current administration rate of the nitroprusside. c. Request insertion of an arterial line for accurate blood pressure monitoring. d. Stop the nitroprusside infusion and assess the patient for potential complications.

ANS: D Nitroprusside is a potent vasodilator medication. A blood pressure of 234/118 mm Hg would have a calculated MAP of 177 mm Hg. Subtracting 25% (or 44 mm Hg) = 133 mm Hg. The initial treatment goal is to decrease MAP by no more than 25% within minutes to 1 hour. For this patient, the goal MAP would be around 133 mm Hg. Minimal MAP required to perfuse organs is around 60 to 65 mm Hg. Lowering the blood pressure too rapidly may decrease cerebral, coronary, or renal perfusion and could precipitate a stroke, myocardial infarction, or renal failure. The priority is to stop the nitroprusside infusion and then use fluids only if necessary to support restoration of MAP.

A patient with a severe pounding headache has been diagnosed with hypertension. However, the hypertension is not responding to traditional treatment. What should the nurse expect as the next step in determining a diagnosis for this patient? a. Administration of β-blocker medications b. Abdominal palpation to search for a tumor c. Administration of potassium-sparing diuretics d. A 24-hour urine collection for fractionated metanephrines

ANS: D Pheochromocytoma should be suspected when hypertension does not respond to traditional treatment. The 24-hour urine collection for fractionated metanephrines is simple and reliable with elevated values in 95% of people with pheochromocytoma. In a patient with pheochromocytoma, an α-adrenergic receptor blocker is used preoperatively to reduce blood pressure. Abdominal palpation is avoided to avoid a sudden release of catecholamines and severe hypertension. Potassium-sparing diuretics are not needed. Most likely they would be used for hyperaldosteronism, which is another cause of hypertension.

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time

ANS: D Platelet aggregation in HIT causes neutralization of heparin, so the activated partial thromboplastin time will be shorter, and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.

The nurse is assessing a patient with stage III Hodgkin's disease. Where should the nurse expect to find enlarged lymph nodes? a. In the neck only. b. Above the diaphragm only c. Below the diaphragm only d. Generalized throughout the body

ANS: D Stage III Hodgkin's disease is characterized by nodes on both sides of the diaphragm, with or without organ involvement. A. B. C. Lymph nodes are enlarged beyond the neck, above, and below the diaphragm.

Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching? a. Potential impact of chemotherapy treatment on fertility b. Application of soothing lotions to treat residual pruritus c. Use of maintenance chemotherapy to maintain remission d. Need for follow-up appointments to screen for malignancy

ANS: D The chemotherapy used in treating Hodgkin's lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. Chemotherapy will not impact the fertility of a 55-yr-old woman. Maintenance chemotherapy is not used for Hodgkin's lymphoma. Pruritus is a clinical manifestation of lymphoma but should not be a concern after treatment.

A female nurse tells a coworker that she is confused because a physician stated that graft-versus-host disease (GVHD) symptoms were desirable for a particular client after a bone marrow transplant. In which type of malignancy is GVHD sometimes desirable? a. Gastrointestinal b. Reproductive c. Neurological d. Hematological

ANS: D The donor lymphocytes can mount a reaction against any lingering tumor cells and destroy them.

The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which consequence? a. Pulmonary embolism b. Pulmonary hypertension c. Postthrombotic syndrome d. Venous thromboembolism

ANS: D The manifestations are characteristic of a superficial vein thrombosis. If untreated, the clot may extend to deeper veins, and venous thromboembolism may occur. Pulmonary embolism, pulmonary hypertension, and postthrombotic syndrome are the sequelae of venous thromboembolism.

A 44-year-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be helpful for the patient problem of disturbed body image related to changes in appearance? a. Reassure the patient that the physical changes are very common in patients with Cushing syndrome. b. Discuss the use of diet and exercise in controlling the weight gain associated with Cushing syndrome. c. Teach the patient that the metabolic impact of Cushing syndrome is of more importance than appearance. d. Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery.

ANS: D The most reassuring and accurate communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively. Reassurance that the physical changes are expected or that there are more serious physiologic problems associated with Cushing syndrome minimize the patient's concerns. The patient's physiological changes are caused by the high hormone levels, not by the patient's diet or exercise choices.

A patient at the clinic says, "I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though." What focused assessment should the nurse make? a. Look for the presence of tortuous veins bilaterally on the legs. b. Ask about any skin color changes that occur in response to cold. c. Assess for unilateral swelling, redness, and tenderness of either leg. d. Palpate for the presence of dorsalis pedis and posterior tibial pulses.

ANS: D The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness indicate venous thromboembolism.

A patient was admitted for possible ruptured aortic aneurysm. Ten minutes later, the nurse notes sinus tachycardia 138 beats/min, blood pressure is palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret the findings? a. Tamponade will soon occur. b. The renal arteries are involved. c. Perfusion to the legs is impaired. d. Bleeding into the abdomen is likely.

ANS: D The patient is likely bleeding into the abdominal space, and it is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space, where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There are no assessment data indicating decreased perfusion to the legs.

An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. After the nurse notifies the health care provider, what should the nurse do next? a. Apply a compression stocking to the leg. b. Elevate the leg above the level of the heart. c. Assist the patient in gently exercising the leg. d. Keep the patient in bed in the supine position.

ANS: D The patient's history and clinical manifestations are consistent with acute arterial occlusion. Resting the leg will decrease the O2 demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.

After obtaining the information shown in the accompanying figure regarding a patient with Addison's disease, which prescribed action will the nurse take first? Assessment: reports fatigue, bronze-colored skin, poor skin turgor Vital signs: BP 76/40 mm Hg, HR 126 bpm, RR 24 breaths/min, O2 sat 94% Laboratory data: Sodium 123 mEq/L, Potassium 5.1 mEq/L, Glucose 62 mg/dL a. Give 4 oz of fruit juice orally. b. Recheck the blood glucose level. c. Administer O2 therapy as needed. d. Infuse 5% dextrose and 0.9% saline.

ANS: D The patient's poor skin turgor, hypotension, and hyponatremia indicate an Addisonian crisis. Immediate correction of the hypovolemia and hyponatremia is needed. The other actions may also be needed but are not the initial action for the patient.

The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism of the left lower leg. Which action by the nurse is best? a. The patient's bed is placed in the Trendelenburg position. b. Two pillows are positioned under the calf of the affected leg. c. The bed is elevated at the knee and pillows are placed under both feet. d. One pillow is placed under the thighs and 2 pillows are under the lower legs.

ANS: D The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing 2 pillows under the feet and another under the thighs. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level.

A 39-yr-old woman with a history of smoking and oral contraceptive use is admitted with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse review to evaluate the expected effect of the heparin? a. Platelet count b. Activated clotting time (ACT) c. International normalized ratio (INR) d. Activated partial thromboplastin time (aPTT)

ANS: D Unfractionated heparin can be given by continuous IV for VTE treatment. When given IV, heparin requires frequent laboratory monitoring of clotting status as measured by activated partial thromboplastin time (aPTT). Platelet counts can decrease as an adverse reaction to heparin.

A client presents to an emergency department after experiencing a seizure at home. A nurse pads the client's side rails, lowers the client's bed, and ensures that suction equipment is available while waiting for the serum laboratory results. Place an X in the right-hand column to indicate the laboratory value indicative of a condition that could lead to a seizure.

ANS: Na 119 Serum sodium is dangerously below normal values.

A client is admitted with a diagnosis of acute infective endocarditis (IE). Which findings during a nursing assessment support this diagnosis? Select all that apply a. Skin petechiae b. Crackles in lung bases c. Peripheral edema d. Murmur e. Arthralgia f. Decreased erythrocyte sedimentation rate (ESR)

ANS: a, b, c, d, e

A nurse evaluates that a client understands discharge teaching following aortic valve replacement surgery with a synthetic valve, when the client states that he/she plans to: Select all that apply a. use a soft toothbrush for dental hygiene b. floss teeth daily to prevent plaque formation c. wear loose-fitting clothing to avoid friction on the sternal incision d. use an electric razor for shaving e. report black, tarry stools f. consume foods high in vitamin K, such as broccoli

ANS: a, c, d, e

The nurse has just finished teaching a hypertensive patient about a newly prescribed drug, ramipril (Altace). Which patient statement indicates that more teaching is needed? a. "The medication may not work well if I take aspirin." b. "I can expect some swelling around my lips and face." c. "The doctor may order a blood potassium level occasionally." d. "I will call the doctor if I notice that I have a frequent cough."

ANS:B Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health care provider should be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy.

A patient with peripheral artery disease has marked peripheral neuropathy. An appropriate nursing diagnosis for the patient is a. Risk for injury related to decreased sensation. b. Impaired skin integrity related to decreased peripheral circulation. c. Ineffective peripheral tissue perfusion related to decreased arterial blood flow. d. Activity intolerance related to imbalance between oxygen supply and demand.

Answer: A Rationale: Peripheral neuropathy is caused by diminished perfusion to neurons and results in loss of both pressure and deep pain sensations. The patient may not notice lower extremity injuries. Neuropathy increases susceptibility to traumatic injury and results in delay in seeking treatment.

A patient with acute myelogenous leukemia is starting chemotherapy. When teaching the patient about the induction stage of chemotherapy, what is an appropriate statement? a. "The drugs are started slowly to minimize side effects." b. "You will be at increased risk for bleeding and infection." c. "High doses will be administered every day for several months." d. "Most patients have more energy and are resistant to infection."

Answer: B Rationale: Induction is aggressive treatment that seeks to bring about remission by the destruction of leukemic cells. During induction therapy, the bone marrow is severely depressed by the chemotherapy agents, and neutropenia, thrombocytopenia, and anemia may occur. High-dose chemotherapy is administered immediately after the induction phase.

The nurse teaches a patient with peripheral arterial disease. The nurse determines that further teaching is needed if the patient makes which statement? a. "I should not use heating pads to warm my feet." b. "I should cut back on my walks if it causes pain in my legs." c. "I will examine my feet every day for any sores or red areas." d. "I can quit smoking if I use nicotine gum and a support group."

Answer: B Rationale: Patients should be taught to exercise to the point of discomfort, stop and rest, and then resume walking until the discomfort recurs. Smoking cessation and proper foot care are also important interventions for patients with peripheral arterial disease.

A patient's BP has not responded consistently to prescribed drugs for hypertension. The first cause of this lack of responsiveness the nurse should explore is a. progressive target organ damage. b. the possibility of drug interactions. c. the patient not adhering to therapy. d. the patient's possible use of recreational drugs.

Answer: C Rationale: Side effects of antihypertensive drugs are common and may be so severe or undesirable that the patient does not comply with therapy.

Following an aortic aneurysm repair, the patient suddenly develops severe pain in the right lower extremity. The right pedal pulse is decreased and the right foot is cool and pale. Which complication should the nurse suspect? a. Hypothermia b. Wound infection c. Bleeding from the graft site d. Embolization or graft occlusion

Answer: D Rationale: A decreased or absent pulse together with a cool, pale, mottled, or painful extremity may indicate embolization or graft occlusion.

The nurse is caring for a patient who just returned to the surgical unit following a thyroidectomy. The nurse is most concerned if which is observed? a. The patient complains of increased thirst. b. The patient reports a sore throat when swallowing. c. The patient supports her head when moving in bed. d. The patient makes harsh, vibratory sounds when breathing.

Answer: D Rationale: After thyroid surgery, the patient may experience an airway obstruction related to excess swelling, hemorrhage, hematoma formation, or laryngeal stridor (harsh, vibratory sound). Emergency equipment should be at the bedside, including oxygen, suction equipment, and a tracheostomy tray.

Patient admitted with BP of 230/118 with stupor and confusion

a. abrupt withdrawal of Catapres

Patient is 75 venous stasis ulcer L lower leg. In planning care for her the nurse recognizes that the healing of the ulcer is most dependent on

a. application of unna boots