CH2 exam 2 questions

The nurse is caring for a patient in the initial stage of hypovolemic shock. What assessment data will the nurse anticipate? A. Heart rate 118 beats/min B. 2+ pedal pulses C. Bilateral fine crackles in lung bases D. BP change from 100/60 to 100/40 mm Hg

A. Heart rate 118 beats/min

Which assessment finding in a client with diagnosis of diabetes insipidus (DI) indicates to the nurse that desmopressin therapy is effective? A. Urine output of 30 to 50 mL/hr B. Blood glucose level of 110 mg/dL (6.1 mmol/L) C. Respiratory rate of 20 breaths/min D. Potassium level of 3.9 mEq/L (mmol/L)

A. Urine output of 30 to 50 mL/hr

The nurse is caring for a client with chest pain. What assessment data would cause the nurse to suspect unstable angina? Select all that apply. A. ST changes B. Troponin T 0.6 ng/mL C. Pain lasts 15 to 25 minutes D. Increased number of angina attacks E. The intensity of the chest pain has increased

A, C, D, E

Which of the following are the priority precautions the nurse will teach the client who remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy to prevent harm related to the disorder? Select all that apply. A. "Avoid crowds and people who are ill." B. "Check your heart rate for irregular or skipped beats twice daily." C. "Do not choose low-sodium versions of prepared foods." D. "Get up slowly from sitting or lying positions." E. "Keep a source of glucose, such as candy, with you at all times." F. "Never skip your hormone replacement drugs."

A, B, C, D, E, F

The nurse is assessing a client with septic shock. What assessment data indicate a progression of shock? Select all that apply. A. BP change from 86/50 to 100/64 mm Hg B. Heart rate change from 98 to 76 beats/min C. Cool and clammy skin D. Petechiae along the gum line E. Urine output 45 mL/hr

A, C, D

A client in the progressive stage of hypovolemic shock has all of the following signs, symptoms, or changes. Which signs will the nurse attribute to ongoing compensatory mechanisms? Select all that apply. A. Increasing pallor B. Increasing thirst C. Increasing confusion D. Increasing heart rate E. Increasing respiratory rate F. Decreasing systolic blood pressure G. Decreasing blood pH H. Decreasing urine output

A, B, D, E, H

A 30-year-old male client having an annual health physical report that all of the following changes have developed during the past year. Which ones alert the nurse to possible pituitary hyperfunction? Select all that apply. A. 15-lb weight gain B. Decreased libido C. Four sinus infections D. Frequent constipation E. Increased foot callus formation F. Occasional dripping of clear fluid from both breasts G. Severely sprained ankle from a volleyball injury

A, B, F

The nurse is providing community education regarding myocardial infarction. What teaching will the nurse include? Select all that apply. A. Denial is common reaction to chest pain. B. A myocardial infarction can occur in minutes. C. Exercise at least 20 minutes three to four times per week. D. Age is a significant risk factor in the development of CAD. E. Women are more likely to experience atypical chest pain. F. Atherosclerosis is a primary factor in the development of CAD.

A, D, E, F

The nurse is preparing to discharge a client who recently experienced a STEMI. Which client statement indicates understanding of nitroglycerin use? A. "The nitroglycerin should tingle when I put it in my mouth." B. "I will keep nitroglycerin in the glove compartment of my car." C. "Since the pills are small, they won't be hard to swallow." D. "The nitroglycerin should relieve the pain immediately."

A. "The nitroglycerin should tingle when I put it in my mouth."

Which primary health care provider order will the nurse perform first for a client with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 105 mEq/L (105 mmol/L)? A. Administering an infusion of 150 mL hypertonic saline over the next 3 hours B. Drawing blood for hemoglobin and hematocrit levels C. Measuring serial weights at the same daily with the client wearing the same amount of clothing D. Inserting an indwelling catheter and monitoring urine output

A. Administering an infusion of 150 mL hypertonic saline over the next 3 hours Rationale: The first intervention the nurse performs is to administer an infusion of 150 mL hypertonic saline over 3 hours. When the serum sodium level is below 115 mEq/L (115 mmol/L), the client is at increased risk for seizures and coma.

Which action immediately after a hypophysectomy will the nurse instruct a client to avoid to prevent harm? (Select all that apply.) A. Bending at the waist B. Talking C. Deep breathing D. Coughing E. Wearing makeup F. Using dental floss

A. Bending at the waist D. Coughing

The nurse is assessing a client who had a coronary artery bypass graft yesterday. Which assessment finding indicates the client is at risk for decreased perfusion? A. Heart rate of 50 beats/min B. Potassium level of 4.2 mEq/L C. Systolic blood pressure of 120 mm/Hg D. 50 mL of bloody drainage in chest tube over 4 hours

A. Heart rate of 50 beats/min

After receiving change-of-shift report in the coronary care unit, which client does the nurse assess first? A. The client with acute coronary syndrome who has a 3-pound weight gain and dyspnea B. The client with percutaneous coronary angioplasty who has a dose of heparin scheduled C. The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min D. A client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction

A. The client with acute coronary syndrome who has a 3-pound weight gain and dyspnea

Which assessment has the highest priority for the nurse to perform for a client with syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24 hours? A. Evaluating serum sodium levels B. Evaluating serum potassium levels C. Examining the skin and sclera for jaundice D. Examining the IV site for indications of phlebitis

A. evaluating serum sodium levels

Performance of which assessment is a priority for the nurse before giving a client the first oral dose of hormone replacement for hypothyroidism? A. Measuring heart rate and rhythm B. Checking core body temperature C. Asking about previous allergic drug reactions D. Listening to bowel sounds in all four abdominal quadrants

A. measuring heart rate and rhythm

The nurse is concerned that a client who had myocardial infarction (MI) has developed cardiogenic shock. Which findings indicate shock? (Select all that apply.) A. Bradycardia B. Cool, diaphoretic skin C. Crackles in the lung fields D. Respiratory rate of 12 breaths/min E. Anxiety and restlessness F. Temperature of 100.4° F

B,C,E

The nurse is teaching a client's family regarding the diagnosis of septic shock. Which teaching will the nurse include? Select all that apply. A. "The blood cultures will tell us for sure if your loved one has septic shock." B. "The client's change in behavior and lethargy may be associated with septic shock." C. "Antibiotics, as prescribed, will be started within the hour to treat the sepsis." D. "An insulin drip has been started to keep the client's glucose as low as possible." E. "Septic shock is easily treated with multiple antibiotics."

B, C

A 45-year-old male client having an annual physical asks the nurse about his risk for developing a myocardial infarction (MI). Which modifiable risk factors will the nurse assess to guide the client's teaching plan? Select all that apply. A. Age B. Tobacco use C. Gender D. Diet E. Family history F. Weight

B, D, F

Which assessment findings in a client with hyperthyroidism indicate to the nurse that the client is in danger of thyroid storm? Select all that apply. A. Increased salivation B. Client report of increased palmar sweating C. Decreased pulse pressure from 40 mm Hg to 36 mm Hg D. Diminished bowel sounds in all four abdominal quadrants E. An increase in temperature from 99.5°F (37.5°C) to 101.3°F (38.5°C) F. Serum sodium level increase from 136 mEq/L (mmol/L) to 139 mEq/L (mmol/L) G. Increase in premature ventricular heart contractions from 4 per minute to 28 per minute

B, E, G

Clients who have deficiencies of which hormones will the nurse assess for increased risk of life-threatening consequences? A. Prolactin and prolactin inhibiting hormone (PIH). B. Adrenocorticotrophicn hormone (ACTH) and thyroid-stimulating hormone (TSH) C. Growth hormone (GH) and melanocyte-stimulating hormone (MSH) D. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH)

B. Adrenocorticotrophicn hormone (ACTH) and thyroid-stimulating hormone (TSH)

A client has just returned from coronary artery bypass graft surgery. For which finding does the nurse contact the surgeon? A. Temperature 98.2° F B. Chest tube drainage 175 mL last hour C. Serum potassium 3.9 mEq/L D. Incisional pain 6 on a scale of 0 to 10

B. Chest tube drainage 175 mL last hour

While making rounds the nurse finds a client with type 1 diabetes mellitus pale, sweaty, and slightly confused; the client can swallow. The client's blood glucose level check is 48 mg/dL (2.7 mmol/L). What is the nurse's best first action to prevent harm? A. Call the pharmacy and order a STAT does of glucagon. B. Immediately give the client 30 g of glucose orally. C. Start an IV and administer a small amount of a concentrated dextrose solution. D. Recheck the blood glucose level and call the Rapid Response Team.

B. Immediately give the client 30 g of glucose orally.

While suctioning a client with a tracheostomy, the client becomes diaphoretic and nauseous and the heart rate decreases to 37 beats/min. What is the priority nursing action? A. Continue to clear the airway. B. Stop suctioning the patient. C. Administer atropine. D. Call the health care provider immediately.

B. Stop suctioning the patient.

The nurse assesses a client who had a coronary artery bypass graft yesterday. Which assessment finding will cause the nurse to suspect cardiac tamponade? A. Incisional pain with decreased urine output B. Muffled heart sounds with the presence of JVD C. Sternal wound drainage with nausea D. Increased blood pressure and decreased heart rate

B. Muffled heart sounds with the presence of JVD

The nurse is reviewing the laboratory profile of a client with hypovolemic shock. What laboratory value will the nurse anticipate? A. pH 7.51 B. PaO 2 106 mm Hg C. PaCO 2 49 mm Hg D. Lactate 0.4 mmol/L

B. PaO 2 106 mm Hg

Prompt pain management with myocardial infarction is essential for which reason? A. The discomfort will increase client anxiety and reduce coping. B. Pain relief improves oxygen supply and decreases oxygen demand. C. Relief of pain indicates that the MI is resolving. D. Pain medication should not be used until a definitive diagnosis has been established.

B. Pain relief improves oxygen supply and decreases oxygen demand.

The nurse is caring for a hospitalized client with infective endocarditis who has been receiving antibiotics for 2 days. The client is now experiencing flank pain with hematuria. What complication will the nurse suspect? A. Pulmonary embolus B. Renal infarction C. Transient ischemic attack D. Splenic infarction

B. Renal infarction

A client is admitted to the hospital with an abdominal aortic aneurysm. Which assessment data would cause the nurse to suspect that the aneurysm has ruptured? A. Shortness of breath and hemoptysis B. Sudden, severe low back pain and bruising along the flank C. Gradually increasing substernal chest pain and diaphoresis D. Rapid development of patchy blue mottling on feet and toes

B. Sudden, severe low back pain and bruising along the flank

Upon entering a client's room, the nurse finds the client unresponsive. In what order will the nurse provide care? A. Begin chest compressions B. Check carotid pulse C. Notify the Rapid Response Team D. Get the crash cart/AED E. Provide rescue breaths

C, D, B, A, E

A client who is 9 days post-coronary artery bypass graft presents to a follow-up appointment. Which client statement requires nursing action? A. "My chest hurts when I sneeze or cough." B. "If I get tired when I walk, then I stop and rest for a bit." C. "I have a bandage on my sternum to collect the drainage." D. "I haven't had my normal appetite since the surgery."

C. "I have a bandage on my sternum to collect the drainage."

A client who recently had a heart valve replacement is preparing for discharge. Which client statement indicates that the nurse will need to do additional health teaching? A. "I need to brush my teeth at least twice daily and rinse with water." B. "I will eat foods that are low in vitamin K, such as potatoes and iceberg lettuce." C. "I need to take a full course of antibiotics prior to my colonoscopy." D. "I will take my blood pressure every day and call if it is too high or low."

C. "I need to take a full course of antibiotics prior to my colonoscopy."

3. The primary health care provider prescribes warfarin for a client with atrial fibrillation. Which client statement indicates that additional education is needed? A. "I need to go to the clinic once a week to have my blood level checked." B. "If my stools turn black, I will be sure to call my primary health care provider." C. "I'm glad I don't need to change my diet. Salads are my favorite food." D. "I need to stop taking my herbal supplement."

C. "I'm glad I don't need to change my diet. Salads are my favorite food."

Which precaution is most important for the nurse to teach a female client to prevent harm while undergoing drug therapy with estrogen and progesterone for hypopituitarism? A. "Use a barrier method of contraception to prevent an unplanned pregnancy." B. "Wear a hat with a brim and use sunscreen when outdoors." C. "Do not smoke or use nicotine in any form." D. "Avoid drinking caffeinated beverages."

C. "do not smoke or use nicotine in any form"

Which changes in laboratory values will the nurse expect to see in a client who has tumor causing excess secretion of aldosterone? (Select all that apply.) A. Hypoglycemia B. Hyponatremia C. Hypokalemia D. Hypernatremia E. Hyperglycemia F. Hyperkalemia

C. Hypokalemia D. Hypernatremia Rationale: Aldosterone is the mineralocorticoid that maintains extracellular fluid volume and electrolyte composition. It promotes sodium and water reabsorption and potassium excretion in the kidney. Excessive amounts of this hormone result in hypernatremia and hypokalemia.

The visiting nurse is seeing a client postoperative for coronary artery bypass graft. Which nursing action should be performed first? A. Assess coping skills. B. Assess for postoperative pain at the client's incision site. C. Monitor for dysrhythmias. D. Monitor mental status

C. Monitor for dysrhythmias.

Which client symptom appearing after a head injury suffered in a car crash is most relevant for the nurse to consider the possibility of diabetes insipidus (DI)? A. New-onset hypertension. B. The client reports extreme salt craving. C. No change in urine output with minimal fluid intake. D. The client's headache is gradually increasing in intensity.

C. No change in urine output with minimal fluid intake.

Which laboratory finding in a client with a possible pituitary disorder will the nurse report to the health care provider immediately? A. Blood glucose 148 mg/dL (7.4 mmol/L) B. Blood urea nitrogen (BUN) 40 mg/dL (14.3 mmol/L) C. Serum sodium 110 mEq/L (110 mmol/L) D. Serum potassium 3.2 mEq/L (3.2 mmol/L)

C. Serum sodium 110 mEq/L (110 mmol/L)

A nurse caring for a client with Cushing syndrome who must remain on continued glucocorticoid therapy for another health problem will use which of the following actions to prevent harm? A. Urging the client to salt his or her food B. Testing voided urine for the present of glucose C. Using nonadhesive methods to secure an IV access D. Ensuring the prescribed glucocorticoid drug is given on an empty stomach

C. Using nonadhesive methods to secure an IV access

Which urine characteristics indicate to the nurse that the client being managed for diabetes insipidus is responding appropriately to interventions? A. Urine output volume increased; urine specific gravity increased B. Urine output volume increased; urine specific gravity decreased C. Urine output volume decreased; urine specific gravity increased D. Urine output volume decreased; urine specific gravity decreased

C. urine output volume decreased; urine specific gravity increased

Which question asked by a 48-year-old client with sleep apnea whose blood glucose level is elevated suggests to the nurse the possibility of a growth hormone excess? A. "Do you think if I lost weight my sleep apnea would improve?" B. "Why do I feel thirsty all the time?" C. How can I make my skin less itchy?" D. "Does everyone's feet get bigger during menopause?"

D. "Does everyone's feet get bigger during menopause?"

A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland asks the nurse whether the physical changes from the excessive cortisol will go away as a result of the surgery so she can look like herself again. What is the nurse's best response? A. "The surgery is to remove the tumor, not reconstructive surgery." B. "You will notice a great difference in your appearance starting within a week after surgery." C. "All the changes will resolve but may take a year or longer to completely disappear." D. "The fatty changes and acne will resolve with time but the stretch marks only fade."

D. "The fatty changes and acne will resolve with time but the stretch marks only fade."

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A. A 42 year old with diabetes insipidus who has a dose of desmopressin due. B. A 35 year old with hyperaldosteronism who has a serum potassium of 3.0 mEq/L (3.0 mmol/L). C. A 50 year old with pituitary adenoma who is reporting a severe headache. D. A 28 year old with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L).

D. A 28 year old with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L). Rationale: The nurse first attends to the client with adrenal insufficiency who has a blood glucose level of 36 mg/dL (2.0 mmol/L). The client's condition is considered a medical emergency and must be assessed and treated immediately.

The nurse is caring for a client with hypovolemic shock who is bleeding from a traumatic injury to the upper chest wall. What is the priority nursing action? A. Insert a large-bore IV catheter. B. Administer supplemental oxygen. C. Elevate the client's feet, keeping the head flat. D. Apply direct pressure to the area of overt bleeding.

D. Apply direct pressure to the area of overt bleeding.

2. A client in the telemetry unit is on a cardiac monitor. The monitor technician alerts the nurse that there are no ECG complexes, and the alarm is sounding. What is the first action by the nurse? A. Suspend the alarm. B. Call the emergency response team. C. Press the record button to get an ECG strip D. Assess the client and check lead placement.

D. Assess the client and check lead placement.

To validate that a client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests? A. Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase B. Homocysteine and C-reactive protein C. Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol D. CK-MB and troponin

D. CK-MB and troponin

For which assessment finding in a client who had a transsphenoidal hypophysectomy yesterday will the nurse notify the primary health care provider immediately? A. Dry lips and oral mucosa on examination B. Nasal drainage that tests negative for glucose C. Urine specific gravity of 1.016 D. Client report of a headache and stiff neck

D. Client report of a headache and stiff neck Rationale: Headache and stiff neck (nuchal rigidity) are symptoms of meningitis that have immediate implications for the client's care. The finding requires the nurse to immediately notify the primary health care provider.Dry lips and mouth are not unusual after surgery. Nasal drainage that tests negative for glucose is normal, expected, and not significant. A urine specific gravity of 1.016 is within normal limits.

Which factor or condition does the nurse expect to result in an increase in a client's production of thyroid hormones (TH)? A. Getting 8 hours of sleep nightly B. Chronic constipation C. Protein-calorie malnutrition D. Cold environmental temperatures

D. Cold environmental temperatures Rationale:Cold and stress are two factors that cause the hypothalamus to secrete thyrotropin-releasing hormone (TRH), which then stimulates the anterior pituitary to secrete thyroid-stimulating hormone (TSH) to increase production of the two major thyroid hormones.

Which action is most important for the nurse to perform when caring for an older client decreased antidiuretic hormone (ADH) production? A. Inspecting feet and legs for ulcers B. Planning for weight-bearing activities C. Stressing the important of fiber in the diet D. Encouraging fluids every 2 hours

D. Encouraging fluids every 2 hours Rationale: A decrease in ADH production in the older adult causes urine to be more dilute. In this instance, urine might not concentrate when fluid intake is low, allowing for excess water loss. Encouraging fluid intake every 2 hours, even during the night, is important to prevent dehydration.

The nurse is caring for client who is experiencing occasional premature ventricular contractions. What assessment data are most concerning to the nurse? A. Potassium 4.8 mEq/L B. Magnesium 2 mEq/L C. Heart rate 90 D. History of smoking

D. History of smoking

The nurse is caring for a client with hypovolemic shock. Which new assessment finding indicates to the nurse that interventions are currently effective? A. Oxygen saturation remains unchanged. B. Core body temperature has increased to 99°F (37.2°C). C. The client correctly states the month and year. D. Serum lactate and serum potassium levels are declining.

D. Serum lactate and serum potassium levels are declining.

Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? a A 70-year-old male, with high cholesterol and hypertension B. A 40-year-old female with obesity and metabolic syndrome C. A 60-year-old male with renal insufficiency who is physically inactive D. A 65-year-old female with hyperhomocysteinemia and substance abuse

a A 70-year-old male, with high cholesterol and hypertension Rationale: The most common etiology 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

A patient with a history of myocardial infarction is scheduled for a transesophageal echocardiogram to visualize a suspected clot in the left atrium. What information should the nurse include when teaching the patient about this diagnostic study? a. IV sedation may be administered to help the patient relax. b. Food and fluids are restricted for 2 hours before the procedure. c. Ambulation is restricted for up to 6 hours before the procedure. d. Contrast medium is injected into the esophagus to enhance images.

a. IV sedation may be administered to help the patient relax.

A patient with a small AAA is not a good surgical candidate. What should the nurse teach the patient is one of the best ways to prevent expansion of the lesion? a. Avoid strenuous physical exertion. b. Control hypertension with prescribed therapy. c. Comply with prescribed anticoagulant therapy. d. Maintain a low-calcium diet to prevent calcification of the vessel.

b. Control hypertension with prescribed therapy.

What are the priority nursing interventions after an abdominal aortic aneurysm repair? a. Assessment of cranial nerves and mental status b. Administration of IV heparin and monitoring of PT c. Administration of IV fluids and monitoring of kidney function d. Elevation of the legs and application of graduated compression stockings

c. Administration of IV fluids and monitoring of kidney function

During the nursing assessment of the patient with a distal descending aortic dissection, what should the nurse expect the patient to manifest? a. Altered LOC with dizziness and weak carotid pulses b. A cardiac murmur characteristic of aortic valve insufficiency c. Severe "ripping" back or abdominal pain with decreasing urine output d. Severe hypertension and orthopnea and dyspnea of pulmonary edema

c. Severe "ripping" back or abdominal pain with decreasing urine output

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

c. control blood pressure

A thoracic aortic aneurysm is found when a patient has a routine chest x-ray. The nurse anticipates that additional diagnostic testing to determine the size and structure of the aneurysm will include which test? a. Angiography b. Ultrasonography c. Echocardiography d. (Computed tomography) CT scan

d. (Computed tomography) CT scan