Chronic Illness Test 2

A nurse in the ED (ER) is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe? A. Troponin 1 B. Lipase C. B-Type natriuretic peptide (BNP) D. Aspartate aminotransferase (AST)

A. Troponin 1 Rationale: The troponins (I and T) are proteins that only exist in cardiac muscle and enter the bloodstream within a few hours of myocardial injury. They are the most specific indicator of myocardial damage.

A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? A. Ventricular depolarization B. Guillain-Barre syndrome C. Myelodysplastic syndrome D. Valvular disease

D. Valvular disease Rationale: Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.

A nurse is planning a presentation for a group of clients who have hypertension. Which of the following lifestyle modifications should the nurse include? (select all that apply) A. Limit alcohol intake B. Regular exercise program C. Decreased magnesium intake D. Reduced potassium intake E. Tobacco cessation

A, B, E. Rationale: Clients who have hypertension should limit alcohol intake. Clients who have hypertension should develop a regular exercise program to help reduce blood pressure. Low magnesium intake is associated with hypertension and is not a lifestyle modification the nurse should include. Low potassium intake is associated with hypertension and is not a lifestyle modification the nurse should include. Clients who have hypertension should have a goal of tobacco cessation because tobacco use exacerbates hypertension.

A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure? A. "I can't get rid of these hiccups." B. "I feel dizzy when I stand" C. "My incision site stings" D. "I have a headache"

A. "I can't get rid of these hiccups." Rationale: Hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can occur as a result of a lead wire perforation.

A nurse is assessing a client who has pulmonary edema related to HF. Which of the following findings indicates effective treatment of the client's condition? A. Absence of adventitious breath sounds B. Presence of a nonproductive cough C. Decrease in respiratory rate at rest D. SaO2 86% on room air

A. Absence of adventitious breath sounds Rationale: Adventitious breath sounds occur when there is fluid in the lungs. The absence of adventitious breath sounds indicates that the pulmonary edema is resolving.

A nurse in an ED (ER) is assessing a client who has a bradydysrhythmia. Which of the following findings should the nurse monitor for? A. Confusion B. Friction rub C. Hypertension D. Dry Skin

A. Confusion Rationale: Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status.

A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect? A. Dyspnea on exertion B. Tracheal deviation C. Pericardial rub D. Weight loss

A. Dyspnea on exertion Rationale: The nurse should identify dyspnea on exertion as an expected manifestation of dilated cardiomyopathy. Dyspnea on exertion is due to ventricular compromise and reduced cardiac output.

A nurse auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear? A. Loud, scratchy sounds B. Squeaky, musical sounds C. Popping sounds D. Snoring sounds

A. Loud, scratchy sounds Rationale: Loud, scratchy sounds caused by inflammation of the pleura are a manifestation of pleurisy.

A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include? A. Place the tablet under your tongue, and then take a small sip of water B. The medication can take up to 15 minutes to take effect C. Avoid taking the medication prior to exercising D. Stop taking the medication and notify your provider if you develop a headache

A. Place the tablet under your tongue, and then take a small sip of water Rationale: A client who takes a sublingual medication should place it under his tongue. A sip of water can help the medication dissolve.

A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately? A. Slurred Speech B. Irregular pulse C. Dependent Edema D. Persistent Fatigue

A. Slurred speech Rationale: The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. Slurred speech can indicate inadequate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.

A nurse is providing discharge teaching to a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider? A. Weight gain of 0.9kg (2 lbs) in 24 hrs. B. increase of 10mm Hg in systolic BP C. Dyspnea with exertion D. Dizziness when rising quickly

A. Weight gain of 0.9kg (2lbs) in 24 hrs. Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1.1 to 2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately.

A nurse is providing teaching to a client who is 2 days post-op following a heart transplant. Which of the following statements should the nurse include in the teaching? A. "You might no longer be able to feel chest pain." B. Your level of activity intolerance will not change C. After 6 months, you will no longer need to restrict your sodium intake D. You will be able to stop taking immunosuppressants after 12 months

A. You might no longer be able to feel chest pain Rationale: Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart.

A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should identify that an increase in which of the following values is diagnostic of a myocardial infarction (MI)? A. Myoglobin B. C-reactive protein C. Creatine kinase-MB D. Homocysteine

C. Creatine kinase-MB Rationale: Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury.

A nurses providing health teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease? A. A client who has hypothyroidism B. A client who has diabetes mellitus C. A client whose daily caloric intake consists of 25% fat D. A client who consumes two 12-oz (0.35-L) bottles of beer a day

B. A client who has diabetes mellitus Rationale: Diabetes mellitus places the client at risk for microvascular damage and progressive peripheral arterial disease.

A nurse is caring for a client who is 8 hr post-op following a coronary artery bypass graft (CABG). Which of the following findings should the nurse report? A. Mediastinal drainage 100mL/hr B. BP 160/80mm Hg C. Temperature 37.1 (98.8) D. Potassium 4.0 mEq/L

B. BP 160/80mm Hg Rationale: The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites.

A nurse is caring for a client who is being treated for HF and has a prescription for furosemide. The nurse should plan to monitor for which of the following adverse effects of the medication? A. Shortness of breath B. Lightheadedness C. Dry cough D. Metallic taste

B. Lightheadedness Rationale: Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness.

A nurse is caring for a client who is post-op and is at risk for VTE. The nurse instruct the client to avoid which of the following unsafe actions? A. Elevating her feet B. Massaging her legs C. Flexing her ankles D. Ambulating soon after surgery

B. Massaging her legs Rationale: Massaging an extremity that has a blood clot can cause it to detach and become an embolus. The use of sequential compression devices and antiembolic stockings and therapeutic anticoagulation can help prevent this postoperative complication.

A nurse is teaching a client who has a new prescription for an ACE inhibitor to treat hypertension. The nurse should instruct the client to notify their provider if they experience which of the following adverse effects of this medication? A. Tendon pain B. Persistent cough C. Frequent urination D. Constipation

B. Persistent cough Rationale: A persistent cough is an adverse effect of ACE inhibitors. The client should report this finding to the provider and discontinue the medication.

A nurse is providing discharge teaching to a client who has a prescription for transdermal nitroglycerin patches. Which of the following instructions should the nurse include in the teaching? A. Apply the new patch to the same site as the previous patch B. Place the patch on an area of skin away from skin folds and joints C. Keep the patch on 24 hr per day D. Replace the patch at the onset of angina

B. Place the patch on an area of skin away from skin folds and joints Rationale: The nurse should instruct the client to apply the patch to an area of intact skin with enough room for the patch to fit smoothly.

A nurse is providing teaching to a client who has family history of hypertension. The nurse should inform the client that his blood pressure of 124/84mm Hg places him in which of the following categories? A. Within the expected reference range B. Prehypertension C. Stage 1 hypertension D. Stage 2 hypertension

B. Prehypertension Rationale: A blood pressure of 124/84 mm Hg places this client in the prehypertension category. Prehypertension is indicated by a systolic pressure between 120 and 130 mm Hg and a diastolic pressure between 80 and 89 mm Hg.

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects? A. Vitamin K B. Protamine sulfate C. acetylcysteine D. Deferasirox

B. Protamine Sulfate Rationale: Protamine sulfate reverses the effects of heparin by binding with heparin to form a heparin-protamine complex that has no anticoagulant properties.

A nurse is caring for a client who was admitted for treatment of left-sided HF and is receiving IV loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular HR. Which of the following actions should the nurse take first? A. Obtain the client's current weight B. Review serum electrolyte values C. Determine the time of the last digoxin dose D. Check the client's urine output

B. Review serum electrolyte values Rationale: Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia.

A nursing is monitoring a client's ECG monitor and notes the client's rhythm has changed from normal sinus rhythm to supraventricular tachycardia. The nurse should prepare to assist with which of the following interventions? A. Initiate chest compressions B. Vagal stimulation C. Adm. of atropine IV D. Defibrillation

B. Vagal stimulation Rationale: The nurse should identify that vagal stimulation might temporarily convert the client's heart rate to normal sinus rhythm. The nurse should have a defibrillator and resuscitation equipment at the client's

A nurse is reviewing the laboratory results of several male clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which of the following lab values? A. Cholesterol 180 mg/dL, HDL 70mg/dL, LDL 90 mg/dL B. Cholesterol 185 mg/dL, HDL 50mg/dL, LDL 120 mg/dL C. Cholesterol 190 mg/dL, HDL 25mg/dL, LDL 160 mg/dL D. Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL

C. Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL Rationale: These laboratory values for HDL and LDL are outside of the expected reference range and indicate that the nurse should provide dietary teaching to the client. The expected reference range for cholesterol is less than 200 mg/dL; for HDL is above 45 mg/dL for males and above 55 mg/dL for females; and for LDL is less than 130 mg/dL.

A nurse is monitoring an older adult client immediately following a bronchoscopy. The nurse's priority is to monitor the client for which of the following? A. Observing for confusion B. Auscultating Breath sounds C. Confirming the gag reflex D. Measuring BP

C. Confirming the gag reflex Rationale: When using the airway, breathing, circulation approach to client care, the nurse should first assess the client's gag reflex to ensure that the client has an open airway.

A nurse is caring for a client who is post-op following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus? A. Positive Kernig's sign B. Positive Homan's sign C. Dull, aching calf pain D. Soft, pliable calf muscle

C. Dull, aching calf pain Rationale: Dull, aching calf pain is a sign of deep-vein thrombosis. Other manifestations are edema, warmth, and redness in the calf.

A nurse in an ED (ER) is caring for a client who has a BP of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first? A. Initiate seizure precautions B. Tell the client to report vision changes C. Elevate the heard of the client's bed D. Start a peripheral IV

C. Elevate the head of bed Rationale: The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation.

A nurse is caring for a client who is scheduled for a CABG in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse? A. My arthritis ice really bothering me because I haven't taken my aspirin in a week B. My BP shouldn't be high because I took my BP med this AM C. I took my warfarin last night according to my usual schedule D. I will check my blood sugar because I took a reduced dose of insulin this AM

C. I took my warfarin last night according to my usual schedule Rationale: Clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding.

A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should the nurse indicate to the nurse the need for additional teaching? A. "I will wear gloves when removing food from the freezer." B. " I will try to anticipate and avoid stressful situations when possible" C. "I will complete the smoking cessation program I started" D. "I will take my medications at the first sign of an attack"

D. " I will take my medications at the first sign of an attack" Rationale: Taking medications at the onset of an episode of Raynaud's disease may help to reduce the severity of the manifestations, but it will not prevent the onset of vasoconstriction.

A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? A. "I'm still hungry after the bowl of cereal I ate at 7 am" B. "I didn't take my heart pills this morning because the dr. told me not to" C. " I have had chest pain a couple of times since I saw my dr. in the office last week" D. "I smoked a cigarette this morning to calm my nerves about having this procedure."

D. "I smoked a cigarette this morning to calm my nerves about having this procedure." Rationale: Smoking prior to this test can change the outcome and places the client at additional risk. The procedure should be rescheduled if the client has smoked before the test.

A nurse in the ED (ER) is caring for a client who had an anterior myocardial infarction. The client's hx reveals that they are 1 wk post-op following an open cholecystectomy. The nurse should identify that which of the following interventions is contraindicated? A. Adm. Iv morphine sulfate B. Adm. O2 @ 2L/min vi nasal cannula C. Helping the client to the bedside commode D. Assisting with thrombolytic therapy

D. Assisting with thrombolytic therapy Rationale: The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? A. Pigeon B. Funnel C. Kyphotic D. Barrel

D. Barrel Rationale: Clients who have COPD use accessory muscles to assist with respiratory effort. The use of those accessory muscles causes the chest wall to eventually increase in anterior-posterior diameter, making it appear barrel shaped.

A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor? A. Diagnosis diabetes mellitus B. Family history of cardiac disease C. Increasing age D. Cigarette Smoking

D. Cigarette Smoking Rationale: Smoking cigarettes is an action clients can change or stop; therefore, the nurse should include smoking cessation as a modifiable risk factor.

A nurse in the ED (ER) is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect? A. Unequal pupils B. Hypertension C. Tympany upon chest percussion D. Confusion

D. Confusion Rationale: Confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia.

A nurse is assessing a client who has a history od DVT and is receiving warfarin. Which of the following findings should indicate to the nurse that the medication is effective? A. Hemoglobin 14 g/dL B. Minimal bruising of extremities C. Decreased BP D. INR 2.0

D. INR 2.0 Rationale: The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and a stroke.

A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select? A. Dorsal metacarpal vein B. Radial vein in the wrist C. Antecubital vein D. Median vein in the forearm

D. Median vein in the forearm Rationale: The nurse should use the median vein in the forearm because it is distal to other potential venipuncture sites and it avoids areas of flexion. The bones in the forearm provide natural splinting and protection for IV insertion sites in the forearm and allow more freedom of movement for the client.

A nurse is preparing a client for coronary angiography. Which of the following findings should the nurse report to the provider prior to the procedure? A. Hemoglobin 14.4 g/dL B. History of peripheral arterial disease C. Urine output 200 mL/4 hr D. Previous allergic reaction to shellfish

D. Previous allergic reaction to shellfish Rationale: The contrast medium used for coronary angiography is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine prior to the procedure.

A nurse is caring for a client who is receiving heparin therapy and develops hematuria. which of the following actions should the nurse take if the client's aPTT is 96 seconds? A. Increase the heparin infusion flow rate by 2mL/hr B. Continue to monitor the heparin infusion as prescribed C. Request a prothrombin time (PT) D. Stop the heparin infusion

D. Stop the heparin infusion Rationale: The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury.

A nurse is assessing a client who has let-sided HF. Which of the following manifestations should the nurse expect to find? A. Increased abdominal girth B. Weak peripheral pulses C. Jugular venous neck distention D. Dependent edema

B. Weak peripheral pules Rationale: Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure.

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? A. Check the clients blood pressure B. Auscultate heart tones C. Perform a 12-lead ECG D. Determine if pain radiates to the left arm

C. Perform a 12-lead ECG Rationale: The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a myocardial infarction.

A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder? A. Maintenance of ideal weight B. Annual influenza immunization C. Smoking cessation D. Regular moderate exercise

C. Smoking Cessation Rationale: Smoking is a major cause of chronic bronchitis; therefore, smoking cessation is an effective preventive strategy.

A nurse is caring for a client who is 1 hr post-op following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider? A. Serosanguineous drainage on dressing B. Severe pain with coughing C. Urine output of 20 mL/hr D. Increase temp. from 36.8 (98.2) to 37.5 (99.5)

C. Urine output of 20 mL/hr Rationale: Urine output less than 30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture.

A nurse is admitting a client who has a leg ulcer and hx of diabetes mellitus. Which of the following focused assessments should the nurse use to help differentiate between an arterial ulcer and a venous stasis ulcer? A. Explore the client's family hx of peripheral vascular disease B. Note the presence or absence of pain at the ulcer site C. Inquire about the presence or absence of claudication D. Ask if the client has had a recent infection

C. inquire about the presence of absence of claudication Rationale: Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.