Exam 1 study

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? Show Explanation QID: 73357

A manifestation of a pulmonary embolism is sudden chest pain that is sharp and stabbing. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood), tachypnea, tachycardia, diaphoresis, and a feeling of impending doom.

A nurse is rewarming a client following coronary artery bypass graft (CABG) surgery. For which of the following complications of the rewarming process should the nurse monitor the client?

Acidosis Metabolic acidosis associated with hypoxia can occur if a client is rewarmed too quickly. Acidosis develops after the client starts to shiver and increases myocardial oxygen consumption. Rewarming of the client after CABG should occur at a rate no faster than 1°C (1.8°F) per hour.

A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of myocardial infarction? Show Explanation

Acute confusion Status: Correct

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? Show Explanation

Addressing the client's perception of the disease process and what might have triggered past attacks

nurse is reviewing the medical record of a client who has heart failure. Which of the following findings should the nurse expect? (Click on "Exhibit NCLEX 3" under Resources on the right-hand side for additional information about the client) Show Explanation

BMP of 200 pg/ml The nurse should identify that a client who has heart failure will have an elevated human B-type natriuretic peptide (BNP) level of >100 pg/mL. Endogenous BNP is released into the client's bloodstream due to decreased cardiac output, a process called natriuresi

nurse is providing teaching about lifestyle changes to a client who experienced a myocardial infarction and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching?

Before taking my medication, I will count my radial pulse rate."

A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? Show Explanation QID: 71447

Chest pain lasts for longer than 15 min. Status: Correct A client who has unstable angina will have chest pain lasting longer than 15 minutes. This is due to reduced blood flow in a coronary artery from atherosclerotic plaque and thrombus formation causing partial arterial obstruction or from an artery spasm. Incorrect Answers: A. A client who has unstable angina will have chest pain even while resting because of insufficient blood flow to the coronary arteries and a decreased oxygen supply. Chest pain at rest is a condition called variant (Prinzmetal's) angina and is caused by an arterial spasm. B. A client who has unstable angina will have minimal, if any, relief of chest pain with nitroglycerin. C. A client who has unstable angina will report chest pain or discomfort with exertion, which can limit the client's activity. QID: 71447 Back Next Multiple Choice Responses Chest pain is relieved soon after resting. Nitroglycerin relieves chest pain. Physical exertion does not precipitate chest pain. Chest pain lasts for longer than 15 min. Status: Correct Flag question for later

A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect? Show Explanation

Dependent edema

A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation? Show Explanation

Discuss ways the client can reduce the number of cigarettes smoked per day

A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications? Show Explanation

Dysrhythmias According to evidence-based practice, dysrhythmias (specifically ventricular fibrillation) are the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately.

A nurse is teaching a client about dietary modifications to control blood pressure. Which of the following food choices should the nurse identify as an indication that the client understands the instructions? Show Explanation

Grilled chicken salad with fresh tomatoes

nurse is completing dietary teaching with a client who has heart failure and is prescribed a 2 g sodium diet. Which of the following statements by the client indicates an understanding of the teaching? Show Explanation

I can have yogurt as a dessert." Yogurt is low in fat and sodium and is a good source of calcium and protein.

nurse is providing discharge teaching to a client who had a pulmonary embolism. Which of the following statements indicates that the client understands the information?

I'll call the doctor if I see any blood in my urine or stool."

nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take?

Increase the oxygen flow and request an arterial blood gas

A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? Show Explanation

Increased pulmonary congestion

nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the post-procedure plan of care? Show Explanation

Monitor for bleeding Bleeding is a post-procedure complication of PTCA because of the administration of heparin during the procedure and the removal of the femoral (or brachial) sheath. Manual pressure or a closure device is used to obtain hemostasis to the site. The client should remain on bed rest until hemostasis is assured.

nurse is caring for a client who is having a possible myocardial infarction (MI). Which of the following findings should the nurse identify as an associated manifestation of an MI?

Nausea

nurse is examining the ECG of a client who is having an acute myocardial infarction. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alterations?

Necrosis

A nurse is auscultating the lungs of a client who is having an acute asthma attack. Which of the following sounds should the nurse expect to hear? Show Explanation

Noisy wheezing

nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease (COPD) with emphysema. This breathing technique accomplishes which of the following? Show Explanation

Promote Co2 elimination

A nurse is caring for an older adult client who has chronic obstructive pulmonary disease (COPD) with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances?

Resp acidosis This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.

A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?

Respiratory alkalosis

nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? Show Explanation

Tachycardia

nurse is reviewing the progress notes for a client who has heart failure. The provider noted some improvement in the client's cardiac output. The nurse should understand that cardiac output reflects which of the following physiologic parameters?

The heart rate times the stroke volume

A nurse is providing discharge teaching to a client who has emphysema. Which of the following instructions should the nurse include? Show Explanation

Try to drink at least 2 to 3 liters of fluid per day."

Anurse is reviewing the menu selections of a client who has heart failure and anticipates discharge to home the following day. Which of the following lunch choices should the nurse identify as an indication that the client understands his dietary instructions? Show Explanation

Turkey on whole wheat

A nurse is providing discharge teaching about improving gas exchange for a client who has emphysema. Which of the following instructions should the nurse include in the teaching?

Use pursed-lip breathing during periods of dyspnea

nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr?

Ventricular dysrhythmias

A nurse is teaching about a low-cholesterol diet to a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching?

chicken breast and corn on the cob