MED SURG FINAL EXAM
You are caring for a hospitalized older patient who has nasal packing in place to treat a nosebleed. Which assessment finding will require the MOST immediate action by the RN? A. The O2 sat is 88% B. Nose is red and swollen. C. Temp is 100.7*F (37.8*C) D. Patient ℅ level 9 (0 to 10) pain
A. The O2 sat is 88%
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Age b. Hypertension c. Obesity d. Smoking e. Stress
ANS: B, C, D, E Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.
A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as a 7/10. What action by the nurse takes priority? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the client's chart. d. Notify the surgeon immediately.
Assess distal pulses and skin color
You are caring for a patient who received benzocaine spray prior to a recent bronchoscopy. The pt presents with continuous cyanosis even with oxygen therapy. What action would the nurse take next? A. Call RT to admin albuterol treatment B. Activate RRT C. Check the pt's peripheral pulses D. Collect blood and sputum cultures
B. Activate RRT
A nurse is assessing a client with peripheral artery disease ( PAD ). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. "Could you walk further than that a few months ago?" b. "Do you walk mostly uphill, downhill, or on flat surfaces?" c. "Have you ever considered swimming instead of walking?" d. "How much pain medication do you take each day?"
" Could you walk further than that a few months ago? " As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates the client's disease is worsening. The other questions are useful, but not as important.
A client has peripheral arterial disease ( PAD ). What statement by the client indicates misunderstanding about self-management activities? a. "I can use a heating pad on my legs if it's set on low." b. "I should not cross my legs when sitting or lying down." c. "I will go out and buy some warm, heavy socks to wear." d. "It's going to be really hard but I will stop smoking."
" I can use a heating pad on my legs if it's set on low " Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.
Which statements by the client indicate good understanding of foot care in the peripheral vascular disease? a. "A good abrasive pumice stone will keep my feet soft." b. "I'll always wear shoes if I can buy cheap flip-flops." c. "I will keep my feet dry, especially between the toes." d. "Lotion is important to keep my feet smooth and soft." e. "Washing my feet in room-temperature water is best."
" I will keep my feet dry, especially between the toes " " Lotion is important to keep my feet smooth and soft " " Washing my feet in room temperature water is best " Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry; wearing good, comfortable shoes; using lotion; washing the feet in room-temperature water; and cutting the nails straight across are all important measures. Abrasive material such as pumice stones should not be used. Cheap flip-flops may not fit well and won't offer much protection against injury.
A student nurse asks what " essential hypertension " is. What response by the registered nurse is best? a. "It means it is caused by another disease." b. "It means it is 'essential' that it be treated." c. "It is hypertension with no specific cause." d. "It refers to severe and life-threatening hypertension."
" It is hypertension with no specific cause " Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension.
A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. "Do you have trouble affording your medications?" b. "Most people with hypertension do not have symptoms." c. "You are lucky; most people get severe morning headaches." d. "You need to take your medicine or you will get kidney failure."
" Most people with hypertension do not have symptoms " Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance. admitted. A urinalysis may or may not be ordered.
An older client with PVD is explaining the daily foot care regimen to the family practices clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. "I nearly always wear comfy sweatpants and house shoes." b. "I'm glad I get energy assistance so my house isn't so cold." c. "My daughter makes sure I have plenty of lotion for my feet." d. "My hands shake when I try to do things requiring coordination."
" My hands shake when I try to do things requiring coordination " Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse should refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.
A client is taking warfarin ( Coummadin ) and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best? a. "No, it may interfere with the warfarin." b. "There isn't any information about that." c. "Why would you want to take that?" d. "Yes, it is a good supplement for you."
" No, it may interfere with the warfarin " Many foods and drugs interfere with warfarin, St. John's wort being one of them. The nurse should advise the client against taking it. The other answers are not accurate.
A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. "No, women should only have one beer a day as a general rule." b. "No, you should not drink any alcohol with hypertension." c. "Yes, since you are larger, you can have more alcohol." d. "Yes, two beers per day is an acceptable amount of alcohol."
" No, women should only have one beer a day as a general rule " Alcohol intake should be limited to two drinks a day for men and one drink a day for women. A "drink" is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited alcohol intake is acceptable with hypertension. The woman's size does not matter.
A nurse is caring for a client who weighs 22o pounds and is started on enoxaparin ( Lovenox ). How much enoxaparin does the nurse anticipate administering?
90 mg 90 mg The dose of enoxaparin is 1 mg/kg body weight, not to exceed 90 mg. This client weighs 220 pounds (110 kg), and so will get the maximal dose
The ED manager is reviewing patient charts to determine how well the staff performs when treating patients with community-acquired pneumonia. What outcome demonstrates that goals for this patient type have been met? A. Antibiotics started before admission B. Blood cultures obtained within 20 minutes C. Chest x-ray obtained within 30 minutes D. Pulse ox obtained on all patients
A. Antibiotics started before admission
Your patient has a tracheostomy, and is vented. During assessment, you observe that the patient's face is puffy and swollen. What should be your first reaction? A. Check oxygen saturation B. Notify the RRT C. Hyper-oxygenate the pt D. Assess the skin of the upper chest
A. Check oxygen saturation
Given that you are performing a comprehensive pulmonary assessment on a patient with respiratory disease. The laboratory result showed some abnormalities. Which patient's laboratory results correctly correlate with the assessment questions? A. Decreased lymphocyte- What medications are you taking? B. Elevated neutrophils- Do you smoke and or do you have any respiratory infection? C. Decreased eosinophils- Are you allergic to any environmental factors? D. Elevated red blood cells- Do you have a history of anemia? E. Decreased PaO2- Do you have any chronic lung disorders?
A. Decreased lymphocyte- What medications are you taking? B. Elevated neutrophils- Do you smoke and or do you have any respiratory infection? E. Decreased PaO2- Do you have any chronic lung disorders?
On auscultation of a patient's lungs, the RN hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the RN document this finding? A. Inspiratory crackles at the bases B. Expiratory wheezes in both lungs C. Abnormal lung sounds in the apices of both lungs D. Pleural friction rub in the right and left lower lobes
A. Inspiratory crackles at the bases
A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the client's favorite channel. d. Speak loudly to the client in case of hearing problems.
ANS: A Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more.
6. The nurse caring for oncology clients knows that which form of metastasis is the most common? a. Bloodborne b. Direct invasion c. Lymphatic spread d. Via bone marrow
ANS: A Bloodborne metastasis is the most common way for cancer to metastasize. Direct invasion and lymphatic spread are other methods. Bone marrow is not a medium in which cancer spreads, although cancer can occur in the bone marrow.
4. A group of nursing students has entered a futuristic science contest in which they have "developed" a cure for cancer. Which treatment would most likely be the winning entry? a. Artificial fibronectin infusion to maintain tight adhesion of cells b. Chromosome repair kit to halt rapid division of cancer cells c. Synthetic enzyme transfusion to allow rapid cellular migration d. Telomerase therapy to maintain chromosomal immortality
ANS: A Cancer cells do not have sufficient fibronectin and so do not maintain tight adhesion with other cells. This is part of the mechanism of metastasis. Chromosome alterations in cancer cells (aneuploidy) consist of having too many, too few, or altered chromosome pairs. This does not necessarily lead to rapid cellular division. Rapid cellular migration is part of metastasis. Immortality is a characteristic of cancer cells due to too much telomerase.
A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? a. "Continue to educate the client on possible healthy changes." b. "Emphasize complications that can occur with noncompliance." c. "Tell the client that denial is normal and will soon go away." d. "You need to make sure the client understands this illness."
ANS: A Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client
A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below: What action by the nurse is most important? a. Assess the client's blood pressure and level of consciousness. b. Call the health care provider or the Rapid Response Team. c. Obtain a permit for an emergency temporary pacemaker insertion. d. Prepare to administer antidysrhythmic medication.
ANS: A Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased perfusion, as seen in this ECG strip showing sinus bradycardia. The nurse should first assess the client's hemodynamic status, including vital signs and level of consciousness. The client may or may not need the Rapid Response Team, a temporary pacemaker, or medication; there is no indication of this in the question.
A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. "Do you have any concerns about sexuality?" b. "I'm glad to hear you are sleeping well now." c. "Sleep near your spouse in case of emergency." d. "Why would you move into the guest room?"
ANS: A Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse should investigate the reason for the move. The other two responses are likely to cause the client to be defensive.
10. A client asks the nurse if eating only preservative- and dye-free foods will decrease cancer risk. What response by the nurse is best? a. "Maybe; preservatives, dyes, and preparation methods may be risk factors." b. "No; research studies have never shown those things to cause cancer." c. "There are other things you can do that will more effectively lower your risk." d. "Yes; preservatives and dyes are well known to be carcinogens."
ANS: A Dietary factors related to cancer development are poorly understood, although dietary practices are suspected to alter cancer risk. Suspected dietary risk factors include low fiber intake and a high intake of red meat or animal fat. Preservatives, preparation methods, and additives (dyes, flavorings, sweeteners) may have cancer-promoting effects. It is correct to say that other things can lower risk more effectively, but this does not give the client concrete information about how to do so, and also does not answer the client's question.
A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety? a. Assess the IV site hourly. b. Monitor the pedal pulses. c. Monitor the client's vital signs. d. Obtain consent for a central line.
ANS: A Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. If it needs to be run peripherally, the nurse assesses the site hourly for problems. When the client is getting the central line, ensuring informed consent is on the chart is a priority. But at this point, the client has only a peripheral line, so caution must be taken to preserve the integrity of the client's integumentary system. Monitoring pedal pulses and vital signs give indications as to how well the drug is working.
An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.
ANS: A Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed.
2. The nurse working with oncology clients understands that interacting factors affect cancer development. Which factors does this include? (Select all that apply.) a. Exposure to carcinogens b. Genetic predisposition c. Immune function d. Normal doubling time e. State of euploidy
ANS: A, B, C The three interacting factors needed for cancer development are exposure to carcinogens, genetic predisposition, and immune function.
4. A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.) a. A sore that does not heal b. Changes in menstrual patterns c. Indigestion or trouble swallowing d. Near-daily abdominal pain e. Obvious change in a mole
ANS: A, B, C, E The seven warning signs for cancer can be remembered with the acronym CAUTION: changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or hoarseness. Abdominal pain is not a warning sign.
A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause
ANS: A, B, D, E The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion.
A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.
ANS: A, C, E The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done.
1. The nursing student learning about cancer development remembers characteristics of normal cells. Which characteristics does this include? (Select all that apply.) a. Differentiated function b. Large nucleus-to-cytoplasm ratio c. Loose adherence d. Nonmigratory e. Specific morphology
ANS: A, D, E Normal cells have the characteristics of differentiated function, nonmigratory, specific morphology, a smaller nucleus-to-cytoplasm ratio, tight adherence, and orderly and well-regulated growth.
A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the client's sheets. What action should the nurse perform first? a. Assess the insertion site. b. Change the client's sheets. c. Put on a pair of gloves. d. Assess blood pressure.
ANS: C For the nurse's safety, he or she should put on a pair of gloves to prevent blood exposure. The other actions are appropriate as well, but first the nurse must don a pair of gloves.
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.
ANS: B A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding.
A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best? a. "The t-PA didn't dissolve the entire coronary clot." b. "The heparin keeps that artery from getting blocked again." c. "Heparin keeps the blood as thin as possible for a longer time." d. "The heparin prevents a stroke from occurring as the t-PA wears off."
ANS: B After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a "blood thinner," although laypeople may refer to it as such.
1. The student nurse learning about cellular regulation understands that which process occurs during the S phase of the cell cycle? a. Actual division (mitosis) b. Doubling of DNA c. Growing extra membrane d. No reproductive activity
ANS: B During the S phase, the cell must double its DNA content through DNA synthesis. Actual division, or mitosis, occurs during the M phase. Growing extra membrane occurs in the G1 phase. During the G0 phase, the cell is working but is not involved in any reproductive activity.
A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals? a. Dirty carpets in need of vacuuming b. Expired food in the refrigerator c. Old medications in the kitchen d. Several cats present in the home
ANS: B Expired food in the refrigerator demonstrates a safety concern for the client and a possible lack of money to buy food. The nurse can consider a referral to Meals on Wheels or another home-based food program. Dirty carpets may indicate the client has no household help and is waiting for clearance to vacuum. Old medications can be managed by the home health care nurse and the client working collaboratively. Having pets is not a cause for concern.
A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking
ANS: B Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for.
A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends. b. Ensure the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowler's position.
ANS: B If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and assessing trends is an important nursing action related to hemodynamic monitoring, but is not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning may or may not affect readings.
The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.
ANS: B If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse should notify the provider immediately. The nurse should not independently increase the suction, re-position the chest tube, or take the tubing apart.
A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. "Fish oil is contraindicated with most drugs for CAD." b. "The best source is fish, but pills have benefits too." c. "There is no evidence to support fish oil use with CAD." d. "You can reverse CAD totally with diet and supplements."
ANS: B Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The best source is fish three times a week or some fish oil supplements. The other options are not accurate.
A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commission's Core Measures outcomes? a. Obtain an electrocardiogram (ECG) now and in the morning. b. Give the client an aspirin. c. Notify the Rapid Response Team. d. Prepare to administer thrombolytics.
ANS: B The Joint Commission's Core Measures set for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG is vital, but getting another one in the morning is not part of the Core Measures set. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed.
A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 4.2 mEq/L
ANS: B The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable.
A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.
ANS: B This client's physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.
3. A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? (Select all that apply.) a. Demonstrating breast self-examination methods to women b. Instructing people on the use of chemoprevention c. Providing vaccinations against certain cancers d. Screening teenage girls for cervical cancer e. Teaching teens the dangers of tanning booths
ANS: B, C, E Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer. Secondary prevention includes screening and early diagnosis. Primary prevention activities include teaching people about chemoprevention, providing approved vaccinations to prevent cancer, and teaching teens the dangers of tanning beds. Breast examinations and screening for cervical cancer are secondary prevention methods.
A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the client's pupillary responses. b. Request a neurologic consultation. c. Stop the infusion and call the provider. d. Take and document a full set of vital signs.
ANS: C A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.
The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? a. "It constricts vessels, improving blood flow." b. "It dilates vessels, which lessens the work of the heart." c. "It increases the force of the heart's contractions." d. "It slows the heart rate down for better filling."
ANS: C A positive inotrope is a medication that increases the strength of the heart's contractions. The other options are not correct.
A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.
ANS: C Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the provider's prescription and the client's current medications.
3. The nursing instructor explains the difference between normal cells and benign tumor cells. What information does the instructor provide about these cells? a. Benign tumors grow through invasion of other tissue. b. Benign tumors have lost their cellular regulation from contact inhibition. c. Growing in the wrong place or time is typical of benign tumors. d. The loss of characteristics of the parent cells is called anaplasia.
ANS: C Benign tumors are basically normal cells growing in the wrong place or at the wrong time. Benign cells grow through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of cancer cells.
A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours
ANS: C Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.
A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed? a. 1530 (3:30 PM) b. 1600 (4:00 PM) c. 1630 (4:30 PM) d. 1700 (5:00 PM)
ANS: C The Joint Commission's Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of diagnosis of myocardial infarction. Therefore, the client should have a percutaneous coronary intervention performed no later than 1630 (4:30 PM).
8. A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. What statement by the client indicates the nurse needs to provide additional teaching? a. "Foods high in vitamin A and vitamin C are important." b. "I'll have to cut down on the amount of bacon I eat." c. "I'm so glad I don't have to give up my juicy steaks." d. "Vegetables, fruit, and high-fiber grains are important."
ANS: C To decrease the risk of developing cancer, one should cut down on the consumption of red meats and animal fat. The other statements are correct.
7. A nurse is assessing a client with glioblastoma. What assessment is most important? a. Abdominal palpation b. Abdominal percussion c. Lung auscultation d. Neurologic examination
ANS: D A glioblastoma arises in the brain. The most important assessment for this client is the neurologic examination.
2. A student nurse asks the nursing instructor what "apoptosis" means. What response by the instructor is best? a. Growth by cells enlarging b. Having the normal number of chromosomes c. Inhibition of cell growth d. Programmed cell death
ANS: D Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of chromosomes is euploidy. Inhibition of cell growth is contact inhibition.
A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.
ANS: D Normal right atrial pressures are from 1 to 8 mm Hg. Lower pressures usually indicate hypovolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain leveled at the phlebostatic axis. Positioning may or may not influence readings. Diuretics would be contraindicated.
A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the client's stress levels. d. Tell the client that anxiety is common and that you can help.
ANS: D Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse should reassure the client that fear is common and offer to help. The other actions will not reduce the client's anxiety.
9. A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the client's chart that the cancer classification is TISN0M0. What does the nurse conclude about this client's cancer? a. The primary site of the cancer cannot be determined. b. Regional lymph nodes could not be assessed. c. There are multiple lymph nodes involved already. d. There are no distant metastases noted in the report.
ANS: D TIS stands for carcinoma in situ; N0 stands for no regional lymph node metastasis; and M0 stands for no distant metastasis.
A nurse is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the nurse hears the following sound. What action by the nurse is most appropriate? (Click the media button to hear the audio clip.) a. Assess for further chest pain. b. Call the Rapid Response Team. c. Have the client sit upright. d. Listen to the client's lung sounds.
ANS: D The sound the nurse hears is an S3 heart sound, an abnormal sound that may indicate heart failure. The nurse should next assess the client's lung sounds. Assessing for chest pain is not directly related. There is no indication that the Rapid Response Team is needed. Having the client sit up will not change the heart sound.
The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.
ANS: D To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority.
5. Which statement about carcinogenesis is accurate? a. An initiated cell will always become clinical cancer. b. Cancer becomes a health problem once it is 1 cm in size. c. Normal hormones and proteins do not promote cancer growth. d. Tumor cells need to develop their own blood supply.
ANS: D Tumors need to develop their own blood supply through a process called angiogenesis. An initiated cell needs a promoter to continue its malignant path. Normal hormones and proteins in the body can act as promoters. A 1-cm tumor is a detectable size, but other events have to occur for it to become a health problem.
A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to target audience should the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps d. Women's health clinics
African American churches African Americans in the United States have one of the highest rates of hypertension in the world. The nurse has the potential to reach this priority population by providing services at African-American churches. Although hypertension education and screening are important for all groups, African Americans are the priority population for this intervention.
A client has a deep vein thrombosis ( DVT ). What comfort measure does the nurse delegate to the unlicensed assistive personnel? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the client's leg. d. Provide an ice pack.
Apply a warm moist pack Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client's legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT
A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the UAP for deep vein thrombosis ( DVT ) prevention? a. Apply compression stockings. b. Assist with ambulation. c. Encourage coughing and deep breathing. d. Offer fluids frequently. e. Teach leg exercises.
Apply compression stockings Assist with ambulation Offer fluids frequently The UAP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT. The UAP can also encourage the client to do pulmonary exercises, but these do not decrease the risk of DVT. Teaching is a nursing function
What nonpharmacologic comfort measures should the nurse include in the plan for a client with severe varicose veins? a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options
Applying elastic compression stockings Elevating the legs when sitting or lying Reminding the client to do leg exercises ANS: B, C, D The three E's of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure
A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the client's temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the client's daily white blood cell count
Appropriate hand hygiene before giving care Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes should be done with sterile technique. Assessing vital signs and white blood cell count will not prevent infection.
The nurse is working with a client who takes atorvastatin ( Lipitor ). The client's recent laboratory results include a blood urea nitrogen ( BUN ) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis.
Ask if the client eats grapefruit There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse should assess if the client eats grapefruit or drinks grapefruit juice.
A nurse is caring for a client with a nonhealing arterial ulcer. The physician has informed the client about possibly needing to amputate the client's leg. The client is cry and upset. What actions by the nurse are best? a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires. d. Relate how smoking contributed to this situation. e. Tell the client that many people have amputations.
Ask the client to describe his or her current emotions Assess the client for support system and family Offer to stay with the client if he or she desires When a client is upset, the nurse should offer self by remaining with the client if desired. Other helpful measures include determining what and whom the client has for support systems and asking the client to describe what he or she is feeling. Telling the client how smoking has led to this situation will only upset the client further and will damage the therapeutic relationship. Telling the client that many people have amputations belittles the client's feelings.
A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mmHg. What actions by the nurse are most important? a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes
Assess distal pulses ever 10 minutes Notify the Rapid Response Team Take vital signs every 10 minutes This client may have a ruptured/rupturing aneurysm. The nurse should notify the Rapid Response team and perform frequent client assessments. Giving pain medication will lower the client's blood pressure even further. The nurse cannot have the client sign a consent until the physician has explained the procedure.
A nurse is caring for a client on IV infusion of heparin. What action does this nurse include in the client's plan of care? a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. c. Stop the IV for aPTT above baseline. d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale.
Assess the client for bleeding Monitor the daily activated partial thromboplastin time ( aPTT ) results Use an IV pump for the infusion Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2 times normal in order to demonstrate that the heparin is therapeutic. Weighing the client is not related.
The nurse is assessing a client on admission to the hospital. The client's leg appears as shown below: What action by the nurse is best? a. Assess the client's ankle-brachial index. b. Elevate the client's leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium.
Assess the client's ankle-brachial index This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse should measure the client's ankle-brachial index. Elevating the leg above the heart will further impede arterial blood flow. Ice will cause vasoconstriction, also impeding circulation and perhaps causing tissue injury. Heparin sodium is not the drug of choice for this condition.
A client with a history of heart failure and hypertension is in the clinic for a follow up visit. The client is on Lisinopril ( Prinvil ) and warfarin ( Coumadin ). The client reports new onset cough. What action by the nurse is most appropriate? a. Assess the client's lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil.
Assess the client's lung sounds and oxygenation ANS: A This client could be having an exacerbation of heart failure or be experiencing a side effect of lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse should assess the client's lung sounds and other signs of oxygenation first. The client may or may not need to switch antihypertensive medications. Vital signs and documentation are important, but the nurse should assess the respiratory system first. If the cough turns out to be a side effect, reminding the client is appropriate, but then more action needs to be taken.
A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin ( Comadin ). The client is adamant about refusing the drug because " it's dangerous ". What action by the nurse is best? aa. Assess the reason behind the client's fear. b. Remind the client about laboratory monitoring. c. Tell the client drugs are safer today than before. d. Warn the client about consequences of noncompliance.
Assess the reason behind the client's fear
A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the client's support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the client's obligations.
Assist in finding one change the client can control. All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse should assist the client in choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can move forward with another change. Determining support systems, daily stressors, and delegation opportunities does not directly impact the client's feelings of control
The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? a. Atherosclerosis b. Down syndrome c. Frequent heartburn d. History of hypertension e. History of smoking
Atherosclerosis History of hypertension History of smoking Atherosclerosis, hypertension, hyperlipidemia, and smoking are the most common related factors. Down syndrome and heartburn have no relation to aneurysm formation.
The nurse discusses management of upper respiratory infections (URI) with a pt who has acute sinusitis. Which statement by the pt indicates that additional teaching is needed? A. I can take acetaminophen (Tylenol) to treat my discomfort B. I will drink lots of juices and other fluids to stay well hydrated C. I can use my nasal decongestant spray until the congestion is all gone D. I will watch for changes in nasal secretions or the sputum that I cough up
C. I can use my nasal decongestant spray until the congestion is all gone Rationale: The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective
Your patient had a bronchoscopy. After the procedure, which intervention is most appropriate? A. Elevate the head of the bed to 80-90 degrees. B. Keep the patient NPO until the gag reflex returns. C. Place on bed rest for at least 4 hours after bronchoscopy. D. Notify the health care provider about blood-tinged mucus.
B. Keep the patient NPO until the gag reflex returns.
A diabetic patient's ABG results are pH 7.29; PaCO2 33 mg Hg; PaO2 87 mm Hg; HCO3 19 mEq/L. The RN would expect which finding? A. Intercostal retractions B. Kussmaul respirations C. Low O2 sat (SpO2) D. Decreased venous O2 pressure
B. Kussmaul respirations
Your pt is scheduled for a CT of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider? A. Patient is claustrophobic B. Patient is allergic to shellfish C. Patient recently used a bronchodilator inhaler D. Patient is not able to remove a wedding band E. BUN and creatinine levels are elevated
B. Patient is allergic to shellfish E. BUN and creatinine levels are elevated Rationale: because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (like shellfish) and monitoring renal function before the CT scan are necessary. The other actions are contraindications for CT of the chest, although they may be for other diagnostic tests, such as MRI or pulmonary function testing.
In a Med Surg unit, a patient is admitted with acute SOB. During initial assessment which action should the RN take? A. Tell the patient to lie down to complete a full PX assessment. B. Quickly ask specific questions about this episode of respiratory distress. C. Complete the admission database to check for allergies before treatment. D. Suspend the PX assessment and focus on the completion pulmonary function tests.
B. Quickly ask specific questions about this episode of respiratory distress.
The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread
Baked chicken breast, broccoli, tomatoes The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.
A patient who had a total laryngectomy has a nursing diagnosis of hopelessness r/t loss of control of personal care. Which info obtained by the RN is the BEST indicator that the identified problem is resolving? A. The patient lets the spouse provide tracheostomy care. B. The patient allows the RN to suction the trach. C. The patient asks how to clean the trach stoma and tube. D. The patient uses a communication board to request "No visitors."
C. The patient asks how to clean the trach stoma and tube. Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.
RN observes a student who is listening to a patient's lungs who is having no problem with breathing. Which action by the student indicates a need to review respiratory assessment skills? A. The student starts at the apices of the lungs and moves to the bases. B. The student compares breath sounds from side to side avoiding bon areas. C. The student places the stethoscope over the posterior chest and listens only during inspiration. D. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.
C. The student places the stethoscope over the posterior chest and listens only during inspiration.
You are caring for a guy with a 20 pack year smoking history. Which action is most important when interviewing him? A. Inform the patient that he needs to quit smoking to stop further cancer development B. Advise the pt to be completely honest about both tobacco and marijuana use C. Use a non prejudicial approach to avoid D. Do not give the pt false hope regarding cancer tx and prognosis
C. Use a non prejudicial approach to avoid
A nurse is caring for four clients. Which one should the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom c. Hypertensive client with a blood pressure of 188/92 mm Hg d. Client who needs pain medication prior to a dressing change of a surgical wound
Client who had a first does of captopril ( Capoten ) and needs to use the bathroom Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse should see this client first to prevent falling if the client decides to get up without assistance. The two blood pressure readings are abnormal but not critical. The nurse should check on the client with higher blood pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards state to hold it if the systolic blood pressure is below 90 mm Hg. The client who needs pain medication prior to the dressing change is not a priority over client safety and assisting the other client to the bathroom.
A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? a. Consult with the Wound Ostomy Care Nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.
Consult with the Wound Ostomy Care Nurse A nonhealing wound needs the expertise of the Wound Ostomy Care Nurse (or Wound Ostomy Continence Nurse). Premedicating prior to painful procedures and maintaining sterile technique are helpful, but if the wound is not healing, more needs to be done. The client may need an amputation, but other options need to be tried first.
A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? a. Assesses the client for back pain b. Auscultates over abdominal bruit c. Measures the abdominal girth d. Palpates the abdomen in four quadrants
Palpates the abdomen in four quadrants Abdominal aneurysms should never be palpated as this increases the risk of rupture. The registered nurse should intervene when the student attempts to do this. The other actions are appropriate.
RN admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching re: med use? A. "I have not had any acute asthma attacks during the last year." B. "I became SOB an hr before coming to the hospital." C. "I've been taking Tylenol 650 mg every 6 hours for chest wall pain." D. "I've been using my albuterol inhaler more frequently over the last 4 days."
D. "I've been using my albuterol inhaler more frequently over the last 4 days."
You are assessing the respiratory system of an 80 year old pt, which finding indicates that you should take immediate action? A. Weak cough effort and non productive B. Anterior posterior view barrel-shaped chest C. Mucous membranes dry and intact D. Crackles bilaterally at lungs bases
D. Crackles bilaterally at lungs bases
A clinic nurse prepared to teach a pt how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? A. Hand washing is the primary way to prevent spreading the condition to others B. Use of oral antihistamines for 2 wks before the allergy season may prevent reactions C. Corticosteroids nasal sprays will reduce inflammation, but systemic effects limit their use D. Identification and avoidance of environmental triggers are best way to avoid symptoms
D. Identification and avoidance of environmental triggers are best way to avoid symptoms
Which ABG result is most important for the nurse to report immediately to the health care provider? A. pH 7.34, PaO2 80 mmhg, PaCO2 41 mmhg, O2 sat 98% B. pH 7.35, PaO2 85 mmhg, PaCO2 45 mmhg, O2 sat 95% C. pH 7.46, PaO2 90 mmhg, PaCO2 32 mmhg, O2 sat 98% D. pH 7.31, PaO2 91 mmhg, PaCO2 50 mmhg, O2 sat 96%
D. pH 7.31, PaO2 91 mmhg, PaCO2 50 mmhg, O2 sat 96%
A client is being discharged on warfarin ( Coumadin ) therapy. What discharge instructions is the nurse required to provide? A. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication
Dietary restrictions Follow up laboratory monitoring Possible drug-drug interactions Reason to take medication The Joint Commission's Core Measures state that clients being discharged on warfarin need instruction on follow-up monitoring, dietary restrictions, drug-drug interactions, and reason for compliance. Driving is typically not restricted.
A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met? a. Pain rated as 2/10 after medication b. Distal pulse on affected extremity 2+/4+ c. Remains on bedrest as directed d. Verbalizes understanding of procedure
Distal pulse on affected extremity 2+/4+ Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+ indicates good perfusion. Pain control, remaining on bedrest as directed after the procedure, and understanding are all important, but do not take priority over perfusion.
A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse? a. Administer oxygen via non-rebreather mask. b. Ensure the client has a patent airway. c. Prepare to assist with suturing the artery. d. Start two large-bore IVs with normal saline
Ensure the client has a patent airway Airway always takes priority, followed by breathing and circulation. The nurse ensures the client has a patent airway prior to providing any other care measures.
The nurse is caring for four hypertensive clients. Which drug-laboratory value combination should the nurse report immediately to the health care provider? a. Furosemide (Lasix)/potassium: 2.1 mEq/L b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L d. Torsemide (Demadex)/sodium: 142 mEq/L
Furosemide ( Lasix )/ potassium: 2.1 mEq/L Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and should be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal.
A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best? a. Ask if the weight loss was intended. b. Encourage a high-protein, high-fiber diet. c. Measure for new compression stockings. d. Review a 3-day food recall diary.
Measure for new compression stockings Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client should be re-measured and new stockings ordered if needed. The other options are appropriate, but not the most important.
A client is receiving an infusion of alteplase ( Activase ) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority? a. Assess the client's neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.
Notify the Rapid Response Team Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurological examination, but should first call the Rapid Response Team based on the client's manifestations. The nurse notifies the Rapid Response Team first. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful if the client is still receiving any of the drug.
A nurse is caring for a client with deep vein thrombosis ( DVT ). What nursing assessment indicates a priority outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors
Oxygen saturation of 98% A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not the priority.
A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same time
Palpating both carotid arteries at the same time The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated.
A nurse wants to provide community service that helps meet the goals of Healthy People 2020 related to cardiovascular disease and stroke. What activity would best meet this goal? a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an "Ask the nurse" booth at the pet store.
Participate in blood pressure screenings at the mall
A nurse is preparing a client for a femoropopliteal bypass operation. What action does the nurse delegate to the UAP? a. Administering preoperative medication b. Ensuring the consent is signed c. Marking pulses with a pen d. Raising the siderails on the bed e. Recording baseline vital signs
Raising the side rails on the bed Recording baseline vital sings The UAP can raise the siderails of the bed for client safety and take and record the vital signs. Administering medications, ensuring a consent is on the chart, and marking the pulses for later comparison should be done by the registered nurse. This is also often done by the postanesthesia care nurse and is part of the hand-off report.
The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. Cholesterol: 126 mg/dL b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL d. Triglycerides: 198 mg/dL
Triglycerides: 198 mg/dL
