MedSurg 2 Final

1. A client's mother asks what is the most important thing she will need to know to care for her son who is having an inner maxillary fixation completed as an outpatient. What does the nurse tell her? a. Give her Phenergan by rectum around the clock so he does not vomit b. He can only drink milk and eat ice cream until the wires come off c. He must brush his teeth every 2 hours d. Make sure he always has wire cutters with him

a. Make sure he always has wire cutters with him

1. What is the highest priority of care for a client with head and neck cancer who underwent a total laryngectomy with neck dissection 24 hours ago? a. Maintaining airway and ventilation b. Monitoring urinary output hourly c. Supporting the family emotionally d. Having the client view the surgical site

a. Maintaining airway and ventilation

Which client has the highest risk for cardiovascular disease? a. Man who smokes and whose father died at 49 from MI b. Woman with abdominal obesity who exercises three times per week c. Woman with diabetes whose HDL cholesterol is 75 d. Man who is sedentary and reports four episodes of strep throat

a. Man who smokes and whose father died at 49 from MI

The nurse is teaching a client ways to increase vitamin D in the diet using natural foods (unfortified). Which food choices indicate the client understands the teaching? Select all that apply.

a. Milk b. Eggs c. Tofu d. Liver

The nurse observes that a client has an ingrown toenail that is hindering the client's ambulation. What treatment does the nurse suggest for this client? Select all that apply.

a. Soaking the foot in warm water b. Applying antibiotic ointment

A client has sustained a fracture of the left tibia. The extremity is immobilized using an external fixation device. Which postoperative instruction does the nurse include in this client's teaching plan?

a. Use pain medication as prescribed to control pain

A client is taking warfarin for the treatment of DVT. Which vitamin can lead to complications if taken during this treatment? a. Vitamin K b. Vitamin A c. Vitamin E d. Vitamin C

a. Vitamin K

The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? a. Friction rub auscultation at the left lower sternal border b. Pain aggravated by breathing, coughing, and swallowing c. Splinter hemorrhages d. Thickening of the endocardium

c. Splinter hemorrhages

Which nursing intervention for a client admitted today with heart failure assist the client to conserve energy? a. Client ambulates around the nursing unit with a walker b. The nurse monitors the client's pulse and BP frequently c. The nurse obtains a bedside commode before administering Lasix d. The nurse returns the client to bed when he becomes tachycardic

c. The nurse obtains a bedside commode before administering Lasix

Which diagnostic test requires the nurse to know whether the client is allergic to iodine-based contrast?

CT

1. Which of these clients should the charge nurse assign to the LPN/LVN working on the med-surg unit? a. Client with group A beta-hemolytic strep pharyngitis who has stridor b. Client with pulmonary Tb who is receiving multiple medications c. Client with sinusitis who has arrived after having endoscopic surgery d. Client with tonsillitis who has a thick-sounding voice and difficulty swallowing

Client with pulmonary Tb who is receiving multiple medications

1. A client is being discharged home with active Tb. Which information does the nurse include in the discharge teaching plan? a. You are not contagious unless you stop taking your medication b. You will need to have your household undergo TB testing c. You will have to take these medications for at least 1 year d. Your sputum may turn a rust color as your condition gets better

You will need to have your household undergo TB testing

The nursing student is assisting with the care of a client who has undergone CABG. Which statement by the student about the procedure indicates a need for further teaching by the supervising nurse? a. "Best outcome from CABG occur when coronary arteries have less than a 50% occlusion." b. "CABG may be used when the left main coronary artery is occluded and a stent cannot be placed." c. "The quality of the client's life will be improved by CABG surgery." d. Best long-term graft patency results when the internal mammary artery is used."

a. "Best outcome from CABG occur when coronary arteries have less than a 50% occlusion."

1. A client has undergone neck dissection surgery and has a skin flap and a closed surgical drain. The nurse has been monitoring drainage hourly on the first postop day and notes a decrease in amount from 20-30 mL hourly less than 5 mL in 1 hours. The nurse suspects which cause for this decrease in drainage? a. A clot obstructing the drain b. Displacement of the drain c. Edema of surrounding tissues d. Formation of granulation tissue

a. A clot obstructing the drain

1. Where does gas exchange occur? a. Acinus b. Alveolus c. Bronchus d. Carina

a. Alveolus

What does the nurse assess to evaluate a client's gait?

a. Ease and length of a stride

Which nursing action has the highest priority when caring for a client with laryngeal trauma? a. Managing pain b. Assessing for bleeding c. Maintaining a patent airway d. Providing a communication method

a. Maintaining a patent airway

Which factors increase the risk of atherosclerosis? Select all that apply. a. Smoking b. Low LDL-C c. DM d. Genetic predisposition e. Decreased triglycerides

a. Smoking c. DM d. Genetic predisposition

Which assessment or test is used to confirm a diagnosis of ineffective endocarditis? a. Presence of third heart sounds b. Echocardiogram c. CBC d. Positive blood cultures

d. Positive blood cultures

The nursing instructor is teaching a group of nursing students about DMD. What statement by a nursing student indicates the need for further instruction?

a. A person with DMD will have a normal life span

1. A client is admitted with symptoms of periorbital and facial edema, swelling of the hands and feet, bilateral crackles in the lungs, and reddish-brown urine. The client reports having had a fever and sore throat 10 days prior to developing symptoms. The nurse suspects that this client may have which condition? a. Acute glomerulonephritis b. HIV c. Peritonsillar abscess d. Rheumatic fever

a. Acute glomerulonephritis

1. A client with chronic COPD has a physician's prescription stating, "Adjust oxygen to keep SpO2 at 90 % to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN? a. Adjust the position of the oxygen tubing b. Assess for signs and symptoms of hypoventilation c. Change the O2 flow rate to keep SpO2 as prescribed d. Choose which O2 delivery device should be used for the client

a. Adjust the position of the oxygen tubing

Which action does the nurse take if the client develops bradycardia during nasopharyngeal suctioning? a. Administer a bronchodilator using a small particle nebulizer b. Ask the client to hold the breath and then cough c. Administer 100% oxygen by bag-valve-mask d. Complete the suctioning as quickly as possible

a. Administer 100% oxygen by bag-valve-mask

1. A client with asthma reports SOB. What is the nurse assessing when auscultating this client's chest? a. Adventitious breath sounds b. Fremitus c. Oxygenation status d. Respiratory excursion

a. Adventitious breath sounds

The nurse is caring for an older adult with Alzheimer's disease. The nurse provides meticulous oral care to prevent which condition? a. Airway obstruction b. Laryngeal edema c. Pharyngeal abscess d. Pharyngitis

a. Airway obstruction

The nurse is teaching a client about INH and RIF drug therapy for TB. The nurse instructs that while on these medications, the client should avoid consuming which food? a. Dairy b. Red meat c. Alcohol d. Eggs

a. Alcohol

1. Which two factors in combination are the greatest risk factors for head and neck cancer? a. Alcohol and tobacco use b. Chronic laryngitis and voice abuse c. Marijuana use and exposure to industrial chemicals d. Poor hygiene and use of chewing tobacco

a. Alcohol and tobacco use

1. A client is being evaluated for laryngeal cancer. Besides tobacco use, which aspect of the client's history is important for the nurse to assess? a. Alcohol consumption b. Dietary habits c. PUD d. SOB

a. Alcohol consumption

1. A healthy client expresses worries about developing TB after spending time at a family reunion and learning later that a family member is being treated for the disease. What does the nurse tell this client? a. Among people exposed to the disease, only a small percentage develop active TB b. TB is spread from person to person by sharing drinking cups and eating utensils c. You have most likely been exposed to TB and will need to be tested d. You should receive TB prophylaxis until your provider rules out active disease

a. Among people exposed to the disease, only a small percentage develop active TB

1. Which client has the most urgent need for frequent nursing assessment? a. An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45 year 2 pack per day smoking hx, and receiving 50 % oxygen through venturi mask b. A young client who has had a tracheostomy for 1 week, who is on room air with SpO2 at percents in the upper 90s, who has been receiving antibiotic therapy for 16 hours, and who has foul smelling drainage on the tracheostomy ties c. An older adult client who is anxious to go home with her new tank of oxygen and supply of nasal cannulas and is being discharged with a new prescription for home oxygen therapy d. A middle aged client who was admitted yesterday with pneumonia and is receiving oxygen at 2 L/min through a nasal cannula

a. An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45 year 2 pack per day smoking hx, and receiving 50 % oxygen through venturi mask

A client has a callus of the foot. What treatment does the nurse anticipate for this client?

a. Application of padding and lanolin cream

1. The nurse is caring for a client after cardiac catheterization. What follow-up care does the nurse provide for this client? a. Restrict oral and IV fluids b. Remove the dressing after 6 hours c. Apply a soft knee brace d. Encourage the client to walk the next day

a. Apply a soft knee brace

1. What is the term for the opening between the vocal cords? a. Artenoid cartilage b. Epiglottis c. Glottis d. Palatine tonsils

a. Glottis

1. A client who is several days postop for partial laryngectomy has successfully learned to swallow without aspiration and is speaking a hoarse voice. The client appears distressed and repeatedly reports feeling unable to provide self-care. Which intervention does the nurse perform first? a. Ask the client to identify underlying fears b. Administer prescribed antianxiety drugs c. Reassure the client that the worst is over d. Refer the client to a support group in the community

a. Ask the client to identify underlying fears

A client who is several days postoperative for partial laryngectomy has successfully learned how to swallow without aspiration and is speaking with a hoarse voice. The client appears distressed and repeatedly reports feeling unable to provide self-care. Which intervention does the nurse perform first? a. Ask the client to identify underlying fears b. Administer prescribed antianxiety drugs c. Reassure the client that the worst is over d. Refer the client to a support group in the community

a. Ask the client to identify underlying fears

1. During shift report, the nurse learns the assigned client with chronic lung disease receiving oxygen at 4 L/min per nasal cannula. When entering the client's room, what is the nurse's initial action? a. Reduce the rate of oxygen to 3 L/min b. Assess the oxygen sat with a pulse ox c. Request an order for ABG's d. Auscultate the lung sounds

a. Assess the oxygen sat with a pulse ox

1. The nurse is planning to care for an 80-year-old long-term care client who takes histamine-2 blocker and who is confused most of the time. To help prevent pulmonary infection in this client, which nursing action is included in the plan of care? a. Assist the client with all oral intake b. Administer prophylactic antibiotic medications c. Request an order for bronchodilator medications d. Provide postural drainage every 8 hours

a. Assist the client with all oral intake

1. A client has lobar pneumonia. To help ensure that the expected outcome of maintaining an oxygen sat of 95% or greater is met, which nursing intervention is most important? a. Assess breath sounds and respiratory effort every 4 hours b. Assist with coughing, deep-breathing, and incentive spirometery every 2 hours c. Monitor VS and effectiveness of antibiotics every 4 hours d. Obtain CBC, sputum and blood cultures

a. Assist with coughing, deep-breathing, and incentive spirometery every 2 hours

1. The nurse is providing teaching to a client who has been diagnosed with bacterial rhinosinusitis. Which instruction does the nurse include when teaching this client about his diagnosis? a. Facial pain that is worse when bending forward is abnormal and should be reported to your provider b. Be sure to complete the full course of antibiotics c. Decongestants may cause rebound rhinitis and should be avoided d. Fluid should be restricted to prevent excess mucus production

a. Be sure to complete the full course of antibiotics

1. The nurse is assisting a client who is learning to use the supraglottic method of swallowing after partial laryngectomy. What does the nurse instruct the client to do immediately after placing food in the mouth? a. Bear down b. Clear the throat c. Swallow twice d. Take a deep breath

a. Bear down

Which statement regarding a venous stasis ulcer is incorrect? a. Black ulceration presents at the tip of the toes b. The medial malleolus has brown discoloration c. The foot swells in the dependent position d. A superficial wound on the ankle is present for 6 months

a. Black ulceration presents at the tip of the toes

1. Which procedure describes a tube inserted into the airway in order to view airway structures and obtain tissue samples for a biopsy? a. Bronchoscopy b. Thoracentesis c. Pulmonary function test d. Transthoracic needle aspiration

a. Bronchoscopy

1. Which component of a clients family history is of particular importance to the home health nurse who is assessing a new client with asthma? a. Brother is allergic to peanuts b. Father is obese c. Mother is diabetic d. Sister is pregnant

a. Brother is allergic to peanuts

Which hormone increases the renal excretion of calcium?

a. Calcitonin

Which conditions increase the risk of pulmonary embolism? Select all that apply. a. Cancer b. Cardiac failure c. Vitamin A deficiency d. Vitamin C deficiency e. Chronic kidney disease

a. Cancer b. Cardiac failure e. Chronic kidney disease

1. An older adult resident in a long-term care facility becomes confused and agitated, telling the nurse "Get out of here! Youre going to kill me!" Which action will the nurse take first? a. Check the resident's Oxygen sat b. Do a complete neuro assessment c. Give prescribed PRN Ativan d. Notify the resident's primary care provider

a. Check the resident's Oxygen sat

Clients with which risk factor warrant close monitoring for an education about cancers of the nose and sinuses? a. Chronic hx of allergies and sinus infections as a child b. Chronic exposure to dust from wood, leather or flour c. Hx of need to sleep with head of bed elevated d. Presence of chronic, persistent nasal drainage

a. Chronic exposure to dust from wood, leather or flour

A client who has chronic exposure to textile dust is fearful about the risk for sinus cancer after a coworker developed the disease. To help assess risk, the nurse asks the client about which other risk factor? a. Alcohol intake b. Cigarette smoking c. Dietary fat d. Exercise habits

a. Cigarette smoking

1. A local hunter is admitted to the ICU with a diagnosis of inhalation anthrax. Which medications does the RN anticipate the HCP will order? a. Amoxicillin 500 mg orally every 8 hours b. Rocephin 2 g IV every 8 hours c. Cipro 400 mg IV every 12 hours d. PZA 1000-2000 mg orally every day

a. Cipro 400 mg IV every 12 hours

1. The nurse is performing a client assessment for the client's potential employer. The client reports dyspnea when climbing stairs, but is not dyspneic at rest. Which dyspnea classification does the nurse assign to this client in the report to the employer? a. Class 1, can perform manual labor b. Class2, can perform desk job c. Class 3, minimally employable d. Class4, must remain at home

a. Class2, can perform desk job

Four client are sent back to the emergency department from triage at the same time. Which client requires the nurse's immediate attention? a. Client with acute allergic reaction b. Client with dyspnea on exertion c. Client with lung cancer with cough d. Client with sinus infection and fever

a. Client with acute allergic reaction

The home health nurse is assigned to visit all of these clients when a change in agency staffing requires that one of the clients should be rescheduled for a visit on the following day. Which client would be best to reschedule? a. Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% b. Client with history of cough, weight loss, and night sweats who has just had a positive Mantoux test c. Client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment d. Client with percutaneous lung biopsy yesterday who called in to report increased dyspnea

a. Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93%

1. The med surg unit has one negative airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? a. Client with bacterial pneumonia and a cough productive of green sputum b. Client with neutropenia and pneumonia caused by Candida albicans c. Client with possible pulmonary TB who currently has hemoptysis

a. Client with possible pulmonary TB who currently has hemoptysis

1. Which manifestation in an older client is the most common indicator for pneumonia? a. Confusion b. Cough c. Fever d. Increased WBC count

a. Confusion

The nurse is counseling a young woman about drug therapy with INH and RIF to treat TB. Before developing the teaching plan, what must the nurse assess for first? a. Color blindness b. Susceptibility to sunburn c. Contraceptive methods used d. Hx of gout

a. Contraceptive methods used

1. Family members of a client with chronic lung disease report increasing the level of oxygen administration for the client because of increased sleepiness and decreased responsiveness, but it did not seem to help. What is the most likely reason for this? a. Insufficient pressure of the oxygen delivery b. Decreased sensitivity to increased PaCO2 levels c. Decreased response to the presence of hypoxia d. Pain medications the client is receiving

a. Decreased sensitivity to increased PaCO2 levels

What is a common side effect of the antihypertensive drug amlodipine (Norvasc)? a. Dependent foot and ankle edema b. Central and peripheral cyanosis c. Postural orthostatic hypotension d. Paradoxical blood pressure

a. Dependent foot and ankle edema

1. A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first? a. Auscultate the client's breath sounds while applying a nasal cannula b. Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask c. Apply a 100% non-rebreather mask while administering high-flow oxygen d. Replace the obturator while reinserting the tracheostomy tube

a. Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask

1. Which assessment findings are considered normal for a 79 year old client? a. Alveolar surface increases and residual volume decreases b. AP diameter decreases and elasticity increases c. Ability to cough and vital capacity increases d. Effectiveness of the cilia decreases and risk of hypoxia increases

a. Effectiveness of the cilia decreases and risk of hypoxia increases

1. The nurse is assisting a client with a tracheostomy to eat. Which is an important nursing action to help the client swallow and avoid aspiration? a. Elevate the head of the bed for at least 30 minutes after eating b. Encourage the client to avoid swallowing between bites of food c. Increase the pressure in the tracheostomy cuff to block food particles d. Offer fluids using a straw and avoid giving thickened fluids

a. Elevate the head of the bed for at least 30 minutes after eating

The initial physical examination of a client suggests that the client has acromegaly. What laboratory assessment finding supports the diagnosis?

a. Elevated serum phosphorus

1. Which measure aids on reducing anxiety in a client with head and neck cancer who is scheduled for surgery? a. Teaching the client and family about management of side effects of radiation therapy b. Teaching the family how to administer emergency resuscitation with a tracheostomy c. Encouraging the client and family to discuss their fears

a. Encouraging the client and family to discuss their fears

1. A chest x-ray is ordered for an ambulatory client receiving nasal oxygen. What does the nurse do when transport personnel come to get the client? a. Since the client will only be gone briefly, turn the oxygen off and then resume immediately upon return b. Call radiology and request that a portable chest x-ray be done at the bedside c. Turn the oxygen rate up briefly before disconnecting for transport d. Ensure portable oxygen is in place before transport to radiology

a. Ensure portable oxygen is in place before transport to radiology

1. A family member of a client tells the nurse that the client is no longer interested in family activities since being diagnosed with emphysema. Which initial nursing action does the nurse take? a. Explore the client's level of anxiety about having emphysema b. Reassure the family member that this lack of interest will disappear over time c. Suggest that the family member take an active role in caring for the client d. Tell the family member that the client is probably depressed about having emphysema

a. Explore the client's level of anxiety about having emphysema

A client who is suffering dyspnea on exertion and congestive heart failure will likely report which symptom during the health history? a. Fatigue b. Swelling of one leg c. Slow heart rate d. Brown discoloration of lower extremities

a. Fatigue

1. A client has undergone nasal surgery. Which finding indicates a safety priority to the nurse? a. Frequent swallowing b. Persistent restlessness c. Excessive sedation d. N/V

a. Frequent swallowing

1. A clinic nurse is providing teaching for a client who has been diagnosed with a peritonsillar abscess. What does the nurse include in this client's teaching? a. A tonsillectomy will be necessary when the acute infection is past b. Gargling with warm saline may make discomfort worse c. GO to the ED if drooling and stridor occur d. Take the prescribed antibiotics until the swelling subsides

a. GO to the ED if drooling and stridor occur

A client has received packing for a posterior nosebleed. In reviewing the client's orders, which order does the nurse question? a. Give ibuprofen 800 mg every 8 hours as needed for pain b. Encourage bedrest, with the head of bed elevated 45-60 degrees c. Provide humidified air d. Suction at the bedside

a. Give ibuprofen 800 mg every 8 hours as needed for pain

A clinic nurse is providing teaching for a client who has been diagnosed with a peritonsillar abscess. What does the nurse include in this client's teaching? a. A tonsillectomy will be necessary when the acute infection is past b. Gargling with warm saline may make discomfort worse c. Go to emergency department if drooling or stridor occur d. Take the prescribed antibiotics until the swelling subsides

a. Go to emergency department if drooling or stridor occur

For which heart condition is it most important for the home health nurse to discuss an advance directive with the client and family? a. Heart failure b. Valvular heart disease c. Infective endocarditis d. Rheumatic carditis

a. Heart failure

Cardiac output is represented by which formula? a. Heart rate x stroke volume b. Systolic - diastolic blood pressure c. Pulmonary artery diastolic= pulmonary artery wedge pressure d. Systolic pressure/ diastolic pressure

a. Heart rate x stroke volume

Which conditions can cause high-output heart failure? Select all that apply. a. High fever b. Septicemia c. Valvular disease d. Hyperthyroidism e. CAD

a. High fever b. Septicemia d. Hyperthyroidism e. CAD

1. A 70 year old client has a complicated medical hx including COPD. Which client statement indicated the need for further teaching about the disease? a. I am here to receive the yearly pneumonia shot again b. I am here to get my yearly flu shot again c. I should avoid large gatherings during cold and flu season d. I should cough into my upper sleeve instead of my hand

a. I am here to receive the yearly pneumonia shot again

The nurse discusses the importance of restricting sodium in the diet of a client with heart failure. Which statement made by the client indicates that the client needs further teaching? a. I should avoid eating hamburgers b. I must cut out bacon and canned foods c. I shouldn't put the salt shaker on the table anymore d. I should avoid lunch meats but may cook my own turkey

a. I should avoid eating hamburgers

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching? a. I will call the provider if I have a cough lasting 3 or more days b. I will report to the provider weight loss of 2-3 pounds in a day c. I will try walking for 1 hour each day d. I should expect occasional chest pain

a. I will call the provider if I have a cough lasting 3 or more days

1. A client who has been homeless and has spent the past 6 months living in shelters has been diagnosed with confirmed TB. Which medications does the nurse expect to be ordered for the client? a. INH, rifampin, PZA, ethambutol (myambutol) b. Flagyl, acyclovir (zovirax), flunisolide (aerobid), rifampin c. Prednisone, guaifenesin, Toradol, PZA d. Salmeterol (serevent), cromolyn sodium (intal), dexamethasone, INH

a. INH, rifampin, PZA, ethambutol (myambutol)

A client is 1 day postop from a total laryngectomy for cancer. He has indicated to the nurse that he is experiencing pain. Pain management for him is best achieved with which medication? a. IV ketorolac (Toradol) b. IV midazolam (Versed) c. IV morphine sulfate d. Oral acetaminophen (Tylenol)

a. IV morphine sulfate

The nurse is developing a plan of care for a client with metastatic bone cancer. What is an appropriate goal of treatment to include in the plan of care for this client?

a. Improve the quality of life and promote pain relief

For which cardiac conditions is antimicrobial therapy most likely to be used? Select all that apply. a. Infective endocarditis b. Rheumatic carditis c. Valvular heart disease d. Cardiomyopathy e. Heart failure

a. Infective endocarditis b. Rheumatic carditis c. Valvular heart disease

A client who is undergoing robotic heart surgery for CAD asks the nurse about disadvantages of the surgery. What does the nurse tell the client? a. It increases the surgery time b. It increases the hospital stay c. It causes more pain for the client d. It reduces the client's depth perception

a. It increases the surgery time

Which statements about complex regional pain syndrome are accurate? Select all that apply.

a. It is also known as reflex sympathetic dystrophy b. It is characterized by paresis and muscle spasms c. It can be managed by biphosphonates and antidepressants

1. An older client presents to the ED with a 2 day hx of cough, pain on inspiration, SOB, and dyspnea. The client never had a pneumococcal vaccine. The client's chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client? a. It would not be beneficial for this client b. It would help decrease the bronchospasm c. It would clear up the density in the bases of the client's lungs d. It would decrease the client's pain on inspiration

a. It would help decrease the bronchospasm

A client who has had a recent laryngectomy continues to report pain. Which mediction would be best used as an adjunct to a narcotic once the client can take oral nutrition? a. Liquid NSAIDs b. Liquid steroids c. Opioid antagonists d. Oral diazepam

a. Liquid NSAIDs

1. A client is diagnosed with a head nd neck lesion that is highly suspicious of cancer. In what way does the nurse demonstrate psychosocial support for the client and family? a. Emphasize that the important thing to consider is long-term cure rate potential b. Provides teaching regarding the opportunities for learning altered speech after therapy c. Explains ease of self-management of airway, dressing changes, and suctioning d. Listens closely to their concerns regarding quality of life after treatment

a. Listens closely to their concerns regarding quality of life after treatment

What is the purpose of the mitral valve? a. Located between the left ventricle and the aorta, it promotes the flow of blood to the entire body b. Located between the right atrium and right ventricle, it prevents the flow of blood between these chambers c. Located between the left atrium and left ventricle, it prevents blood from flowing back into the atrium during systole d. It prevents blood from flowing from the right atrium into the right ventricle during systole

a. Located between the left atrium and left ventricle, it prevents blood from flowing back into the atrium during systole

Which factor reflects the most common etiology of heart failure? a. MI b. Valvular disorders c. Fluid volume excess d. Ventricular dilation

a. MI

A client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care? a. My leg might turn white after surgery b. I should be concerned if my foot turns blue c. I should report a fever of any drainage d. Warmness, redness, and swelling are expected

a. My leg might turn white after surgery

What are common signs and symptoms of right-sided heart failure? Select all that apply. a. N/V b. Increase in weight c. A hacking cough d. Dependent edema e. Oliguria during the day

a. N/V b. Increase in weight d. Dependent edema

A client who has begun standard multidrug treatment for TB reports orange-tinged sputum and urine. The nurse tells the client that this symptom represents which response to the treatment regimen? a. Drug resistance with spread of infection b. Hemolysis and a potential for anemia c. Hepatotoxicity caused by drinking alcohol d. Normal drug side effects of rifampin

a. Normal drug side effects of rifampin

1. Which is considered the priority in treatment planning for clients with head and neck cancers? a. Cures with radiation are unlikely; surgery is required b. Chemotherapy is only curative if used with radiation therapy c. Normal lifestyle and functional ability must be presented d. Nonsurgical management is strictly palliative in nature

a. Normal lifestyle and functional ability must be presented

1. A client is admitted to the hospital with a streptococcal peritonsillar abscess following incomplete treatment with an oral antibiotic. The nurse notes that the client is experiencing stridor. Which action does the nurse take next? a. Elevate the head of the bed to at least 30 degree angle b. Contact HCP to request an order for a steroid medication c. Notify Rapid Response Team to assist with airway management d. Provide clear, cool oral liquids to help soothe the throat

a. Notify Rapid Response Team to assist with airway management

1. The nurse is caring for a client after extensive head and neck surgery and notes a small area of bright-red blood on the dressing, which is bigger 30 minutes later. Which nursing action is important to take? a. Apply pressure to the site to stop bleeding b. Move the client to an upright position c. Notify The RRT d. Reinforce the dressing with clean gauze

a. Notify The RRT

Which nursing action should the nurse delegate to a nursing assistant working on the medical unit? a. Determine the usual alcohol intake for a client with cardiomyopathy b. Monitor the pain level for a client with acute pericarditis c. Obtain daily weights for several clients with class IV heart failure d. Check for peripheral edema in a client with endocarditis

a. Obtain daily weights for several clients with class IV heart failure

The charge nurse in the hospital-based day surgery center is making client assignments for the staff. Which client is most appropriate to assign to a nurse who has floated from the general surgical unit?

a. Older adult who has undergone arthroscopic surgery of the shoulder under local anesthesia

Which signs/symptoms does the nurse expect to assess in a client diagnosed with cardiogenic shock? Select all that apply. a. Oliguria b. Bradycardia c. Hypokalemia d. Change in mental status e. Vesicular breath sounds f. Low mean arterial BP

a. Oliguria d. Change in mental status f. Low mean arterial BP

A diabetic client is admitted to the health care facility with a foot ulcer. The nurse teaches wound care to the client and the caregiver to prevent the risk for which condition?

a. Osteomyelitis

1. A client being discharged home after being diagnosed with COPD will require home oxygen therapy. Which statement by the client's spouse indicates that further teaching is required? a. We will not allow smoking at our house b. We have several fire extinguishers, and we know how to use them c. Our grandson will blow out the birthday candles for her at the party d. We will return to the hospital if she seems to be having trouble breathing

a. Our grandson will blow out the birthday candles for her at the party

1. Which nursing assessment has the highest priority when caring for a client with facial trauma? a. Infection b. Oxygenation c. Pain level d. Self-image

a. Oxygenation

The nurse is caring for a client with prostate cancer who has bone metastasis. The nurse anticipates that the HCP will prescribe which medication?

a. Pamidronate (Aredia)

1. What is the key difference between seasonal influenza and pandemic influenza? a. Seasonal influenza is caused by viral infections; pandemic influenza is more likely to be bacterial in nature b. Humans have a natural resistance to viral infections found in animals and birds, and do not require immunization against pandemic influenza c. People over the age 50 who have chronic illness should be vaccinated yearly to decrease the risk of pandemic influenza d. Pandemic influenza has the potential to spread globally because of its highly infectious nature in humans

a. Pandemic influenza has the potential to spread globally because of its highly infectious nature in humans

1. When assessing the adequacy of a client's oxygenation, which information is important for the nurse to note? a. Fraction of inspired oxygen b. Partial pressure of arterial oxygen c. Positive end-expiratory pressure d. The client's acceptance of the continuous positive airway pressure machine

a. Partial pressure of arterial oxygen

1. The nurse is counseling a client whose parent has just been diagnosed with TB. The client tells the nurse that the parent was exposed several years ago, but developed symptoms only recently. What does the nurse tell this client about his or her risk of contracting the disease? a. As soon as drug therapy is initiated, your parent will not be contagious b. People are infectious to others only when symptoms are present c. Since you have had prolonged contact with your parent, you are most likely infected d. You will need to begin treatment for TB since you have been exposed to your parent

a. People are infectious to others only when symptoms are present

Which factors are associated with the development of infective endocarditis? Select all that apply. a. Sepsis b. Heart failure c. Pulmonary embolism d. Myocardial infarction e. Cystoscopy 2 days ago f. IV heroin use

a. Sepsis e. Cystoscopy 2 days ago f. IV heroin use

A client with stage 2 hypertension is suspected to have renal failure. Which assessment parameter helps to evaluate the glomerular filtration ability of the kidney? a. Serum creatinine levels b. Protein levels in urine c. Pus in urine d. BUN

a. Serum creatinine levels

The nurse is performing an admission assessment on a 90 year old client and notes confusion with poor orientation to person, place, time and situation. The client's daughter tells the nurse that this isn't normal. Which initial action by the nurse is correct? a. Contact the provider to request an order for an IV antibiotic b. Notify the provider and request orders for serum electrolytes and kidney fx tests c. Perform a detailed respiratory assessment including lung sounds, pulse ox, and temperature d. Reassure the daughter that confusion is common in older clients who are admitted to the hospital

a. Perform a detailed respiratory assessment including lung sounds, pulse ox, and temperature

1. The nurse is planning care for the Non-English speaking client who is on complete voice rest. What alternative method of communication does the nurse implement? a. Alphabet board b. Picture board c. Translator at the bedside d. Word board

a. Picture board

1. A client who has recently traveled to Vietnam comes to the ED with fatigue, lethargy, right sweats, and low-grade fever. What is the nurse's first action? a. Contact the HCP for TB medications b. Perform a TB skin test c. Place a respiratory mask in the client d. Test all family members for TB

a. Place a respiratory mask in the client

Which interventions are appropriate to include in the plan of care for a client admitted with a DVT? Select all that apply. a. Placing the client on strict bed rest b. Monitoring the client for sudden onset of SOB c. Administering warfarin to achieve an INR of 3.1-4 d. Administering unfractionated heparin to keep the aPTT 1.5-2 times the normal value e. Maintaining the distal portion of the extremity lower than the proximal portion f. Teaching the client to massage the affected extremity to reduce swelling

a. Placing the client on strict bed rest b. Monitoring the client for sudden onset of SOB d. Administering unfractionated heparin to keep the aPTT 1.5-2 times the normal value

1. The RN and LPN/LVN are working together to provide care for a client hospitalized with dyspnea who requires all of these nursing actions. Which action is best accomplished by the RN? a. Administer the purified protein derivative for TB testing b. Assess vital signs and the puncture site after thoracentesis c. Monitor oxygen sat using pulse oximetry every 4 hours d. Plan client and family teaching regarding upcoming pulmonary function testing

a. Plan client and family teaching regarding upcoming pulmonary function testing

1. A client calls the nurse to report a nosebleed that started with a sneeze. What does the nurse do first? a. Instruct the client not to sneeze or blow the nose for 24 hours b. Loosely pack the affected naris with gauze or nasal tampons c. Reassure the client to reduce anxiety and help lower BP d. Position the client upright and leaning forward over an emesis basin

a. Position the client upright and leaning forward over an emesis basin

1. Which nursing action will decrease the risk of aspiration in a client with head and neck cancer who has undergone a supraglottic laryngectomy? a. Maintaining the NG/feeding tube for adequate nutrition b. Having the client take multiple swallows of liquid with each bite of food c. Starting the client on clear liquids before advancing the diet d. Positioning the client upright for all meals and meds

a. Positioning the client upright for all meals and meds

1. A client returns to the clinic to have the TB Mantoux test analyzed by the nurse, which was administered 2 days ago. The client's left forearm shows a red raised area, which measures 10 mm in diameter. How does the nurse document this finding? a. Positive reaction that indicates exposure to and the possible presence of TB infection b. Positive reaction that indicates the presence of active TB infection c. Possible false positive reading; that test will need to be read again at 72 hours d. Possible false positive; the test will need to be administered again

a. Positive reaction that indicates exposure to and the possible presence of TB infection

1. Which principle about anterior vs posterior nasal bleeding must the nurse consider the priority? a. Anterior bleeding is more likely related to a vessel in a nasal poly b. Include the amount and color of nasal drainage in any documentation c. The stimulus that triggered the initial nasal bleeding must be determined d. Posterior bleeding is an emergency because it cannot be easily reached

a. Posterior bleeding is an emergency because it cannot be easily reached

The nurse is preparing to suction an intubated client on a ventilator. What are the best-practice actions by the nurse? Select all that apply. a. Preoxygenate the client with 100% oxygen b. Quickly insert the catheter while suctioning c. Repeat suctioning the tube until no secretions are obtained d. Never suction longer than 10-25 seconds e. Use protective eyewear f. Maintain Standard Precautions

a. Preoxygenate the client with 100% oxygen d. Never suction longer than 10-25 seconds e. Use protective eyewear f. Maintain Standard Precautions

1. A client who is receiving combination chemo and radiation for neck cancer reports increasingly uncomfortable oral cavity effects such as stomatitis and gingivitis. What does the nurse recommend for this client? a. Interrupting radiation treatment temporarily b. Providing oral care and comfort measures c. Stopping chemo temporarily d. Taking break from therapy to allow healing to occur

a. Providing oral care and comfort measures

1. A client undergoing an admission assessment for respiratory distress is coughing and producing sputum that is frothy and pink-colored. Which cause of respiratory distress does the nurse suspect? a. Bacterial pneumonia b. Cystic fibrosis c. Lung abscess d. Pulmonary edema

a. Pulmonary edema

The telemetry nurse is assessing a 12 lead ECG of a client with CAD. Which finding indicates the client has had an acute MI? a. Q wave noted on ECG b. Normal ECG with chest pain c. ST elevation in all precordial leads d. ST segment depression during chest pain

a. Q wave noted on ECG

1. The lunch tray is served to a client wearing a Venturi mask. What does the nurse do to facilitate eating? a. Teach the client to lift the lower edge of the mask with each bite of food b. Increase the flow rate, loosen the strap, and allow the mask to drop down around neck c. Request a prescription for a nasal cannula to only be used during mealtime

a. Request a prescription for a nasal cannula to only be used during mealtime

A client with nasal congestion, fever, and cough has been using OTC medications for a week without improvement. The client exhibits tenderness to percussion over the sinuses and referred pain to the back of the head. These findings may indicate which condition? a. Rhinosinusitis b. Rhinitis c. Pharyngitis d. Tonsilitis

a. Rhinosinusitis

The nurse is caring for a client admitted with pericarditis. Which symptom does the nurse anticipate the client will report? a. Substernal chest pain described as sharp and stabbing b. Abrupt awakening with dyspnea which worsens after sitting on the edge of the bed c. Viselike substernal chest pain in response to exertion d. Dizziness requiring the client to stop activities and rest

a. Substernal chest pain described as sharp and stabbing

The nurse is teaching a group of nursing students about venous thromboembolism. What statement made by a participant indicates a need for further teaching?

a. Surgery lasting at least one hour can cause VTE.

Which are major compensatory mechanisms when cardiac output is insufficient to meet the demands of the body? Select all that apply. a. Sympathetic nervous system stimulation b. Renin-angiotensin system activation c. Chemical responses d. Myocardial hypertrophy e. Pulmonary hypertension

a. Sympathetic nervous system stimulation b. Renin-angiotensin system activation c. Chemical responses d. Myocardial hypertrophy

1. A client with a sore throat has a temperature of 99.9F. The nurse palpates mild enlargement of cervical lymph nodes without tenderness and notes erythema of the tonsils without exudate. After performing a throat culture, and reporting these findings to the provider, the nurse expects an order for which treatment course? a. Antiviral therapy b. IV antibiotic therapy c. Oral antibiotic therapy d. Symptomatic care

a. Symptomatic care

1. The nurse is caring for a client who has unilateral vocal cord paralysis after injury to the neck. Which has the highest priority when developing a discharge teaching plan for this client? a. Instructing the client to hold the breath while talking to improve the quality and tone of the voice b. Providing written materials and Internet website information about vocal cord paralysis support groups c. Reviewing the S/S and home care for minor upper respiratory infections d. Teaching the client to tuck the chin down and tilt the forehead forward while swallowing

a. Teaching the client to tuck the chin down and tilt the forehead forward while swallowing

1. The nurse is assessing a client with facial trauma and observes clear drainage form the client's left nostril. What is the nurse's next action? a. Suction the nares b. Test the drainage for glucose c. Pack the nostril with gauze d. Notify the HCP

a. Test the drainage for glucose

The nurse is assigned to all of these clients. Which client should be assessed fist? a. The client who had a PTCA of the right femoral artery 30 minutes ago b. The client admitted with hypertensive crisis who has a nitroprusside (nipride) drip and BP of 149/80 c. The client with PVD who has a left leg ulcer draining purulent yellow fluid d. The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot

a. The client who had a PTCA of the right femoral artery 30 minutes ago

An RN from the orthopedic unit has been floated to the medical unit. Which client assignment for the floated RN is the best? a. The client with a resolving pulmonary edema who is receiving oxygen at 6 L/min through a nasal cannula b. The client with chronic lung disease who is being evaluated for possible home oxygen use c. The client with a newly placed tracheostomy who is receiving oxygen through a tracheostomy collar d. The client with chronic bronchitis who is receiving oxygen at 60% through a Venturi mask

a. The client with a resolving pulmonary edema who is receiving oxygen at 6 L/min through a nasal cannula

The nurse is caring for a client with MI. In which order do physical and functional changes of MI occur in the heart?

a. The infarcted region becomes blue and swollen b. The infarcted area turns gray with yellow streaks c. Granulation tissue forms on the edges of necrotic tissue d. A shrunken, thin, firm scar develops in the area

1. A 75-year-old client tells that nurse he is not planning to receive a flu shot this year because the shot makes him sick. What is the nurse's nest response? a. The injectable flu vaccine is not a live virus and cannot cause influenza b. The virus in the injection is attenuated, meaning it can cause mild symptoms c. If you had a flu shot last year, you should still have immunity to influenza d. If the shot makes you sick, your provider can order an antiviral medication

a. The injectable flu vaccine is not a live virus and cannot cause influenza

1. A client has a sore throat; enlarged, red tonsils; and tender swollen lymph nodes. A rapid antigen test performed in the clinic is negative for group A beta-hemolytic streptococcus. What does the nurse tell this client? a. The provider will have the final results of a culture in 2 days b. The throat culture is negative for group A strep c. You may have a nonstrep bacterial infection d. You most likely have a viral infection

a. The provider will have the final results of a culture in 2 days

1. A client has developed SQ emphysema after surgery for a tracheostomy. Why must the nurse notify the HCP immediately? a. The client has a pneumothorax and will require a chest tube for decompression b. Ventilator pressures are too high, forcing air into tissue, and must be lowered c. Bleeding has occurred related to the surgical incision; hemoglobin is low d. There is an opening or tear in the trachea allowing air leakage into the tissues

a. There is an opening or tear in the trachea allowing air leakage into the tissues

1. A client comes to the ED with a sore throat. Examination reveals redness and swelling of the pharyngeal mucous membranes. Which diagnostic test does the nurse expect will be requested first? a. Chest x-ray b. CBC c. Tb skin test d. Throat culture

a. Throat culture

Which laboratory findings are consistent with ACS? Select all that apply. a. Troponin 3.2 ng/mL b. Myoglobin of 234 mcg/L c. C-reactive protein 13 mg/dL d. Triglycerides 400 mg/dL e. Lipoprotein-a 18 mg/dL

a. Troponin 3.2 ng/mL b. Myoglobin of 234 mcg/L

The nurse is caring for a client who has had abdominal aortic aneurysm repair would be most alarmed by which finding? a. Urine output of 20 ml over 2 hours b. Blood pressure of 106/58 c. Absent bowel sounds d. +3 pedal pulses

a. Urine output of 20 ml over 2 hours

A new client arrives in the med surg unit with a flap after a total laryngectomy. The flap appears dusky in color. What is the nurse's first action? a. Apply a hot pack over the flap site b. Massage the flap site vigorously c. Place a tight dressing over the flap d. Use a Doppler to assess flow to the area

a. Use a Doppler to assess flow to the area

1. A client with seasonal allergies has developed vocal cord polyps and ask the nurse what can be done to treat this condition. What does the nurse suggest? a. Allergy medications are used to treat polyps b. Laser surgery will be necessary to treat polyps c. Voice rest and avoiding heavy lifting are helpful d. Whispering instead of speaking out loud will help

a. Voice rest and avoiding heavy lifting are helpful

1. The nurse manager at a long-term care facility is planning care for a client who is receiving radiation therapy for laryngeal cancer. Which of these tasks will be best to delegate to a nursing assistant? a. Administering throat-numbing lozenges b. Assessing the mouth for inflammation and infection c. Teaching about skin care while receiving radiation d. Washing the skin with soap and water

a. Washing the skin with soap and water

What are common symptoms of hypokalemia? Select all that apply. a. Weakness b. Cool extremities c. Dependent edema d. Depressed reflexes e. Irregular heart beat

a. Weakness d. Depressed reflexes e. Irregular heart beat

Which points should be covered in the teaching plan for a client with essential hypertension? Select all that apply. a. Weight loss if obese b. Smoking cessation c. Potassium restriction d. Managing stress e. Avoiding driving a motor vehicle

a. Weight loss if obese b. Smoking cessation d. Managing stress

When caring for a client with head and neck cancer following a total laryngectomy 12 hours ago, which potential complications are important for the nurse to address? Select all that apply. a. Wound breakdown and hemorrhage b. Preparing the client for radiation c. Airway obstruction and inadequate oxygenation d. Comfort and nonverbal communication e. Educating the client about various types of chemo

a. Wound breakdown and hemorrhage c. Airway obstruction and inadequate oxygenation d. Comfort and nonverbal communication

1. A coworker tells the nurse that she will not get the flu shot because she believes it is better to develop her own immunity to the flu. What does the nurse tell this coworker? a. Getting the flu shot causes you to have flu symptoms b. If you are exposed to the flu, you can take an antiviral medication c. Since you are healthy, you will probably only have a mild case of the flu d. You are putting your clients at increased risk for serious respiratory illness

a. You are putting your clients at increased risk for serious respiratory illness

1. A young adult client refuses an influenza vaccine, saying,"im healthy and wont get that sick if I get the flu." Which is the beat response by the nurse? a. If a flu pandemic begins, you should get the vaccine immediately b. If you get the flu, you can always take an antiviral medication c. Not getting the vaccine increases the chances of a worldwide pandemic d. You may spread the disease to people who are more at risk for severe symptoms

a. You may spread the disease to people who are more at risk for severe symptoms

The nurse is providing preoperative teaching to a client who is about to undergo a supraglottic partial laryngectomy. The client asks the nurse whether his voice will be normal after surgery. How does the nurse respond? a. You will be hoarse after surgery, but your voice may become normal b. You will not have a natural voice after you recover from surgery c. Your voice will be normal after recovering from surgery d. Your voice will be permanently hoarse after surgery

a. You will be hoarse after surgery, but your voice may become normal

A client who is scheduled for EMG asks the nurse to explain the procedure. What does the nurse teach the client about EMG? Select all that apply.

a. You will be subjected to episodes of electric current during the test b. You may report pain and anxiety after the test c. You may be mildly sedated for the test

1. A client tells the nurse that after 3 weeks of multidrug therapy to treat TB, the symptoms seem to have resolved. What does the nurse tell this client? a. Directly observed therapy will be necessary in your case b. If a TB skin test is negative, you may stop taking the drugs c. The provider may reduce the number of drugs you are taking d. You will need to continue therapy for at least 6 months

a. You will need to continue therapy for at least 6 months

1. client who has received radiation therapy for laryngeal cancer 2 weeks prior asks the nurse when the hoarseness will improve. Which answer by the nurse is correct? a. Gargling with mouthwash will help treat the hoarseness b. Persistent hoarseness indicates spreading of the cancer c. Radiation therapy causes permanent vocal cord changes d. You will need to continue voice rest for 2-4 weeks

a. You will need to continue voice rest for 2-4 weeks

Which dietary supplements promote wound healing in venous leg ulcers? Select all that apply. a. Zinc b. Vitamin C c. Vitamin K d. Vitamin E e. High-protein foods

a. Zinc b. Vitamin C e. High-protein foods

Which statement about BP is correct? a. Kidneys help to regulate cardiovascular activity b. Sodium and water is retained when renal blood flow increases c. BP rises when body temperature decreases d. Anger causes the sympathetic nervous system to decrease BP and heart rate

a. kidneys help to regulate cardiovascular activity

Which symptom reported by a client who has had a total hip replacement requires emergency action? a. Localized swelling of one of the lower extremities b. Positive Homan's sign c. Shortness of breath and chest pain d. Tenderness and redness at the IV site

c. Shortness of breath and chest pain

An RN and an LPN/LVN, both of whom have several years of experience in the ICU, are caring for a group of clients. Which client is appropriate for the RN to assign to the LPN/LVN? a. A client with pulmonary edema who requires hourly monitoring of pulmonary artery wedge pressures b. A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index c. A client who has intermittent chest pain and requires teaching about myocardial nuclear perfusion imaging d. A client with acute coronary syndrome who has just been admitted and needs an admission assessment

b. A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index

Which statement about diagnostic cardiovascular testing in correct? a. Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism b. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography c. Holter monitoring allows periodic recording of cardiac activity during an extended period of time d. The left side of the heart is catheterized first and may be the only side examined

b. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography

A client with COPD who has been receiving oxygen via NC is becoming increasingly dyspneic with increased use of accessory muscles to breathe. The nurse auscultates markedly diminished breath sounds in all lung fields. The nurse correctly notifies the provider and discusses which oxygen delivery method for this client? a. BiPAP b. CPAP c. Transtracheal oxygen d. Venturi mask

b. CPAP

Which medication when given in heart failure may reduce the incidence of morbidity and mortality? a. Dobutamin (dobutrex) b. Carvedilol (coreg) c. Digoxin d. Bumetamide (bumex)

b. Carvedilol (coreg)

While seated, a client's right brachial blood pressure is 168/94 mm Hg. Which actions does the nurse take next? Select all that apply. a. Instruct the client to stand and recheck the right brachial blood pressure b. Check the left brachial blood pressure with the client seated c. Wait 15 minutes and repeat the sitting blood pressure assessment in the same location d. Advise the client to return in 2 weeks to recheck blood pressure e. Auscultate for a bruit over the right brachial artery

b. Check the left brachial blood pressure with the client seated c. Wait 15 minutes and repeat the sitting blood pressure assessment in the same location

Among a group of med surg clients, which individual is at highest risk for DVT? a. Client who sleeps 9 hours per night b. Client who had suprapubic prostatectomy c. Female client who uses a barrier method for contraception d. Client who had a TIA 48 hours ago

b. Client who had suprapubic prostatectomy

Which client is best to assign to an LPN/LVN working on the telemetry unit? a. Client with heart failure who is receiving Dobutrex b. Client with restrictive cardiomyopathy who uses oxygen for exertional dyspnea c. Client with pericarditis who has a paradoxical pulse and distended jugular veins d. Client with rheumatic fever who has a new systolic murmur

b. Client with restrictive cardiomyopathy who uses oxygen for exertional dyspnea

The nurse in the coronary care unit is caring for a group of clients who have had MI. Which client does the nurse see first? a. Client with dyspnea on exertion when ambulating to the bathroom b. Client with third degree heart block on the monitor c. Client with normal SR and PR interval of 0.28 second d. Client who refuses to take heparin or nitroglycerin

b. Client with third degree heart block on the monitor

The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action should be taken by the nurse? a. No intervention is needed; this is a normal reading b. Collaborate with the HCP to administer a positive inotropic agent c. Administer a stat dose of Lopressor d. Ask the client to perform the Valsalva maneuver

b. Collaborate with the HCP to administer a positive inotropic agent

What are symptoms of aortic stenosis? Select all that apply. a. Polyuria b. Debilitation c. Marked fatigue d. Nocturnal angina e. Peripheral cyanosis

b. Debilitation c. Marked fatigue e. Peripheral cyanosis

The nurse is providing education to a client with HF about an appropriate diet. Which information is most important for the nurse to emphasize? a. Avoid grapefruit juice b. Do not add any salt to your food c. Increase fluids to 100 ounces daily d. Try to increase the amount of green leafy veggies you eat

b. Do not add any salt to your food

Which atypical symptoms may be present in a female client experiencing MI? Select all that apply. a. Sharp, inspiratory chest pain b. Dyspnea c. Dizziness d. Extreme fatigue e. Anorexia

b. Dyspnea c. Dizziness d. Extreme fatigue

The nurse is teaching a client the precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective? a. I can use an electric razor or a regular razor b. Eating foods like green beans wont interfere with my Coumadin therapy c. If I notice I am bleeding a lot, I should stop taking Coumadin right away d. When taking Coumadin, I may notice some blood in my urine.

b. Eating foods like green beans wont interfere with my Coumadin therapy

The nurse is caring for a client who has had abdominal surgery. Which action does the nurse take to help prevent pulmonary infection in this client? a. Administer Lovenox b. Encourage regular use of an incentive spirometer c. Give IV antibiotics d. Provide adequate analgesia

b. Encourage regular use of an incentive spirometer

The standard laryngectomy plan of care for a client admitted with laryngeal cancer includes these interventions. Which intervention will be most important for the nurse to accomplish before the surgery? a. Educate the client about ways to avoid aspiration when swallowing after surgery b. Establish a means for communicating during the immediate postop period, such as Magic Slate or an alphabet board c. Discuss appropriate clothing to wear that will help cover the laryngectomy stoma and decrease social isolation after surgery d. Teach the client and significant others about how to suction and do wound care of the stoma

b. Establish a means for communicating during the immediate postop period, such as Magic Slate or an alphabet board

Which risk factors may contribute to a client having arterial occlusive disease of the extremities? Select all that apply. a. Elevated HDl level b. Hispanic descent c. Age 65 years d. Walking barefoot frequently e. Occupation as a teacher

b. Hispanic descent c. Age 65 years

When caring for a client with an abdominal aortic aneurysm, the nurse suspects dissections of the aneurysm when the client makes which statement? a. I feel my heart beating in my abdominal area b. I just started to feel a tearing pain in my belly c. I have a headache. May I have some acetaminophen? d. I have had hoarseness for a few weeks

b. I just started to feel a tearing pain in my belly

Which characteristics place women at high risk for MI? Select all that apply. a. Premenopausal b. Increasing age c. Family history d. Abdominal obesity e. Breast cancer

b. Increasing age c. Family history d. Abdominal obesity

A client who is to undergo cardiac catheterization should be taught which essential information by the nurse? a. Monitor the pulses in your feet when you get home b. Keep your affected leg straight for 2-6 hours c. Do not take your BP medications on the day of the procedure d. Take you oral hypoglycemic with a sip of water on the morning of the procedure

b. Keep your affected leg straight for 2-6 hours

The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states," I feel so tired and SOB." Which action does the nurse take first? a. Assess the client for peripheral edema b. Listen to the client's posterior breath sounds c. Notify the HCP about the client's weight gain d. Remind the client about dietary sodium restrictions

b. Listen to the client's posterior breath sounds

Which parameter, determined through laboratory testing, is known as the "early warning detector" for heart failure? a. Hematocrit b. Microalbuminuria c. EKG d. B-type natriuretic peptide

b. Microalbuminuria

A client comes to the ED with chest discomfort. Which action does the nurse perform first? a. Administers oxygen therapy b. Obtains the client's description of the chest discomfort c. Provides pain relief medication d. Remains calm and stays with the client

b. Obtains the client's description of the chest discomfort

A client is receiving unfractionated heparin by infusion. Of which finding does the nurse notify the provider? a. PTT 60 seconds b. Platelets 32,000/mm3 c. WBCs 11,000/mm3 d. Hemoglobin 12.2 g/dL

b. Platelets 32,000/mm3

The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the HCP by the nurse for further instructions? a. Calcium 8.5 mEq/L b. Potassium 3.0 mEq/L c. Magnesium 2.1 mEq/L d. INR of 1.0

b. Potassium 3.0 mEq/L

The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of dig toxicity does the nurse notify the provider? Select all that apply. a. Hypokalemia b. Sinus bradycardia c. Fatigue d. Serum dig level of 1.5 e. Anorexia

b. Sinus bradycardia c. Fatigue e. Anorexia

After a cardiac catheterization, the client should increase his or her fluid intake for which reason? a. NPO status will cause the client to be thirsty b. The dye causes an osmotic diuresis c. The dye contains a heavy sodium load d. The pedal pulses will be more easily palpable

b. The dye causes an osmotic diuresis

Which statement describes the cause of venous insufficiency? a. Coronary veins are unable to return blood to the heart b. Valves in the veins of the legs become incompetent c. A blood lot develops in a large vessel in the lower extremity d. Infection leads to cellulitis, reddened skin and swelling

b. Valves in the veins of the legs become incompetent

A client is prescribed Lasix for control of hypertension. What health teaching does the nurse provide before the client begins therapy? Select all that apply. a. You may develop a slower pulse rate b. You should take this medication in the morning c. You may notice some swelling in your feet d. You may develop a nagging cough e. Your diet should include foods high in potassium

b. You should take this medication in the morning e. Your diet should include foods high in potassium

While listening to bowel sounds, the nurse hears a bruit. What is the significance of this finding? a. The lumen of the bowel is narrowed and could indicate an impeding ileus b. Fluid accumulation in the abdomen is muffling heart sounds c. An artery may be partially obstructed by atherosclerosis d. The pancreatic duct may be obstructed by a gallstone

c. An artery may be partially obstructed by atherosclerosis

The nurse is assessing the cardiac health of a client with a BMI of 30. What does the nurse tell the client about maintaining a healthy weight? a. Take a 30 minute brisk walk twice a week b. Include veggies and dairy products in your diet c. Avoid eating more calories than you can burn every day d. Include high calorie, nutrient rich foods.

c. Avoid eating more calories than you can burn every day

Which finding indicates that a client taking valsartan (Diovan) is having success with the drug therapy? a. Cholesterol level of 183 mg/dL b. Pulse of 60 beats/min c. BP 118/78 d. Potassium level of 3.8 mEq/L

c. BP 118/78

What are the intended outcomes of ultrafiltration when performed in a client with renal dysfunction? Select all that apply. a. Increase in aldosterone b. Decrease in cardiac index c. Decrease in filling pressure d. Reduction in norepinephrine e. Decrease in pulmonary arterial pressure

c. Decrease in filling pressure d. Reduction in norepinephrine e. Decrease in pulmonary arterial pressure

What are signs and symptoms of pulmonary edema? Select all that apply. a. Increased urination b. Decreased heart rate c. Disorientation regarding time and place d. Difficulty in breathing at rest e. Crackles in the lung bases

c. Disorientation regarding time and place d. Difficulty in breathing at rest e. Crackles in the lung bases

The nurse is teaching a group of teens about prevention of heart disease. Which point should the nurse emphasize? a. Reduce abdominal fat b. Avoid stress c. Do not smoke or chew tobacco d. Avoid alcoholic beverages

c. Do not smoke or chew tobacco

A client is hospitalized with posterior nasal bleeding and has a gauze pack in the posterior nasal cavity. The nurse assesses the client and notes restlessness and anxiety and an oxygen sat of 92%. Which initial action by the nurse is correct? a. Assess for hypotension and tachycardia b. Check the client's gag and cough reflexes c. Evaluate the position of the packing string d. Request an order for an antianxiety medication

c. Evaluate the position of the packing string

When evaluating the laboratory values of a client who is taking a lipid-lowering agent, which value would indicate the need for further intervention? a. Total cholesterol 194 mg/dL b. LDL-C 68 mg/dL c. HDL-C 28 mg/dL d. Triglyceride level 132 mg/dL

c. HDL-C 28 mg/dL

Which side effects does the nurse monitor for in a client taking losartan (Cozar) and eplerenone (Inspra)? a. Bradycardia b. Hypertension c. Hyperkalemia d. Hyperglycemia

c. Hyperkalemia

The nurse is teaching a client about self-management of hypertension. Which client statement indicates a correct understanding of the teaching? a. I can have a glass of wine every night to relax b. I will avoid eating in restaurants from now on c. Ill cut back on the salt when I cook d. Ill take my pulse every day and call my HCP if its more than 100 beats/min

c. Ill cut back on the salt when I cook

In assessing a client at risk for PAD, which factor concerns the nurse most? a. Consumption of a high carb diet b. Consumption of two mixed drinks each day c. Leg pain with walking d. Medication reconciliation not in the medical record

c. Leg pain with walking

Which position is best for a client with PAD? a. High fowler's position b. Legs elevated above heart level c. Legs in dependent position d. Sitting with the legs crossed

c. Legs in dependent position

What does the nurse anticipate administering to a client with pulmonary edema to promote diuresis? a. Morphine b. Ultrafiltration c. Loop diuretic by infusion d. NTG by infusion

c. Loop diuretic by infusion

In which condition does reduced pulse pressure occur? a. Atherosclerosis b. Aortic regurgitation c. Mitral stenosis d. Hypertension

c. Mitral stenosis

The visiting nurse is seeing a client postoperative for CABG. Which nursing action should be performed first? a. Assessing coping skills b. Assess for postoperative pain at the client's incision site c. Monitor for dysrhythmias

c. Monitor for dysrhythmias

Which complementary and alternative therapy is known to reduce lipid levels and stabilize atherosclerotic plaques in clients with CAD? a. Vitamin B complex b. Pantesin supplements c. Omega-3 fatty acids d. Vitamin E supplements

c. Omega-3 fatty acids

Which intervention does the nurse perform to decrease dyspnea in a client with acute heart failure? a. Avoid waking the client at night b. Elevate swollen legs above heart level c. Place the client in high Fowler's position d. Assess for orthostatic hypotension and dizziness.

c. Place the client in high Fowler's position

The nurse is caring for a client in phase 1 cardiac rehab. Which activity does the nurse suggest? a. The need to increase activities slowly at home b. Planning and participating in a walking program c. Placing a chair in the shower for independent hygiene d. Consultation with social worker for disability planning

c. Placing a chair in the shower for independent hygiene

The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "how can this be? I am in great shape. I eat right and exercise." What is the nurse's best response? a. How does this make you feel? b. This can be caused by taking performance enhancing drugs c. This may be caused by a genetic trait d. Just imagine how bad it would be if you weren't in good shape

c. This may be caused by a genetic trait

A client has a magnesium level of 1.0 mEq/L. Which complication of this electrolyte imbalance does the nurse anticipate? a. Diabetes b. Heart failure c. Ventricular dysrhythmia d. MI

c. Ventricular dysrhythmia

Which teaching point does the nurse include for a client with PAD? a. Elevate your legs above heart level to prevent swelling b. Inspect your legs daily for brownish discoloration around the ankles c. Walk to the point of leg pain, then rest, resuming when pain stops d. Apply a heating pad to the legs if they feel cold

c. Walk to the point of leg pain, then rest, resuming when pain stops

The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea; pink, frothy sputum; and crackles throughout the lung fields. Which prescription does the nurse implement first? a. Enalapril b. Heparin c. Lasix d. I&O

c. lasix

In testing arterial blood gas values which condition can be probable cause of metabolic acidosis? a. Hyperventilation b. Potassium retention c. Carbon dioxide retention d. Accumulation of lactic acid

d. Accumulation of lactic acid

What is a contraindication for taking an HMG-CoA reductase inhibitor (statin)? a. Pulmonary fibrosis b. Kidney failure c. Seizure activity d. Active liver disease

d. Active liver disease

An older adult client with type 2 diabetes mellitus is being treated with Avandia. Which condition is the client susceptible to? a. Difficulty in breathing b. Obstructive sleep apnea c. Cardiac infection d. Acute MI

d. Acute MI

Which step is essential for the nurse to complete before the client undergoes cardiac catheterization? a. Obtaining informed consent b. Administering an ordered diuretic c. Providing client education about sensations during the procedure d. Assessing for allergies to iodine-containing substances and contrast media

d. Assessing for allergies to iodine-containing substances and contrast media

A client has been diagnosed with oral and laryngeal cancer. He completed a course of radiation, and it is 2 days since he underwent a total laryngectomy. The client has been very anxious about his surgery. Which medications does the nurse expect to find on his home medication list? a. Elavil b. Valium c. Toradol d. Ativan

d. Ativan

When performing a cardiovascular physical assessment, which finding indicates the client is experiencing chronic hypoxemia? a. Decreased skin turgor over the chest b. Petechiae on the arms and inner thigh c. Peripheral pitting edema d. Clubbing of the fingers and toes

d. Clubbing of the fingers and toes

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? Select all that apply. a. Hypertension b. Tachycardia c. Bounding right pedal pulses d. Cold right foot e. Numbness and tingling of right foot f. Mottling of right foot and lower leg

d. Cold right foot e. Numbness and tingling of right foot f. Mottling of right foot and lower leg

Which complementary and alternative therapy can be helpful in preventing coronary atherosclerotic disease? a. Reducing or stopping smoking b. Avoiding foods with trans-fatty acids c. Taking a multivitamin tablet each day d. Consuming foods high in omega-3 fatty acids

d. Consuming foods high in omega-3 fatty acids

What manifestations does the nurse expect in a client who has class IV heart failure or cardiogenic shock? Select all that apply. a. Very hot skin b. Alert and oriented times 3 c. Urine output< 60 mL/hr d. Frothy sputum e. Tachypnea

d. Frothy sputum e. Tachypnea

Which condition can increase the risk for clotting in the surgical vessel immediately after a peripheral artery bypass graft? a. Anemia b. Bedrest c. Hyperglycemia d. Hypovolemia

d. Hypovolemia

Which finding in the history of a client with an AAA is a risk factor for aneurysm formation? a. Peptic ulcer disease b. DVT c. Osteoarthritis d. Marfan syndrome

d. Marfan syndrome

What is the disadvantage of off-pump CAB surgery performed on clients with CAD? a. Longer hospital stays b. Increased risk for infection c. Increased cost d. Need for skilled surgeons

d. Need for skilled surgeons

Which action does the nurse delegate to experienced UAP working in the cardiac catheterization laboratory? a. Assess preprocedure medications the client took that day b. Have the client sign the consent form before the procedure is performed c. Educate the client about the need to remain on bedrest after the procedure d. Obtain client VS and a resting ECG

d. Obtain client VS and a resting ECG

A client reports waking with a feeling of breathlessness 2 to 5 hours after falling asleep. What condition may this indicate? a. Orthopnea b. Exertional dyspnea c. High output heart failure d. Paroxysmal nocturnal dyspnea

d. Paroxysmal nocturnal dyspnea

Which description is characterized of peripheral cyanosis? a. Presence of warmth and pink coloration in the palm and nail beds b. Presence of moisture, coolness, and pale coloration in the palms and nail beds c. Presence of bluish discoloration of the nail beds and earlobes d. Presence of rubor (dusky redness) in a dependent foot

d. Presence of rubor (dusky redness) in a dependent foot

A client is scheduled for surgical removal of a neck tumor followed by radiation treatments. The client asks the nurse why radiation therapy is not performed prior to the surgery. How does the nurse respond? a. Radiation therapy causes tissue edema b. Radiation therapy compromises respiratory function c. Radiation therapy increases the risk of metastasis d. Radiation therapy slows tissue healing

d. Radiation therapy slows tissue healing

A client admitted for heart failure has a priority problem of hyervolemia relate to compromised regulatory mechanisms. Which assessment data obtained the day after admission is the best indicator that the treatment has been effective? a. The client had diuresis of 400 mL in 34 hours b. The client's BP is 122/84 c. The client has an apical pulse of 82 beats/min d. The client's weight decreases by 2.5 kg

d. The client's weight decreases by 2.5 kg

Which is a desirable serum lipid level for a female client at high risk for coronary artery disease? a. Fasting total cholesterol should be below 250 mg/dl b. LOL cholesterol should be less than 90 mg/dl c. HDL cholesterol should be above 35 mg/dl d. Triglycerides should be less than 135 mg/dl

d. Triglycerides should be less than 135 mg/dl

The nurse is suctioning the artificial airway of a client who has undergone a partial laryngectomy the day before and notes blood-tinged secretions. Which action by the nurse is correct? a. Assess for correct placement of the airway and reinsert if needed b. Contact the surgeon immediately to report postop hemorrhage c. Place the client in an upright position and instruct the client not to cough d. Use Standard Precautions when suctioning and monitor for increased bleeding

d. Use Standard Precautions when suctioning and monitor for increased bleeding

The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram today. Which nursing action is essential? a. Auscultate the client's precordium for murmurs b. Teach the client about the reason for the TEE c. Reassure the client that the test is painless d. Validate that the client has remained NPO

d. Validate that the client has remained NPO

A client is scheduled for a bone marrow aspiration. What does the nurse do before taking the client to the treatment room for the biopsy? a. Clean the biopsy site with an antiseptic or povidone-iodine b. Hold the client's hand and ask about concerns c. Review the client's platelet count d. Verify that the client has given informed consent

d. Verify that the client has given informed consent

The nurse is educating a group of women about the differences in symptoms of MI in men versus those in women. Which information should be included? a. Men do not tend to report chest pain b. Men are more likely than women to die after MI c. Men more than women tend to deny the importance of symptoms d. Women may experience extreme fatigue an dizziness as sole symptoms

d. Women may experience extreme fatigue an dizziness as sole symptoms