N2 T2
A nurse is caring for a client who has hemophilia A and hemarthrosis of the left knee. Which of the following actions should the nurse take?
Assess client for s/s of bleeding
A home health nurse visits a client who has COPD and receives oxygen at 2L/min via nasal cannula. The client reports having difficulty breathing. Which of the following actions is the nurse's priority?
Assess the client's respiratory status.
35. The nurse recognizes that which of the following client conditions would be responsible for increased PCO2 levels? (Select all that apply)
Asthma, Pneumonia , Airway obstruction
A client receiving a heparin infusion is demonstrating signs of acute bleeding. Which of the following should the nurse prepare to administer to this client?
Protamine sulfate
Which intervention will the nurse plan to implement to reduce a client's pain during a sickle cell crisis?
Provide warm blankets and a warm environment.
A client comes into the E.R. with acute shortness of breath and a cough that produces pink, frothy sputum. Admission assessment reveals crackles and wheezes, a BP of 85/46, a HR of 122 BPM, and a respiratory rate of 38 breaths/minute. The client's medical history included DM, HTN, and heart failure. Which of the following disorders should the nurse suspect?
Pulmonary edema
A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan?
Red meat
A nurse is reviewing the labs for a newly admitted heart failure patient and notes a K+ level of 5.6. Upon reviewing the patient's medications, the nurse realizes which of the following medications most likely contributed to this electrolyte imbalance?
Spironolactone
A nurse is assessing a client diagnosed with Buerger's disease. While assessing this client and extremities, the nurse correlates which clinical manifestations with this disease process?
Ulcerations on digits an dcomplaints of claudication
Which of the following conditions are caused by left
sided heart failure? (Select all that apply) -Pulmonary edema, Decreased urine output
Which of the following would the nurse most likely assess in a client diagnosed with right
sided heart failure? -Distended neck veins
A client with atherosclerosis asks a nurse which factors are responsible for this condition. What is the nurse's best response?
"A combination of platelets and fats accumulate, narrowing the lumen of the artery, reducing blood flow."
The nurse is caring for a client who has hypertension is being prescribed Digoxin for their newly diagnosed heart failure. When going over discharge instructions related to diet, which of the following would be included in these instructions?
"Adhere to a Heart Healthy Diet (DASH Diet) and reduce your sodium intake."
Which intervention suggested to the client with Raynaud's disease is aimed at preventing worsening complications?
"Wear warm clothing when exposed to cool temperatures."
A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg PO daily. Available is digoxin PO 0.25 mg/tablet. How many tablets should the nurse administer per dose? ____ Tablets (Round the answer to the nearest tenth. Use a leading zero if it applies. Type only the numbers, not the units.)
0.5
You are the nurse caring for a client newly diagnosed with a deep vein thrombosis. You receive an order to infuse heparin 1250 units/hr. The IV bag contains 25,000 units of heparin in 250mL D5W. Calculate the IV rate in mL/hr. ____mL/hr (Round the answer to the nearest tenth. Type only the numbers, not the units.
12.5
A nurse is caring for a client who arrived at an emergency department with status asthmaticus. Based on the Progress Note: BP 140/90, P 104, and T. 98.4 F, RR 34, diminishing wheezing. ABG results pH 7.22, PaCO2 69, and HCO3
26. The nurse suspects that the client has what abnormality? -Uncompensated Respiratory acidosis.
You are working in the clinic today, which of your patients is at highest risk for developing essential hypertension?
A 61 year old Caucasian male who drinks 6-7 cups of coffee every day
A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take?
Administer a short-acting-beta2-agonist (SABA)
The nurse notes that the international normalized ratio (INR) of a client with aortic valve replacement who is taking warfarin is 3.2. What is the priority intervention at this time?
Administer the daily dose of warfarin as ordered.
The health care provider has just prescribed the client Warfarin Sodium. The nurse knows that this client is still receiving intravenous heparin. Which is the nurse's best action?
Administer the medications as prescribed.
The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)?
Blood pressure of 85/48 mmHg
Patient teaching for a patient taking warfarin should include to only eat small amounts of foods rich in vitamin K each day. Which of the following food sources would the nurse note as rich in vitamin K?
Broccoli
The nurse is assessing a client diagnosed with an abdominal aortic aneurysm. Which of the following sounds did the nurse auscultate during the assessment?
Bruit
A nurse is caring for a client who has HF and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should be a priority for the nurse to take?
Check the client's vital signs and heart rhythm
A nurse is caring for a client who has heart failure and is taking Digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should be a priority for the nurse to take?
Check the client's vital signs and heart rhythm
Which assessment finding does the nurse expect in the client with mitral valve prolapse?
Chest pain and palpitations
Which symptom is most characteristic of a factor VIII deficiency?
Excessive bleeding from a cut
The nurse is to collect a stool specimen from a client diagnosed with cystic fibrosis. The nurse would expect to see which of the following?
Foul-smelling stool.
Isoniazid (INH) and Rifampin (Rifadin) have been prescribed for a client with tuberculosis. A nurse reviews the medical record of the client. Which of the following noted in the client's history would require the nurse to question the order for these medications?
Hepatitis C
You are educating a patient with newly diagnosed Vitamin B12 deficiency anemia. Which of the following statements indicate a need for further teaching?
I will limit my intake of dried beans and citrus fruit.
You are providing patient education on their new medication, Amlodipine (Norvasc). Which statement by the patient indicates patient understanding?
I will need to avoid grapefruit juice and grapefruit while taking this medication.
The nurse is assessing a client diagnosed with asthma. The client's initial breath sounds heard by the nurse consisted of wheezing but have diminishing until no audible sounds are heard. This has occurred due to which of the following?
Increased airway constriction is blocking the airway.
Which of the following conditions is most commonly responsible for right heart failure?
Left heart failure
A client diagnosed with asthma is receiving instructions about the use of Albuterol. The client should be aware that albuterol may cause which of the following?
Nervousness and tachycardia.
A nurse is assessing a male client who has a new diagnosis of peripheral artery disease (PAD). Which of the following findings should the nurse expect to find on the affected extremity? (Select all that apply)
Pain, Paresthesia, Poikilocythermia, Pallor
The graduate nurse is assessing her newly admitted client's abdomen and notes a bruit upon auscultation. Which assessment technique by this nurse should be questioned in this client?
Palpate and document if artery is found to have doubled in size
The graduate nurse is assessing her newly admitted the client's abdomen and notes a bruit upon auscultation. Which assessment technique by this nurse should be questioned in this client?
Palpate and document if artery is found to have doubled in size
A patient who has a history of pulmonary valve stenosis tells the healthcare provider, "I don't have a lot of energy anymore, and both of my feet get swollen in the late afternoon." Which of these problems does the healthcare provider conclude is the likely cause of these clinical findings?
Right side heart failure
A patient is diagnosed with heart failure and is prescribed digoxin (Lanoxin) and furosemide (Lasix). Before administering the furosemide to the patient, which laboratory result should the healthcare provider to review?
Serum Potassium
A patient is diagnosed with heart failure and is prescribed digoxin (Lanoxin) and furosemide (Lasix). Before administering the furosemide to the patient, which laboratory result should the healthcare provider to review?
Serum potassium
You are the nurse preparing to give a client 1 unit of packed red blood cells. As you prepare, you know that which of the following is true?
Severe reactions usually occur within the first 50mL of blood
A nurse is assessing a client who is taking Lisinopril to treat hypertension. Which of the following findings is a priority to report?
Swelling of the tongue
The nurse is assigned to a client who just arrived to the emergency room after a motor vehicle accident and has multiple rib fractures. Knowing the client could potentially have a pneumothorax, what are the signs and symptoms the nurse would correlate with this condition? (Select all that apply)
Tachypnea, Decreased breath sounds on affected side, Respiratory distress, Decreased oxygen saturation
The nurse determines which client as at greatest risk for acidosis?
The adult client with pneumonia
The post
anesthesia care nurse is caring for a client who just had a mitral valve replacement surgery. The client's blood gases are as follows: pH, 7.22; HCO3-, 21 mEq/L; PCO2, 65 mm Hg; and PO2 58 mm Hg. Which is the priority action by the nurse? -Assessing the client's airway
A client diagnosed with asthma is being assessed by the nurse after an administration of Albuterol. The nurse notes which of the following as the expected outcome of this medication?
decreased wheezing
The nurse is caring for a client with COPD and is reviewing the new ABGs. Which of the following arterial blood gas values is consistent with fully compensated respiratory acidosis?
pH 7.37, HCO3- 36 mEq/L, PCO2 65 mm Hg, PO2 78 mm Hg
Which ABG values are expected with anxiety induced hyperventilation?
pH 7.48; PaCO2 32 mm Hg
The nurse is caring for a client who has a 25
pack-year history of cigarette smoking. The client asks about warning signs associated with lung cancer. The nurse includes which of the following as potential signs and symptoms of lung cancer? - hoarseness, clubbing of fingers, hemoptysis, dyspnea, recurrent pneumonia
A nurse is providing information about TB to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? Select all that apply:
persistent cough, fatigue, night sweats, purulent sputum
A nurse is assessing a client diagnosed with Buerger's disease. While assessing this client and extremities, the nurse correlates which clinical manifestations with this disease process?
ulcerations on digits and complaints of claudication