NUR 233 Exam 2

A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidence by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates clients progress in meeting goals for this problem. A. Ambulates 10 ft farther each day B. Verbalize the benefits of increasing activity C. Chooses a healthy diet that meets caloric needs D. Sleeps without awakening throughout the night

A

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. The patient is experiencing stridor. b. The patient complains of generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.

A

In a patient with prolonged vomiting, the nurse monitors for fluid deficit because vomiting results in A. Fluid movement from the cells into interstitial space and blood vessels B. Excretion of large amount if ICF with depletion of ECF C. An overload of ECF with increase of ICF D. Fluid movement from vascular system into cells, swelling

A

The nurse is assessing a client newly diagnosed with mild HTN. Which assessment finding should the nurse expect? A. Asymptomatic B. SOB C. Visual disturbances D. Frequent nosebleeds

A

The nurse is assessing a patient who is suspected to have left-sided heart failure. Which assessment provides specific information regarding left-sided heart failure? A. Auscultating lung sounds B. Monitor for hepatomegaly C. Palpate for peripheral edema D. Assess for jugular vein distension

A

The nurse is caring for a patient with a potassium level of 6.0. What is the nurse's priority action? A. Place patient on cardiac monitor B. Obtain baseline weight C. Deliver spironolactone orally D. Assess LOC

A

The nurse is reviewing a clients laboratory report and notes that the total serum calcium level is 6.0. The nurse understands that which condition most likely caused this serum calcium level. A. Prolonged bed rest B. Renal insufficiency C. Hyperparathyroidism D. Excessive ingestion of vitamin D

A

A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value? a. Daily alcohol intake b. Dietary protein intake c. Multivitamin/mineral use d. Over-the-counter (OTC) laxative use

A D (if MG levels were high)

Implementation of nursing care for a patient with hyponatremia includes A. Fluid Restriction B. Administration of hypotonic IV fluids C. Administration of cation-exchange renin D. Increased water intake for patient on NG suction

A - need hypertonic solution B (hypotonic IV fluids are for someone with hypernatremia)

Tp promote airway clearance in the patient with pneumonia, what should the nurse instruct the patient to do? A. Maintain adequate fluid intake B. splint the chest when cough C. maintain semi-fowlers position D. cough with expectoration

A, B, D

The HCP prescribes limited activity (bed rest and bathroom only) for a client who developed DVT after surgery. What interventions should the nurse plan to include in the clients plan of care? A. Instruct the patient to cough with deep breathe B. Place in high fowlers position for eating C. Encourage increased oral intake of water daily D. Place thigh-length elastic stockings on client E. Place sequential compression boots on unaffected leg F. Encourage the intake of dark green leafy vegetables

A, D, E A (lung capacity) NOT C or F (encourage is not an implementation)

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale, deep and surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? A. Stage 1 ulcer B. Vascular ulcer C. Arterial ulcer D. Venous stasis ulcer

C

A patient comes into the clinic complaining of frequent, watery stool for the past 2 days. Which action should the nurse take first A. Obtain a baseline weight B. Check the patients BP C. Draw blood for serum electrolytes D. Ask about extremity numbness

B

The client complains of calf tenderness, and thrombophlebitis is suspected. The nurse should next assess the client for which finding? A. Bilateral edema B. Increased calf circumference C. Diminished distal peripheral pulses D. Coolness and pallor of affected limb

B

You are assessing a patient suspected of having right-sided heart failure. What assessment finding indicate right sided heart failure A. Pulmonary Edema B. Distended neck veins C. Dry cough D. Orthopnea

B

IV potassium chloride 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should nurse take? A. Administer KCL as rapid IV bolus B. Infuse KCL at rate of 10 mEq/hour C. Only give KCL through central venous line D. Discontinue cardiac monitoring during infusion

B A (never give bolus)

The nurse is assessing a patient with a positive Chvostek's sign. Which actions are priority? Select all that apply A. Assess lung sounds B. Request soft diet C. Evaluate phosphorus level D. Assess for thrombosis and clots E. Monitor for cardiac dysrhythmias

B, C, D

The nurse is planning to teach a client with PAD about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? Select all that apply A. Soak feet in hot water daily B. Be careful not to injure legs or feet C. Use heating pas on legs to aid vasodilation D. Walk each day to increase circulation to legs E. Cut down on the amount of fats consumed in diet

B, D, E

After receiving change-of-shift report, which patient should the nurse assess first? A. Patient with serum potassium level of 5.0 with complaint of abdominal pain B. Patient with serum sodium level 145 who has dry mouth asking for water C. Patient with serum magnesium 1.1 who has tremors and hyperactive deep tendon reflexes D. Patient with serum phosphorus level 4.5 who has multiple soft tissue calcium-phosphate precipitates

C

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a. K+ 3.4 mEq/L (3.4 mmol/L) b. Ca+2 7.8 mg/dL (1.95 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L)

C

Clinical assessment of dehydration would be confirmed if you identify A. 1-pound weight loss B. Engorged neck veins C. Dry mucous membranes D. Full bounding pulse

C

The nurse is caring for a patient with a medical diagnosis of hypernatremia. The following orders are written in the clients electronic health record. Which one should the nurse question? A. Administer an IV of D5W at 125 mL/hr B. Strict I&O monitoring C. Restrict oral intake to 900 mL every 24 hrs D. Monitor serum electrolytes every 4 hours

C

The nurse is providing instructions to a client with a diagnosis of hypertension regarding high sodium items to be avoided. Avoid consuming which item A. Banana B. Broccoli C. Antacids D. Cantaloupe

C

The nurse is working in the heart failure clinic will know that teaching for a 74 y/o patient with newly diagnosed HF has been effective when the patient A. Weighs himself twice a week B. Tells the home care nurse that hydrodiuril is taken at bedtime C. Calls the clinic when the weight increases from 124-130 lbs in a week D. Says that Nitro-Bid will be used for any chest pain that develops

C

It is important for the nurse to assess for which client manifestations in a patient who can undergone a total thyroidectomy? A. Weight gain B. Depressed reflexes C. Positive Chvostek's sign D. Confusion and personality changes

C (sign of hypocalcemia)

Client with cardiac history is taking potassium-wasting diuretics (furosemide) and is seen in the ER for complaints of weakness. You except to evaluate which lab values? A. Albumin and protein B. Sodium and chloride C. Hemoglobin and hematocrit D. Potassium and blood glucose

D

The nurse is caring for a patient with potassium level of 2.8 mEq/L. Which assessment related is most concerning? A. Lightheadedness when getting out of bed B. Tremors when stretching C. Bone pain and joint stiffness D. Palpitations and irregular pulse

D

The nurse is planning the care of a client diagnosed with pneumonia and writes problem of "impaired gas exchange". Which is an expected outcome? A. Perform chest physiotherapy 3 times a day B. Able to complete activities of daily living C. Ambulates in the hall several times during shift D. Alert and oriented to person, place, time

D