NUR 356 Exam 3

A client is teaching a client who has a new prescription for hydrochlorothiazide for management of hypertension. Which of the following instructions should the nurse include? A. "Take this medication before bedtime." B. "Monitor for leg cramps." C. "Avoid grapefruit juice.' D. "Reduce intake of potassium-rich foods."

Hydrochlorothiazide can cause hypokalemia. The client should monitor for manifestations of hypokalemia, such as fatigue, tachycardia, leg cramps, and muscle weakness.

A nurse is preparing to administer atenolol 25mg PO q 12 hr. The amount available is atenolol 50mg/tab. How many tablets should the nurse administer per dose?

0.5 tab

A nurse is preparing to administer digoxin 0.25mg PO daily. The amount available is digoxin 0.125mg tablets. How many tablets should the nurse administer?

2

A nurse in a clinic is caring for a client who has recently begun taking warfarin. The nurse is reviewing potential drug and food interactions risks and should instruct the client to avoid which of the following? A. Cabbage B. Cantaloupe C. Green Beans D. White Beans

A. Cabbage Rationale: Cabbage should be limited because it is rich in Vitamin K.

A nurse is assessing a client who is 2 days postoperative and auscultates bilateral breath sounds, but absent breathe sounds in the bases. The nurse should suspect which of the following postoperative complications? A. Atelectasis B. Pneumonia C. Pulmonary embolism D. Arterial thrombus

A. Atelectasis Rationale: - an incomplete alveolar expansion or collapse. Breath sounds are dull or absent over areas of alveolar collapse.

A nurse is caring for a client who has congestive HF and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? A. Check the client's vital signs. B. Request a dietitian consult. C. Suggest that the client rests before eating the meal. D. Request an order for an antiemetic.

A. Check the client's vital signs. Rationale: Possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs, the nurse can assess for brachycardia, which is a symptom of digoxin toxicity. The nurse should withhold the medication and call the provider if the client's HR is less than 60 bpm.

A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication? A. Decreased BP B. Increase of HDL cholesterol C. Prevention of bipolar maniac episodes. D. Improved sexual function

A. Decreased BP Rationale: ACE inhibitor; may be used alone or in combination with other antihypertensives in the management of hypertension and congestive HF. A therapeutic effect is decreased BP.

A nurse is caring for an older adult client who has left-sided HF. Which of the following assessment findings should the nurse expect? A. Frothy sputum B. Dependent edema C. Nocturnal polyuria D. Jugular distention

A. Frothy Sputum Rationale: Left-sided HF reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness.

A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching? A. I may eat 10oz of lean protein each day B. Fresh fruits make a good snack option C. I will replace table salt with dried herbs. D. I may thicken gravies with cornstarch as I cook.

A. I may eat 10oz of lean protein each day. Rationale: Lean meats should be limited to 5-6oz per day.

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take first? A. Repeat auscultation after asking the client to breathe deeply and cough. B. Instruct the client to limit fluid intake to less than 2,000 mL/day C. Prepare to administer antibiotics D. Place the client on bed rest in semi-Fowler's position.

A. Repeat auscultation after asking the client to breathe deeply and cough. Rationale: Although crackles often indicate fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breathe or a cough.

When caring for a patient with acute bronchitis, the nurse will prioritize interventions by: A. auscultating sounds B. encouraging fluid restriction C. administering antibiotic therapy D. teaching the patient to avoid cough suppressants.

A. auscultating sounds

The nurse in the cardiac care unit is caring for a client with acute right-sided HF. Which of the following findings should the nurse expect? A. decreased brain natriuretic peptide (BNP). B. Elevated central venous pressure (CVP). C. Increased pulmonary artery wedge pressure (PAWP). D. Decreased specific gravity

B. Elevated central venous pressure (CVP) Rationale: This is a measurement of pressure in the right atria or ventricle at the end of diastole. An elevated CVP is indicative of HF.

A nurse is receiving a client who is immediately post-op following hip arthroplasty. Which of the following medications should the nurse plan to administer for DVT prophylaxis? A. Aspirin PO B. Enoxaparin sub Q C. heparin infusion D. warfarin PO

B. Enoxaparin Sub Q. low molecular heparin that inhibits thrombus and clot formation.

A nurse is caring for a client who has HF and is receiving IV furosemide. The nurse should monitor the client for which of the following electrolyte imbalances? A. Hypernatremia B. Hyperuricemia C. Hypercalcemia D. Hyperchloremia

B. Hyperuricemia Rationale: The nurse should instruct the client to notify the provider for any tenderness or swelling of the joints.

A nurse in a provider's office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client? A. Bradycardia B. Night sweats C. Confusion D. Narrowed pulse pressure

C. Confusion Rationale: Confusion, weakness, and anorexia are manifestations of pneumonia in an older adult client.

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? A. Encourage the client to ambulate frequently B. Encourage coughing and deep breathing C. Encourage the client to increase fluid intake D. Encourage regular use of the incentive spirometer

C. Encourage the client to increase fluid intake Rationale: Increasing fluid intake to 1,500 to 2,000 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.

A nurse is providing discharge instructions to a client who developed DVT post-op and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include? A. Apply cool compresses to her legs B. wearing loose, non-constricting stockings C. flexing her knees and feet frequently D. taking an NSAID tablet daily

C. Flexing her knees and feet frequently

A nurse is caring for a client who has just developed a PE. Which of the following medications should the nurse anticipate administering? A. Furosemide B. Dexamethasone C. Heparin D. Atropine

C. Heparin

A patient with tricupsid valve disorder disorder has impaired blood flow between the A. Vena cava and right atrium B. left atrium and left ventricle C. right atrium and right ventricle D. right ventricle and pulmonary artery

C. Right atrium and right ventricle

A nurse is providing teaching to a client who has hypertension and a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse provide? A. Weigh weekly to monitor therapeutic effect B. Take the medication on an empty stomach. C. Take the medication early in the day. D. Muscle pain is an expected adverse effect.

C. Take the medication early in the day. Rationale: to avoid nocturia.

A nurse in the ED is assessing an older adult client who has acquired pneumonia. Which of the following findings should the nurse expect? A. unequal pupils B. hypertension C. tympany upon chest percussion D. confusion

D. Confusion

A nurse is planning care for a client who has DVT and it receiving anticoagulation therapy. Which of the following interventions should the nurse include in the plan of care? A. Apply cold compresses to the affected extremity B. Massage the affected extremity gently C. Apply compression stockings at bedtime. D. Encourage the client to walk

D. Encourage the client to walk

A nurse is assessing a client who is at risk for DVT. Which of the following findings is a manifestation of DVT? A. Pallor in the affected extremity B. Cramping pain in one foot C. Auscultation of bruit over pedal pulse D. Groin tenderness

D. Groin tenderness

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first. A. Administer oxygen at 2L/min B. Administer prescribed analgesic medication C. Encourage coughing and deep breathing. D. Raise the head of the bed.

D. Raise the head of the bed. Rationale: Raising the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway. This is the first action the nurse should take and is the least invasive.

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? A. Bradypnea B. Somnolence C. Pallor D. Tachycardia

D. Tachycardia Rationale: The nurse should expect the client who has hypoxia to manifest tachycardia.

A nurse is assessing a client who has post op atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? A. Bradycardia B. Bradypnea C. Lethargy D. Intercostal retractions

D. Intercostal retractions Hypoxia is a condition in which the tissues of the body are oxygen-starved. It follows hypoxemia (low oxygen in the blood) and is manifested as substernal or intercostal retractions as the body works harder to draw more oxygen into the lungs.

A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? A. Bradycardia B. Bradypnea C. Lethargy D. Intercostal retractions.

D. Intercostal retractions Rationale: Hypoxia is a condition in which the tissue of the body are oxygen-starved. It follows hypoxemia (low oxygen in the blood) and is manifested as substernal or intercostal retractions as the body works harder to draw more oxygen into the lungs.

A nurse is teaching a client who has a new prescription for simvastatin. Which of the following instructions should the nurse include? A. You should expect brown-colored urine. B. You should avoid grapefruit. C. You should monitor for ringing in the ears. D. You should take the medication in the morning.

You should avoid grapefruit juice. Rationale: can inhibit the drug metabolizing enzyme CYP3A4 which slows the metabolism of simvastatin. This can cause an increase in serum simvastatin. Potential adverse effects include elevated liver enzymes, and rhabdomyolysis.

A nurse is assessing a client who is 2 days post op and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications? A. Atelectasis B. Pneumonia C. Pulmonary Embolism D. Arterial thrombus

A. Atelectasis Rationale: incomplete alveolar expansion or collapse. Breath sounds are dull or absent over areas of alveolar collapse.

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? A. Attach a humidifier bottle to the base of the flow meter. B. Remove the nasal cannula while the client eats C. Secure the oxygen tubing to the bed sheet near the client's head D. Apply petroleum jelly to the nares as needed to soothe mucous membranes.

A. Attach a humidifier bottle to the base of the flow meter.

A nurse is providing teaching about the Mediterranean diet to a client newly who has a new diagnosis of hypertension. Which of the following statements by the client indicates a need for further teaching? A. I will limit my intake of red meat to twice weekly. B. I can have dairy in moderate portions daily. C. I can have fish two times a week. D. I can drink wine in moderation.

A. I will limit my intake of red meat to twice weekly. Rationale: Following the mediterranean diet, red meat should be limited to two times monthly.

Which patients have the greatest risk for aspiration pneumonia? (select all that apply) A. patient with seizures B. Patient with head injury C. patient who has thoracic surgery D. Patient who had a myocardial infarction E. patient who is receiving nasogastric tube feeding

A. Patient with seizures B. Patient with head injury E. Patient who is receiving nastrogastric tube feeding

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? A. The P wave falls before the QRS complex. B. The T wave is in the inverted position C. The P-R interval measures 0.22 seconds D. The QRS duration is 0.20 seconds.

A. The P wave falls before the QRS complex. Rationale: The nurse should recognize that in normal sinus rhythm the P wave, representing atrial depolarization, falls before the QRS wave.

A nurse is caring for a client who has hypertension and is afraid to take his blood pressure medication. Which of the following nursing statements is an example of therapeutic communication response of reflection? A. You seem upset about taking your BP medication B. Why do you feel afraid to take your medication C. You won't get better until you take your medication. D. Did your symptoms occur before or after you took the medication?

A. You seem upset about taking your BP medication

A nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. Which of the following instructions should the nurse include? A. Eat 3 large meals each day B. Limit water intake with meals C. Reduce protein intake D. Use a bronchodilator 1 hour before eating.

B. Limit water intake with meals. Rationale: Limit low nutrients liquid during meals to prevent early satiety (absence of hunger) and increase intake of nutrient dense foods.

A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hand, and cannot talk. Which of the following actions should the nurse should take? A. Observe the client before taking further action B. Perform the Heimlich maneuver C. Assist the client to the floor and begin mouth-to-mouth resuscitation D. Slap the client on the back several times.

B. Perform the Heimlich maneuver.

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? A. The client will list foods that are high in calcium, which should be avoided. B. The client will walk for 30 min 5 days a week. C. The client will increase calorie intake by 200 cal per day. D. The client will replace cigarettes with smokeless tobacco products.

B. The client will walk for 30 min 5 days a week

A nurse is teaching the parents of a child who is starting a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching? A. The spacer increases the amount of medication delivered to the oropharynx. B. The spacer increases the amount of medication delivered to the lungs C. Inhale rapidly using the spacer with the MDI D. Cover exhalation slots of the spacer with lips when inhaling.

B. The spacer increases the amount of medication delivered to the lungs

A nurse is providing discharge instructions for a client who has congestive HF. Which of the following client statements indicates to the nurse that the teaching was effective. A. I will read food labels and limit my sodium to 4g per day. B. I should use naproxen to manage discomfort. C. I plan to slow down if I am tired the day after exercising. D. I will take my diuretic before sleeping and drink fluids during the day.

C. I plan to slow down if I am tired the day after exercising. Rationale: Clients who are experiencing pain the next day are probably advancing the activity too quickly and should slow down.

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? A. Pigeon B. Funnel C. Kyphotic D. Barrel

D. Barrel Rationale: Clients who have COPD use accessory muscles to assist with respiratory effort. The use of those accessory muscles causes the chest wall to eventually increase in anterior-posterior diameter, making it appear barrel shaped.

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygenation? A. Restlessness B. Retractions C. Dependent edema D. Clubbing of the fingers

D. Clubbing of the fingers

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse,"I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up". Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a semi-Fowler's position as often as possible B. Administering oxygen via nasal cannula at 2L/min C. Helping the client select a low-salt diet D. Encouraging the client to drink 2-3 L of water daily.

D. Encouraging the client to drink 2-3 L of water daily. Rationale: COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration.

A nurse is providing teaching to a client who has a new prescription for lisinopril. Which of following statements by the nurse indicates an understanding of the teaching? A. I should increase my intake of potassium rich foods B. I should expect to have facial swelling when taking this medication. C. I should take this medication with food. D. I should report a cough to my provider.

D. I should report a cough to my provider . Rationale: The provider should discontinue the medication for a persistent, irritating cough.

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? A. Restrict the client's fluid intake to less than 2L/day. B. Provide the client with a low-protein diet. C. Have the client use the early-morning hours for exercise and activity. D. Instruct the client to use pursed-lip breathing.

D. Instruct the client to use pursed-lip breathing Rationale: Pursed lip breathing lengthens the expiratory phase of respiration and also increases the pressure in the airway during exhalation. This action reduces airway resistance and decreases trapped air for clients who have COPD.

A nurse is caring for a client who has a prescription for digoxin 0.25mg PO daily. The amount available is digoxin 0.125mg tab. The client's current vitals are: blood pressure 144/96, heart rate 54/min, respirations 18/min, and temperature 98.6F. Which of the following actions should the nurse take? A. Administer digoxin 0.125mg B. Administer digoxin 0.25mg C. Withhold the digoxin dose for elevated blood pressure. D. Withhold the digoxin dose for decreased pulse rate.

D. Withhold the digoxin for decreased pulse rate. Rationale: The nurse should withhold the prescribed dose of digoxin as the HR is less than 60/min and notify the provider.

A nurse is caring for a client who develops a PE. Which of the following interventions should the nurse implement first? A. Give morphine IV B. Administer oxygen therapy C. Start an IV infusion of lactated Ringer's D. Initiate cardiac monitoring

B. Administer oxygen therapy Rationale: greatest risk to the safety of the client who has PE is hypoxemia with respiratory distress and cyanosis.