Nursing 301 Exam 2 Practice Questions

C. obtain ECG

A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU? A. obtain family history B. auscultate lung fields C. obtain ECG D. assess all pulses

B. maintaining a low-sodium diet

A client hospitalised for treatment of hypertension is being prepared for discharge. Which teaching topic should the nurse should be sure to cover? a. receiving IV antihypertensive medications b. maintaining a low-sodium diet c. maintaining a low-potassium diet d. skipping a medication dose if dizziness occurs

A)Decreased cardiac output related to depressed myocardial function, fluid volume deficit, or impaired electrical conduction 9%

A client is recovering from coronary artery bypass graft (CABG) surgery. Which nursing diagnosis takes highest priority at this time? A)Decreased cardiac output related to depressed myocardial function, fluid volume deficit, or impaired electrical conduction 9% b) Anxiety related to an actual threat to health status, invasive procedures, and pain 1% c) Disabled family coping related to knowledge deficit and a temporary change in family dynamics 8% d) Hypothermia related to exposure to cold temperatures and a long cardiopulmonary bypass time

A. antiplatlet

A client who has a history of myocardial infarction (MI) is prescribed aspirin (Ecotrin) 325 mg. The nurse correctly understands that the aspirin is ordered due to its action as an: A. antiplatlet B. anti-inflammatory C. analgesic D. antipyretic

C. When the pain begins

A client who has a long leg cast for a fractured bone is to be discharged from the emergency department. When discussing pain management, when does the nurse advise the client to take the prescribed as-needed oxycodone? A. only as a last resort B. when the pain becomes intense C. when the pain begins D. only before activity

A. elevating the extremity above heart level D. applying cold compresses

A client with a fracture is found to have compartment syndrome. Which interventions will be contraindicated? Select all that apply. A. elevating the extremity above heart level B. reducing the traction weight C. loosening the client's bandage D. applying cold compresses E. splitting the cast in half

D. "Exercise, keep your cholesterol in check, and manage your stress."

A client with a strong family history of coronary artery disease asks the nurse how to reduce the risk of developing the disorder. Which is the best response by the nurse? A. "ask your physician to prescribe the new reverse lipid drug." B. "increase the soy in your diet." C. "moderation with alcohol" D. "exercise, keep your cholesterol in check, and manage your stress."

D. green pepper stuffed with fresh tomatoes and chicken

A client, newly prescribed a low-sodium diet due to hypertension, is asking for help with meal choices. The client provides four meal choices, which are favorites. Which selection would be best? a) Toasted cheese sandwich on whole wheat toast with tomato soup b) Creamed chipped beef over with mashed potatoes c) Hot dog with ketchup on whole wheat bun d) Green pepper stuffed with fresh tomatoes and chicken

C. keeping the legs in a neutral or dependent position

A home health nurse is teaching a client with peripheral arterial disease ways to improve circulation to the lower extremities. The nurse encourages which of the following in teaching? A. elevation of the legs above the heart B. application of ace wraps from the toe to below the knees C. keeping the legs in a neutral or dependent position D. use of antiemolytic stockings

B. place a pillow under the client's head

A nurse enters the room of a client and finds the on the floor in the clonic phase of a tonic-clonic seizure. Which of the following interventions is appropriate? A. insert a padded tongue blade into the client's mouth B. place a pillow under the client's head C. apply a face mask for oxygen administration D. gently restrain the client's extremities

D. degree of myocardium damage

A nurse in an intensive care unit is caring for a client who had an acute myocardial infarction (MI) and had cardiac enzymes drawn. The nurse should know that the results of the cardiac enzyme studies help determine the: A. location of pulmonary congestion B. location of infarction C. size of infarction D. degree of myocardium damage

C. Initiate Oxygen therapy myocardial cell death is reason to prioritize O2 therapy - getting O2 to damaged cells to prevent further injury

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first? A: Attach the leads for a 12 lead EKG B: Obtain a blood sample C: Initiate Oxygen Therapy D: Insert the IV Catheter

A. scanning speech B. intention tremors D. nystagmus

A nurse is assessing a client with multiple sclerosis. Which common initial clinical effects should the nurse expect to find? Select all that apply. A. scanning speech B. intention tremors C. headaches D. nystagmus E. skin infections

B. numbness, cool skin temp, and pallor

A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? A. numbness, warm skin temp, redness B. numbness, cool skin temp, pallor C. redness, cool skin temp, swelling D. swelling, warm skin temp, drainage

B. place the child in a lateral position

A nurse is caring for a child that is experiencing a seizure. Which of the following would be the most appropriate action for the nurse to take? A. stop the seizure B. place the child in a lateral position C. use a padded tongue blade D. restrain the arms

B. plan to alternate activity with periods of rest

A nurse is caring for a client admitted to the hospital with a diagnosis of myasthenia gravis. The nurse should observe the client for: A. engage in a vigourous exercise program B. plan to alternate with periods of rest C. wear an eye patch on the right eye at all times D. plan to relax in a hot tub spa each day

C. Respiratory difficulty

A nurse is caring for a client admitted to the hospital with a diagnosis of myasthenia gravis. The nurse should observe the client for: A. increased urine output B. increased intracranial pressure C. respiratory difficulty D. confusion and disorientation

D. Administer oxygen therapy

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A. initiate cardiac monitoring B. start an IV of lactated ringers C. administer morphine D. administer oxygen therapy

D. ask the client to wiggle their toes

A nurse is caring for a client who has a fractured femur. Which of the following techniques should the nurse use when performing a assessment of circulatory status? A. ask the client to cough and deep-breathe B. observe the client's ability to turn himself in bed C. assist the client in performing biceps exercise D. ask the client to wiggles their toes

C. Heparin

A nurse is caring for a client who has just developed pulmonary embolism. The nurse should prepare to administer which of the following medications? A. Lasix B. Atropine C. heparin D. Dexamethasone

B. obtain a pair of slipper-socks for the client

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? A. rub the client's feet briskly for several minutes B. obtain a pair of slipper-socks for the client C. increase the client's oral fluid intake D. place a moist heating pad under the client's feet

B. The Coumadin takes several days to work, so the IV heparin will be used until the Coumadin reaches a therpeutic level

A nurse is caring for a client who is hospitalized with deep vein thrombosis and has been on IV heparin for 5 days. The provider prescribes oral warfarin (Coumadin) without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following is an appropriate nursing response? A. Both heparin and Coumadin work together to dissolve the clots B. The Coumadin takes several days to work, so the IV heparin will be used until the Coumadin reaches a therapeutic level C. The IV heparin inceases the effets of the Coumadin and decreases the length of your hospital stay D. I will call the provider to get a prescription for discontinuing the IV heparin today

A. Keep the client in a side-lying position

A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. keep the client in a side-lying position B. monitor the client's vital signs C. reoritent the client to the environment D. check the client for injuries

B. make a mental notation of the time after looking at a watch

A nurse is caring for a client who was admitted to the hospital after having two seizures at work. The client suddenly gives a short cry and stiffens. Which of the following should be the initial nursing action? A. turn the client's head to the side B. make a mental notation of the time after looking at a watch C. administer an IV anticonvulsant D. loosen the clothing around the client's neck

C. DVT

A nurse is caring for a client who's had surgery. The physician encourages the client to increase mobility as soon as possible. The nurse notes edema to the right leg with skin color changes to the right lower extremity. The client reports pain at the incision site as 5 on a 0- to 10-point scale and pain to the right calf as 7 on a 0- to 10-point scale. The nurse reports the findings to the physician. She suspects that the client has: A. Physiologic pain indicator B. Wound evisceration C. DVT D. Allergic reaction

D. intermittent claudication

A nurse is caring for a client with peripheral arterial disease (PAD). Which of the following symptoms is typically the initial reason clients with PAD seek medical attention? A. foot ulcers B. rest pain C. rubor D. intermittent claudication

A. keep an oxygen setup at the bedside B. elevate the side rails when in bed C. place the bed in the lowest position E. provide a suction setup at the bedside

A nurse is creating a plan of care for a client who has a tonic-clonic seizures disorder. Which of the following seizure precautions should the nurse implement? (Select all that apply.) A. keep an oxygen setup at the bedside B. elevate the side rails when in bed C. place the bed in the lowest position D. Furnish restraints at the bedside E. provide a suction setup at the bedside

D. a straight-backed chair with an elevated seat

A nurse is giving discharge instructions to a client who had an internal repair of a right hip fracture. The nurse knows that teaching has been effective when the client tells her that he will rest during the day sitting on which of the following pieces of furniture? A. a couch with plush cushions B. a reclinign chair with an ottoman C. a rocking chair with a curved back D. a straight-backed chair with an elevated seat

B. "I will take my medications at the first sign of an attack."

A nurse is instructing a client newly diagnosed with Raynaud's disease about the prevention of the onset of symptoms. Which of the following client statements should indicate to the nurse the need for additional teaching? A. I will wear gloves when removing food from the freezer B. I will take my medications at the first sign of an attack C. I will try to anticipate and avoid stressful situations when possible D. I will complete the smoking cessation program I started

C. Oxygen

A nurse is planning care for a client who has a suspected myocardial infarction. Which of the following should the nurse administer first? A. Aspirin B. Nitroglycerin C. Oxygen D. Morphine Sulfate

A. CAD D. Mi E. Stroke

A nurse is providing education about hypertension to a community group. One client reports that his doctor has diagnosed him with hypertension, but that he feels just fine. He asks, "What would happen if I did not treat my hypertension?" Which of the following are possible consequences of untreated hypertension? Choose all that apply. A. CAD B. Pneumonia C. Pancreatitis D. MI E. Stroke

A. exertion and anxiety can trigger the pain

A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. The nurse should give the client which of the following information about anginal pain? A. exertion and anxiety can trigger the pain B. the pain often radiates to the jaw or the back C. the pain usually lasts more than 20 min D. the pain persists with rest and organic nitrates

B. I must stop smoing D. I should limit by intake of fast foods E. I need to monitor my weight

A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicate understanding of the teaching? (Select all that apply.) A. I should limit my exercise B. I must stop smoing C. I must stop drinking alcohol D. I should limit by intake of fast foods E. I need to monitor my weight

C. I eat two eggs for breakfast each morning

A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low cholesterol diet? A. I flavor my meat with lemon juice B. I cook my food with canola oil C. I eat two eggs for breakfast each morning D. I take an omega-3 supplement daily

C. beans

A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflects the client's understanding of these dietary instructions? A. eggs B. liver C. beans D. milk

B. "diuretics are the first type of medication to control hypertension."

A nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching? A: "Reaching your goal blood pressure will occur within 2 months." B: "Diuretics are the first type of medication to control hypertension." C: "Limit your alcohol consumption to three drinks a day. D: "Plan to lower saturated fats to 10 percent of your daily calorie intake."

C. assess chest pain and administer prescribed drugs and oxygen

A patient complains about chest pain and heavy breathing when exercising or when stressed. Which of the following is a priority nursing intervention for the patient diagnosed with coronary artery disease? A. not important to assess the patient or to notify the physician B. assess the blood pressure and adminsiter aspirin C. assess chest pain and administer prescribed drugs and oxygen D. assess the physical history of the patient

D. attempt to palpate the dorsalis pedis and posterior tibial pulses

A patient in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete? A. assess for unilateral swelling and tenderness of either leg B. check for the presence of tortuous veins bilaterally on the legs C. ask about any skin color changes that occur in response to cold D. attempt to palpate the dorsalis pedis and posterior tibial pulses

B. throbbing headache or dizziness VS to monitor with nitro = BP

A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects? A. nervousness or paresthesia B. throbbing headache or dizziness C. drowsiness or blurred vision D. tinnitus or diplopia

C. the patient has at least a 70% occlusion of a major coronary artery

A patient with coronary artery disease (CAD) is having a cardiac catheterization. What indicator is present for the patient to have a coronary artery bypass graft (CABG)? A. the patient has an ejection fraction of 65% B. the patient has compromised left ventricular function C. the patient has at least 70% occlusion of a major coronary artery D. the patient has had angina longer than 3 years

A. report swelling of the fingers C. elevate casted arm when standing

A toddler has just had a cast applied for a fractured wrist. The wrist and elbow are immobilized. What information should the nurse include in the home care instructions before discharge? Select all that apply. A. report swelling of the fingers B. resume usual activities C. elevate casted arm when standing D. lower the casted arm when laying down

C. history of diabetes

An obese white male client, age 49, is diagnosed with hypercholesterolemia. The physician orders a low-fat, low-cholesterol, low-calorie diet to reduce blood lipid levels and promote weight loss. This diet is crucial to the client's well-being because his race, sex, and age increase his risk for coronary artery disease (CAD). To determine whether the client has other major risk factors for CAD, the nurse should assess for: A. alcoholism B. history of aortic aneurysm C. history of diabetes D. elevated HDL levels

D. obtaining an ECG for the client

An older adult client with a history of myocardial infarction (MI) comes to the emergency department reporting bilateral calf pain. He states that it started 2 weeks ago when he began a more advanced stretching and exercise regimen. The client also states that he has been having indigestion for the past 24 hr. Which of the following is the nurse's priority action? A. checking the client's calves for redness and warmth B. further questioning the client about his indigestion C. applying warm, moist wraps to the client's lower legs D. Obtaining an ECG for the client

D. perform a doppler

For a client with thrombosis, what does the nurse initially do if pulses cannot be palpated? A. notify the provider B. order Ct scan C. panic D. perform a doppler

A. All options are correct

Hypertension is defined as "sustained elevations in systolic or diastolic blood pressures that exceed prehypertension levels." What are some of the consequences of hypertension that make it such a health menace in the United States? A. all options are correct B. CVA C. renal disease D. cardiac failure

D. to decrease workload of the heart

In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD? A. to dilate B. to prevent angiotensin II conversin C. to decrease hemocysteine levels D. to decrease workload of the heart

A. increases the HR, constricts arterioles, and reduces the heart's ability to eject blood

It is appropriate for the nurse to recommend smoking cessation for patients with hypertension because nicotine: a) increases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. b) decreases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. c) increases the heart rate, constricts arterioles, and increases the heart's ability to eject blood. d) decreases circulating blood volume.

A. 140,90

Officially, hypertension is diagnosed when the patient demonstrates a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg over a sustained period. A. 140, 90 B. 130, 80 C. 120, 70 D. 110, 60

A. the urine output is an important indicator of cardiac function: poor urine output may indicate inadequate blood flow to the kidneys

The client asks the nurse what his urine output has to do with his cardiac function. The best reply by the nurse is which of the following? A. the urine output is an important indicator of cardiac function: poor urine output may indicate inadequate blood flow to the kidneys B. Too much urine output indicates a need for a blood transfusion C. high urine output indicates poor cardiac function D. poor urine output indicates a need for a blood transfusion

B. high HDL level

The lab values of a patient diagnosed with coronary artery disease (CAD) have just come back from the lab. His low-density lipoprotein (LDL) level is 112 mg/dL. This lab value is indicative of which of the following? A. extremely low LDL level B. high LDL level C. within normal range D. low LDL level

D. increase in the size of the artery's lumen

The nurse is caring for a patient who has undergone percutaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure? A. increase in the patient's resting heart rate B. increase in the patient's LOC C. decrease in arterial blood flow in relation to venous flow D. increase in the size of the artery's lumen

A. Morphine sulfate

The nurse is caring for a patient who is having chest pain associated with a myocardial infarction (MI). What medication should the nurse administer intravenously to reduce pain and anxiety? A. Morphine sulfate B. Codeine sulfate C. Meperidine Hydrochloride D. hydromorphone hydrochloride

D. Liver enzymes Atorvastatin (Lipitor) is an HMG-CoA reductase inhibitor and is hepatotoxic. Therefore, liver enzymes should be monitored in patients taking this medication

The nurse is caring for a patient with hypercholesterolemia who has been prescribed atorvastatin (Lipitor). What serum levels should be monitored in this patient? A. CBC B. Blood cultures C. Na and K levels D. Liver enzymes

C. Blood pressure of 86/58mmHg

The nurse is caring for a patinet who has severe chest pain after working outside on a hot day and is brought to the emergency center. The nurse administers nitroglycerin to help alleviate chest pain. What side effects should concern the nurse the most? A. dry mucous membranes B. heart rate of 88bpm C. BP of 86/58mmHg D. compaints of headache

B. Left intercostal space at the midclavicular line

The nurse is performing an assessment of the patient's heart. Where would the nurse locate the apical pulse if the heart is in a normal position? A. left 2nd intercostal space at the midclavicular line B. left 5gh inercostal space at the midclavicular line C. right 2nd intercostal space at the miclavicular line D. right 3rd intercostal space at the midclavicular line

A. Abrupt closure of the coronary artery C. arterial occulsion D. retroperitoneal bleeding E. bleeding at the insertion site

The nurse providing care for a patient post PTCA knows to monitor the patient closely. For what complications should the nurse monitor the patient? Select all that apply. A. Abrupt closure of the coronary artery B. venous insufficiency C. arterial occulsion D. retroperitoneal bleeding E. bleeding at the insertion site

B. Vasospasm

The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes A. slowed HR B. vasospasm C. diuresis D. vasodilation

D. Inactivity

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? A. aerobic exercise B. tight clothing C. pregnancy D. inactivity

C. an incomplete fracture with one side bent

The x-ray report of a client shows the presence of a greenstick fracture. What is a greenstick fracture? A. a fracture with more than two fragments b. a spontaneous fracture at the site of bone disease c. an incomplete fracture with one side bent d. a fracture extends across the longitudinal axis of the bone shaft

B. anterior surface of the foot near the ankle joint

To asses the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: A. exterior surface of the foot near the heel B. anterior surface of the foot near the ankle joint C. inside the ankle just above the heel D. outside of the foot just below the heel

A. "the pain occured while I was mowing the lawn."

When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris? A. "The pain occured while i was mowing the lawn." B. "the pain resolved after i ate a sandwich" C. "the pain lasted about 45 min"

C. unstable

When the patient diagnosed with angina pectoris complains that he is experiencing chest pain more frequently, even at rest, the period of pain is longer, and it takes less stress for the pain to occur, the nurse recognizes that the patient is describing which type of angina? A. Stable B. Variant C. Unstable D. intractable

B. A 70 year old female who is obese with a LDL of 195

Which client is a greatest risk for CAD? A. 32 year old female with mitral valve prolapse who quit smoking 15 years ago B. A 70 year old female who is obese with a LDL of 195 C. A 43 year old male with a family history of CAD and overall cholesterol level of 140 D. A 56 year old female with an HDL of 50 who takes atorvastatin

C. pain radiating to the hip and leg

Which clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disk? a. overgrowth of tissue on the lower back b. paralysis of both lower extremities c. pain radiating to the hip and leg d. stiffness in shoulders

D. duplex venous doppler

Which diagnostic study is used to detect DVT in the client's lower extremities? A. plethysmography B. somatosensory evoked potential C. thermography D. duplex venous doppler

B. monitor the site for bleeding or hematoma

Which of the following discharge instructions for self-care should the nurse provide to a patient who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure? A. refrain from sexual activity for one month B. monitor the site for bleeding or hematoma C. Normal activities of daily living can be resumed the first day post op D. cleanse the site with disinfectants and dress the wound appropriately

A. Renal dysfunction resulting from atherosclerosis

Which of the following is the nurse most correct to recognize as a direct effect of client hypertension? a) Renal dysfunction resulting from atherosclerosis b) Anemia resulting from bone marrow suppression c) Hyperglycemia resulting from insulin receptor resistance d) Emphysema related to poor gas exchange

C. Angina pectoris

Which of the following terms refers to chest pain brought on by physical or emotional stress and relieved by rest or medication? A. athersclerosis B. angioedema C. angina pectoris D. ischemia

A. compare the temperature of the two hand

While assessing a school-aged child who has just had a short arm cast applied to a fractured right wrist, the nurse discovers that the fingers of the right hand are cool. What should the nurse do first? A. compare the temperature of the two hands B. elevate the right arm to reduce the swelling C. inform the healthcare provider of the circulatory impairment D. clip the edge of the cast to reduce pressure