Nursing Exam 4 - med surg
HIV Stage 1: Acute Infection
- Increase in virus -Decrease in CD4 cells - sanctuary sites (lymph nodes, genitals) 2-4 week time period - CD4+ count >500 - flu-like symptoms
A nurse is teaching a group of clients about risk factors for heart disease. Which factors increase a client's risk for a MI? SATA (ch 35) a. Obesity b. HTN c. Increased HDL d. Diabetes insipidus e. Asian-American ancestry
A, B
The nurse is teaching a patient who is at risk for venous thromboembolism (VTE). The patient is currently asymptomatic and is living in the community. What interventions does the nurse instruct the patient to do to minimize the risk of VTE? (Select all that apply.) a. Avoid oral contraceptives. b. Drink adequate fluids to avoid dehydration. c. Exercise the legs during long periods of bedrest or sitting. d. Arise early in the morning for ambulation. e. Use a venous plexus foot pump.
A, B, C
A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.) (ch 35) a. Advanced age b. Diabetes c. Ethnic background d. Medication use e. Smoking
A, B, C, E
A nurse assesses a client who is recovering from a heart transplant. Which assessment findings would alert the nurse to the possibility of heart transplant rejection? (SATA) (ch 32) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension f. Fatigue
A, B, C, F
The nurse assesses a patient diagnosed with advanced AIDS for malnutrition. Which findings does the nurse most likely assess? (Select all that apply.) (ch 17) a. Pain b. Anorexia c. Urinary incontinence d. Diarrhea e. Vomiting
A, B, D, E
The nurse is giving a community presentation about heart disease in women. What information does the nurse include in the presentation? (Select all that apply.) (ch 30) a. Dyspnea on exertion may be the first and only symptom of heart failure. b. Symptoms are subtle or atypical. c. Pain is often relieved by rest. d. Having waist and abdominal obesity is a higher risk factor than having fat in buttocks and thighs. e. pain always responds to nitroglycerin. f. Common symptoms include back pain, indigestion, nausea, vomiting, and anorexia
A, B, D, F
A nurse is assessing a client with left-sided heart failure. For which clinical manifestations would the nurse assess? (SATA) (ch 32) a. Pulmonary crackles b. Confusion c. Pulmonary hypotension d. Dependent edema e. Cough that worsens at night f. Jugular venous distension
A, B, E
A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? (Select all that apply.)(ch 17) a. Assess the clients mouth and throat. b. Determine if the client has a stiff neck. c. Ensure that the consent form is on the chart. d. Maintain NPO status as prescribed. e. Percuss the clients abdomen.
A, C, D
A nurse collaborates with assistive personnel to provide care for a client with congestive heart failure. Which instructions would the nurse provide to the AP when delegating care for this client? (Select all that apply) (ch 32) a. Reposition the client every 2 hours b. Teach the client to perform deep-breathing exercises c. Accurately record intake and output d. Use the same scale to weigh the client each morning e. Place the client on oxygen if the client becomes short of breath
A, C, D
Which are risk factors for cardiovascular disease (CVD) in women? (select all that apply.) (ch 30) a. Waist and abdominal obesity b. Excess fat in the buttocks, hips, and thighs c. Postmenopausal d. Diabetes mellitus e. Asian ethnicity
A, C, D
A patient is admitted with a vascular problem. Based on the pathophysiology of systemic arterial pressure, what is the systemic arterial pressure a product of? (Select all that apply.) (ch 33) a. Cardiac output b. Peripheral vascular volume c. Preload d. Peripheral vascular resistance e. Diastolic blood pressure
A, D
After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) a. "I'll read the nutritional labels on food items for salt content." b. "I will drink at least 3 liters of water each day." c. "Using salt in moderation will reduce the workload of my heart." d. "I will eat oatmeal for breakfast instead of ham and eggs." e. "Substituting fresh vegetables for canned ones will lower my salt intake."
A, D, E
The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.) (ch 33) a. Atherosclerosis b. Down syndrome c. Frequent heartburn d. History of hypertension e. History of smoking
A, D, E
What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.) (ch 33) a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options
B, C, D
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) (ch 35) a. Age b. Hypertension c. Obesity d. Smoking e. Stress
B, C, D, E
A nurse prepares to discharge a client who has heart failure. Based on national quality measures, what actions would the nurse complete prior to discharging this client? (SATA) (ch 32) a. Teach the client about energy conservation techniques b. Ensure that the client is prescribed a beta blocker c. Document a discussion about advanced directives d. Confirm that a post-discharge nurse visit had been scheduled e. Consult a social worker for additional resources f. Care transition record transmitted to next level of care within 7 days of discharge
B, C, D, F
An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) (ch 30) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath
B, C, E
A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) (ch33) a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.
B, D, E
The nurse is assessing a 62-year-old native Hawaiian woman. She is postmenopausal, diabetic for 10 years, smokes 1 pack a day of cigarettes for 20 years, walks twice a week for 30 minutes, is an administrator, and describes her lifestyle as sedentary. for her weight and height she has a body mass index of 32. Which risk factors for this patient are controllable for CVD? (Select all that apply.) (Ch 30) a. Ethnic background b. Smoking c. Age d. Obesity e. Postmenopausal f. Sedentary lifestyle
B, D, F
A client who had open abdominal surgery 4 hours ago reports feeling weak and dizzy. The client's current blood pressure has decreased to 98/50, and pulse rate is 108. What is the nurse's best action at this time? A. Document the vital signs, and continue to monitor the client. B. Remind the client to stay in bed if feeling weak and dizzy. C. Call the health care provider immediately. D. Increase the client's IV rate to restore fluid volume.
C. Call the health care provider immediately.
A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) (ch 33) a. Administering preoperative medication b. Ensuring the consent is signed c. Marking pulses with a pen d. Raising the siderails on the bed e. Recording baseline vital signs
D, E
which statements regarding HIV/AIDS among older adults are true? (ch 17) A. the risk for HIV infection after exposure is minimal for older adults B. older men are more susceptible to HIV C. it is not necessary to assess an older adult for history of drug use D. older adults who participate in high-risk behaviors are susceptible to HIV
D. older adults who participate in high-risk behaviors are susceptible to HIV
A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities?(ch33) a. "I can use a heating pad on my legs if it's set on low." b. "I should not cross my legs when sitting or lying down." c. "I will go out and buy some warm, heavy socks to wear." d. "It's going to be really hard but I will stop smoking."
a. "I can use a heating pad on my legs if it's set on low."
A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? (ch 33) a. "No, women should only have one beer a day as a general rule." b. "No, you should not drink any alcohol with hypertension." c. "Yes, since you are larger, you can have more alcohol." d. "Yes, two beers per day is an acceptable amount of alcohol."
a. "No, women should only have one beer a day as a general rule."
A nurse assesses clients on a cardiac unit. Which client would the nurse identify as being at GREATEST risk for the development of left-sided heart failure? (ch 32) a. A 36 year old woman with aortic stenosis b. A 42 year old man with pulmonary hypertension c. A 59 year old woman who smokes cigarettes daily d. A 70 year old man who had a cerebral vascular accident
a. A 36 year old woman with aortic stenosis
A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? (ch 33) a. Appropriate hand hygiene before giving care b. Assessing the client's temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the client's daily white blood cell count
a. Appropriate hand hygiene before giving care
A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate? (ch 33) a. Assess the client's lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil.
a. Assess the client's lung sounds and oxygenation.
A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take FIRST? (ch 32) a. Assess the client's respiratory status b. Draw blood to assess the client's serum electrolytes c. Administer intravenous furosemide d. Ask the client about current medications
a. Assess the client's respiratory status
A nurse is teaching a client with heart failure who has been prescribed enalapril. Which statement would the nurse include in this client's teaching? (ch 32) a. Avoid using salt substitutes b. Take your medication with food c. Avoid using aspirin-containing products d. Check your pulse daily
a. Avoid using salt substitutes
A client had a percutaneous angioplasty for renovascular hypertension 3 months ago. What assessment finding by the nurse indicates that an important outcome for this client has been met? a. Client is able to decrease blood pressure medications. b. Insertion site has healed without redness or tenderness. c. Most recent lab data show BUN: 19 mg/dL and creatinine 1.1 mg/dL. d. Verbalizes understanding of postprocedure lifestyle changes.
a. Client is able to decrease blood pressure medications.
A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? (ch 33) a. Consult with the Wound Ostomy Care Nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.
a. Consult with the Wound Ostomy Care Nurse.
The nurse is caring for four hypertensive clients. Which drug-laboratory value combination should the nurse report immediately to the health care provider? (ch 33) a. Furosemide (Lasix)/potassium: 2.1 mEq/L b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L d. Torsemide (Demadex)/sodium: 142 mEq/L
a. Furosemide (Lasix)/potassium: 2.1 mEq/L Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and should be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal.
An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? (ch 17) a. Truvada does not reduce the need for safe sex practices. b. This drug has been taken off the market due to increases in cancer. c. Truvada reduces the number of HIV tests you will need. d. This drug is only used for postexposure prophylaxis.
a. Truvada does not reduce the need for safe sex practices.
A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? (ch 33) a. "Do you have trouble affording your medications?" b. "Most people with hypertension do not have symptoms." c. "You are lucky; most people get severe morning headaches." d. "You need to take your medicine or you will get kidney failure.
b. "Most people with hypertension do not have symptoms."
A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? (ch 33) a. Assess the client's support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the client's obligations.
b. Assist in finding one change the client can control.
A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia would the nurse assess? (ch 32) a. Preventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia
b. Atrial fibrillation
A nurse is providing discharge teaching to a client recovering from a heart transplant. Which statement would the nurse include? (ch 32) a. Use a soft-bristled toothbrush and avoid flossing b. Avoid large crowds and people who are sick c. Change positions slowly to avoid hypotension d. Check your heart rate before taking the medication
b. Avoid large crowds and people who are sick
A nurse teaches a client with heart failure about energy conservation. Which statement would the nurse include in this client's teaching? (ch 32) a. Walk until you become short of breath, then walk back home b. Begin walking 200 feet a day three times a week c. Do not lift heavy weights for 6 months d. Eat plenty of protein to build your strength
b. Begin walking 200 feet a day three times a week
A nurse assesses a client with pericarditis. Which assessment finding would the nurse expect to find? (ch 32) a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regular gallop rhythm d. Coarse crackles in bilateral lung bases
b. Friction rub at the left lower sternal border
The provider requests the nurse start an infusion of an milrinone on a client. How does the nurse explain the action of these drugs to the client and spouse? (ch 35) a. "It constricts vessels, improving blood flow." b. "It dilates vessels, which lessens the work of the heart." c. "It increases the force of the heart's contractions." d. "It slows the heart rate down for better filling."
c. "It increases the force of the heart's contractions."
Which assessment findings in a client who is HIV positive and has new-onset acute confusion will the nurse report immediately to the provider?
unequal pupil size reduced grip strength
The nurse is teaching a patient who is at risk for venous thromboembolism (VTE). The patient is currently asymptomatic and is living in the community. What interventions does the nurse instruct the patient to do to minimize the risk of VTE? Select all that apply. (ch 33) a. Avoid oral contraceptives. b. Drink adequate fluids to avoid dehydration. c. Exercise the legs during long periods of bedrest or sitting. d. Arise early in the morning for ambulation. e. Use a venous plexus foot pump. f. Avoid potential trauma such as contact sports.
A, B, C, F
A nurse assesses clients on a cardiac unit. Which clients would the nurse identify as at GREATEST risk for the development of acute pericarditis? (SATA) (ch 32) a. 36 year old woman with systemic lupus erythematosus (SLE) b. 42 year old man recovering from coronary artery bypass graft surgery c. 59 year old woman recovering from a hysterectomy d. 80 year old man with a bacterial infection of the respiratory tract e. 88 year old woman with a stage III sacral ulcer
A, B, D
A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this client's safety prior to discharging home? (Select all that apply.) a. "Are your bedroom and bathroom on the first floor?" b. "What social support do you have at home?" c. "Will you be able to afford your oxygen therapy?" d. "What spiritual beliefs may impact your recovery?" e. "Are you able to accurately weigh yourself at home?"
A, B, D
The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective? (Select all that apply.) (ch 33) a) Has maintained a low-sodium, no-added-salt diet b) Has lost 3 pounds since last seen in the clinic c) Cooks food in palm oil to save money d) Exercises once weekly e) Has cut down on caffeine
A, B, E
A nurse evaluates laboratory results for a client with heart failure. Which results would the nurse expect? (SATA) (ch 32) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L c. Serum potassium: 4.0 mEq/L d. Serum creatinine: 1.0 mg/dL e. Proteinuria f. Microalbuminuria
A, B, E, F
Which nursing actions can the nurse delegate to the unlicensed assistive personnel (UAP) who will be giving mouth care to a patient with HIV/AIDS? (Select all that apply.) (ch 17) a. Offer the patient mouth rinses with sodium bicarbonate and sterile water several times a day. b. Assess the patient's mouth for increased presence of candidiasis lesions. c. Encourage the patient to drink plenty of fluids. d. Provide the patient with a soft toothbrush. e. Administer an oral analgesic gel as needed.
A, C, D
Metabolic syndrome increases the risk for coronary heart disease. Which are indicators of this syndrome? (SATA) a. Triglyceride level of 170 mg/dL b. HDL cholesterol level of 45 mg/dL in a male c. HDL cholesterol level of 45 mg/dL in a female d. Blood pressure of 140/86 mm Hg while taking a beta blocker e. Fasting blood sugar level of 120 mg/dL
A, C, D, E
A patient with varicose veins asks the nurse to provide a list of all available treatment options. Which options does the nurse include on the list for the patient? Select all that apply. (ch33) a. Elastic stockings and elevation of the extremities b. Thrombolytic therapy c. Application of radiofrequency (RF) energy d. Endovenous ablation e. Anticoagulant therapy f. Sclerotherapy
A, C, D, F
*A nurse reviews a client's laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.) (ch 32) a. Total cholesterol: 280 mg/dL b. High-density lipoprotein cholesterol: 50 mg/dL c. Triglycerides: 200 mg/dL d. Serum albumin: 4 g/dL e. Low-density lipoprotein cholesterol: 160 mg/dL
A, C, E
An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? (ch 35) a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.
a. Assess for any hemodynamic effects of the rhythm.
While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next? (Ch 32) a. Assess for symptoms of left-sided heart failure b. Document this as a normal finding c. Call the primary health care provider immediately d. Transfer the client to the intensive care unit
a. Assess for symptoms of left-sided heart failure
A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best? (ch 17) a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.
a. Assess the client for support systems.
The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? (ch 17) a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands HIV+ d. Wearing a mask within 3 feet of the client
a. Consistent use of Standard Precautions
The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure. The nurse questions the client about the use of which medication because it raises an index of suspicion as to the cause of heart failure? (ch 32) a. Ibuprofen (Motrin) b. Hydrochlorothiazide (HydroDIURIL) c. NPH Insulin d. Levothyroxine (Synthroid)
a. Ibuprofen (Motrin)
The nurse is providing health teaching for a patient at risk for heart disease. which factor is the most modifiable, controllable risk factor?(ch 30) a. Obesity b. Diabetes mellitus c. Ethnic background d. Family history of cardiovascular disease
a. Obesity
The nurse is assessing a patient with dis- tended, protruding veins. In order to assess for varicose veins, what technique does the nurse use? (ch 33) a. Place the patient in a supine position with elevated legs; as the patient sits up, observe the veins filling from the proximal end. b. Place the patient in the Trendelenburg position and observe the distention and protruding of the veins. c. Ask the patient to stand and observe the leg veins; then ask the patient to sit or lie down and observe the veins. d. Ask the patient to walk around the room and observe the veins; then have the patient rest for several minutes and reassess the veins.
a. Place the patient in a supine position with elevated legs; as the patient sits up, observe the veins filling from the proximal end.
A client admitted after using crack cocaine develops ventricular fibrillation. After determining unresponsiveness, which action does the nurse take next? a. Prepare for defibrillation. b. Establish IV access. c. Place an oral airway and ventilate. d. Start cardiopulmonary resuscitation (CPR).
a. Prepare for defibrillation.
A 25-year-old woman reports bilateral blanch- ing of both upper extremities that occurs in cold temperatures. She reports numbness and cold sensation, and afterwards the arms become very red. Which condition are these symptoms most consistent with? (ch 33) a. Raynaud's disease b. Buerger's disease c. Subclavian steal d. Thoracic outlet syndrome
a. Raynaud's disease
A nurse cares for a client with right-sided HF. The client asks, "Why do I need to weigh myself every day?" How would the nurse respond? (ch 32) a. Weight is the best indication that you are gaining or losing fluid b. Daily weights will help us make sure that you're eating properly c. The hospital requires that all clients be weighed daily d. You need to lose weight to decrease the incidence of heart failure
a. Weight is the best indication that you are gaining or losing fluid
A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best? (ch 35) a. "The t-PA didn't dissolve the entire coronary clot." b. "The heparin keeps that artery from getting blocked again." c. "Heparin keeps the blood as thin as possible for a longer time." d. "The heparin prevents a stroke from occurring as the t-PA wears off."
b. "The heparin keeps that artery from getting blocked again."
A nurse assesses a client who has a history of heart failure. Which question would the nurse ask to assess the extent of the client's heart failure? (ch 32) a. Do you have trouble breathing or chest pain? b. Are you still able to walk upstairs without fatigue? c. Do you awake with breathlessness during the night? d. Do you have new-onset heaviness in your legs?
b. Are you still able to walk upstairs without fatigue?
A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority? (ch 33) a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the client's chart. d. Notify the surgeon immediately.
b. Assess distal pulses and skin color.
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.
b. Assess the client for bleeding.
A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition? (ch 17) a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic examination
b. Assessing mucous membranes
A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met? (ch33) a. Pain rated as 2/10 after medication b. Distal pulse on affected extremity 2+/4+ c. Remains on bedrest as directed d. Verbalizes understanding of procedure
b. Distal pulse on affected extremity 2+/4+
A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness
b. Dyspnea on exertion
A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends. b. Ensure the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowler's position.
b. Ensure the balloon does not remain wedged.
A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commission's Core Measures outcomes? a. Obtain an electrocardiogram (ECG) now and in the morning. b. Give the client an aspirin. c. Notify the Rapid Response Team. d. Prepare to administer thrombolytics.
b. Give the client an aspirin.
After administering the first dose of captopril to a client with heart failure, the nurse implements interventions to decrease complications. Which intervention is MOST important for the nurse to implement? (ch 32) a. Provide food to decrease nausea and aid in absorption b. Instruct the client to ask for assistance when rising from bed c. Collaborate with assistive personnel to bathe the client d. Monitor potassium levels and check for signs of hypokalemia
b. Instruct the client to ask for assistance when rising from bed
The health care provider orders orthostatic vital signs on a patient who experienced dizziness and feeling lightheaded. What is the nurse's first action? (ch 30) a. Patient changes position to sitting or standing. b. Measure the blood pressure when the patient is supine. c. Place the patient in supine position for at least 3 minutes. d. Wait for at least 1 minute before auscultating blood pressure and counting the radial pulse.
b. Measure the blood pressure when the patient is supine.
The client with heart failure has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema. Which is the priority nursing intervention? (ch 32) a. Insert an indwelling urinary catheter. b. Monitor the client's blood pressure. c. Place the nitroglycerin under the client's tongue. d. Monitor the client's serum glucose level.
b. Monitor the client's blood pressure.
A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? (ch 32) a. I sleep with four pillows at night b. My shoes fit really tight lately c. I wake up coughing every night d. I have trouble catching my breath
b. My shoes fit really tight lately
A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority? (ch 33) a. Assess the client's neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.
b. Notify the Rapid Response Team.
A student nurse asks what "essential hypertension" is. What response by the registered nurse is best? (ch 33) a. "It means it is caused by another disease." b. "It means it is 'essential' that it be treated." c. "It is hypertension with no specific cause." d. "It refers to severe and life-threatening hypertension."
c. "It is hypertension with no specific cause."
The HIV-positive patient tells the nurse that that his HIV-negative partner will be using the preexposure drug emitricitabine (Truvada). Which statement indicates to the nurse the need for additional teaching about this drug? (ch 17) a. "My partner will need to be tested for HIV every 3 months." b. "This drug will decrease the chances of my partner becoming HIV positive." c. "Once we start using Truvada I will no longer need to use a condom." d. "My partner will need to be monitored for any side effects of this drug."
c. "Once we start using Truvada I will no longer need to use a condom."
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma b. A 32-year-old Asian-American man with colorectal cancer c. A 45-year-old American Indian woman with diabetes mellitus d. A 53-year-old postmenopausal woman who is on hormone therapy
c. A 45-year-old American Indian woman with diabetes mellitus
In monitoring the diagnostic test of a client admitted with heart failure (HF), which finding is consistent with this diagnosis? (ch 32) a. Serum potassium level of 3.2 mEq/L b. Ejection fraction of 60% c. B-type natriuretic peptide (BNP) of 760 ng/dL d. Chest x-ray report showing right middle lobe consolidation
c. B-type natriuretic peptide (BNP) of 760 ng/dL
A nurse assesses an older adult client who is experiencing a potential myocardial infarction. Which clinical manifestation should the nurse expect? (ch 30) a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Disorientation and confusion d. Numbness and tingling of the arm
c. Disorientation and confusion
A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? (ch 32) a. I have been drinking more water than usual b. I am awakened by the need to urinate at night c. I must stop halfway up the stairs to catch my breath d. I have experienced blurred vision on several occasions
c. I must stop halfway up the stairs to catch my breath
A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? (ch 35) a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.
c. Maintain airway patency.
Which patient has the greatest risk for a pul- monary embolus related to a venous disorder? (ch33) a. Patient with bilateral varicose veins b. Patient with phlebitis of superficial veins c. Patient with thrombophlebitis in a deep vein of the lower extremity d. Patient with venous insufficiency throughout the leg
c. Patient with thrombophlebitis in a deep vein of the lower extremity
A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours
c. Poor peripheral pulses and cool skin
A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? (ch 35) a. Assess the client's pupillary responses. b. Request a neurologic consultation. c. Stop the infusion and call the provider. d. Take and document a full set of vital signs.
c. Stop the infusion and call the provider.
A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need tostop eating so much chili to keep that indigestion pain from returning. How should the nurse respond? (ch 30) a. Chili is high in fat and calories; it would be a good idea to stop eating it. b. The provider has prescribed an antacid for you to take every morning. c. What do you understand about what happened to you? d. When did you start experiencing this indigestion?
c. What do you understand about what happened to you?
After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How would the nurse respond? (ch 32) a. Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures b. Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness c. Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes d. While your heart is recovering, blood flow is diverted away from the brain, increasing the risk of stroke when you stand up
c. Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes
The professional nurse and the nursing student are caring for a group of clients with hypertension. Which problem identified by the nursing student correctly identifies the client at risk for secondary hypertension? (ch 33) a) Psychiatric disturbance b) High sodium intake c) Physical inactivity d) Kidney disease
d) Kidney disease
A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client's teaching? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods that are high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."
d. "Do not take this medication within 1 hour of taking an antacid."
An emergency department nurse triages clients who present with chest discomfort. Which client should thenurse plan to assess first? (Ch 30) a. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers b. A 49-year-old male who reports moderate pain that is worse on inspiration c. A 53-year-old female who reports substernal pain that radiates to her abdomen d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest
d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest
client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? (ch 17) a. Chooses high-protein food b. Has decreased oral discomfort c. Eats 90% of meals and snacks d. Has a weight gain of 2 pounds/1 month
d. Has a weight gain of 2 pounds/1 month
The nurse is giving a community presentation about heart disease. Because many sudden cardiac arrest victims die of ventricular fibrillation before reaching the hospital, which teaching point does the nurse emphasize? A. Controlling alcohol consumption and quitting cigarette smoking b. Modifying risk factors such as diet and weight, and blood pressure medication compliance c. Recognizing the difference between chronic stable angina and unstable angina d. Learning to operate the automatic external defibrillators (AEDs) in the workplace
d. Learning to operate the automatic external defibrillators (AEDs) in the workplace
A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? (ch 33) a. Assesses the client for back pain b. Auscultates over abdominal bruit c. Measures the abdominal girth d. Palpates the abdomen in four quadrants
d. Palpates the abdomen in four quadrants
The nurse is caring for the client with congestive heart failure (CHF) in the coronary care unit (CCU). The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? a. Determines the client's physical limitations b. Encourages alternate rest and activity periods c. Monitors and documents heart rate, rhythm, and pulses d. Positions the client to alleviate dyspnea
d. Positions the client to alleviate dyspnea
A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.
d. Prepare to administer a fluid bolus.
A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side fo the neck. Which nonpharmacologic comfort measure would the nurse implement? (ch 32) a. Apply an ice pack to the client's chest b. Provide a neck rub, especially on the left side c. Allow the client to lie in bed with the lights down d. Sit the client up with a pillow to lean forward on
d. Sit the client up with a pillow to lean forward on
A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond? (ch 30) a. I will consult the provider to prescribe a sleep study to determine the problem. b. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help. c. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night. d. Use pillows to elevate your head and chest while you are sleeping.
d. Use pillows to elevate your head and chest while you are sleeping.
A patient has been on bedrest following a motor vehicle accident. While assessing the patient, the nurse notes that the patient's left lower extremity has edema and is warm to the touch. The patient reports the calf of the left leg is slightly painful. The nurse suspects that this assessment may indicate which disorder? (ch 33) a. Raynaud's syndrome b. Cellulitis c. Aneurysm d. Venous thromboembolism
d. Venous thromboembolism
A nurse teaches a client who has a history of heart failure. Which statement would the nurse include in this client's discharge teaching? (Ch 32) a. Avoid drinking more than 3 quarts (3 L) of liquids each day b. Eat six small meals daily instead of three larger meals c. When you feel short of breath, take an additional diuretic d. Weigh yourself each day while wearing the same amount of clothing
d. Weigh yourself each day while wearing the same amount of clothing
A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How would the nurse respond? (ch 32) a. Would you like to speak with a priest or chaplain? b. I will arrange for a psychiatrist to speak with you c. Do you want to come off the transplant list? d. Would you like more information about advance directives?
d. Would you like more information about advance directives?
