PCCII Exam 2

19. A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates that an important outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. V erbalizing risk factors

Oxygen saturation of 98%

The nurse is caring for a client who has possible hypothyroidism. What possible risk factors can cause this health problem? a. Lithium drug therapy b. Thyroid cancer c. Autoimmune thyroid disease d. Iodine deficiency e. Laryngitis f. Pituitary tumors

ANS: A,B,C,D,F

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition would the nurse include in this client's teaching? (Select all that apply.) a. "Avoid drinking fluids just before and during meals." b. "Rest before meals if you have dyspnea." c. "Have about six small meals a day." d. "Eat high-fiber foods to promote gastric emptying." e. "Use pursed-lip breathing during meals." f. "Choose soft, high-calorie, high-protein foods."

ANS: A,B,C,E,F

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the assistive personnel (AP) for deep vein thrombosis (DVT) prevention? (Select all that apply.) a. Apply compression stockings. b. Assist with ambulation. c. Encourage coughing and deep breathing. d. Offer fluids frequently. e. Teach leg exercises

ANS: A,B,D

A nurse prepares to discharge a client who has heart failure. Which questions would 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?"

ANS: A,B,D

A nurse studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause f. Can be precipitated by exertion or stress

ANS: A,B,D,E

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Ask the client to drink 2 L of fluids daily. b. Add humidity to the prescribed oxygen. c. Suction the client every 2 to 3 hours. d. Use a vibrating chest physiotherapy device. e. Encourage diaphragmatic breathing. f. Administer the ordered mucolytic agent.

ANS: A,B,D,F

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations would the nurse assess? (Select all that apply.) a. Pulmonary crackles b. Confusion c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night f. Jugular venous distention

ANS: A,B,E

A client is taking ethambutol for tuberculosis. What instructions does the nurse provide the client regarding this drug? (Select all that apply.) a. Contact the primary health care provider if preexisting gout becomes worse. b. Report any changes in vision immediately to the health care provider. c. Avoid drinking alcoholic beverages due to the chance of liver damage. d. Do not take antacids or eat within 2 hours after taking this medication. e. You will take this medication along with some others for 8 weeks .f. Take this medicine with a full glass of water.

ANS: A,B,E,F

A home health nurse evaluates a client who has chronic obstructive pulmonary disease. Which assessments would the nurse include in this client's evaluation? (Select all that apply.) a. Examination of mucous membrane and nail beds b. Measurement of rate, depth, and rhythm of respirations c. Auscultation of bowel sounds for abnormal sounds d. Check peripheral veins for distention while at rest e. Determine the client's need and use of oxygen f. Ability to perform activities of daily living

ANS: A,B,E,F

A nurse evaluates laboratory results for a client with heart failure. Which results would the nurse expect? (Select all that apply.) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L (130 mmol/L) c. Serum potassium: 4.0 mEq/L (4.0 mmol/L) d. Serum creatinine: 1.0 mg/dL (88.4 mcmol/L) e. Proteinuriaf. Microalbuminuria

ANS: A,B,E,F

A nurse collaborates with assistive personnel (AP) 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.) 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."

ANS: A,C,D

A nurse teaches a client with hyperthyroidism. Which dietary modifications should the nurse include in this client's health teaching? (Select all that apply.) a. Increased carbohydrates b. Decreased fats c. Increased calorie intake d. Supplemental vitamins e. Increased proteins

ANS: A,C,E

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 L 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." f. "Salt substitutes are a good way to cut down on sodium in my diet."

ANS: A,D,E

The nurse is caring for a client who has diabetes mellitus type 1 and is experiencing hypoglycemia. Which assessment findings will the nurse expect? (Select all that apply.) a.Warm, dry skin b.Nervousness c.Rapid deep respirations d.Dehydration e.Ketoacidosis f.Blurred vision

ANS: B,F

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. What actions by the nurse are best?(Select all that apply.) a. Administer prescribed salmeterol inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen and place client on an oximeter. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol inhaler. f. Assess the client's lung sounds after administering the inhaler.

ANS: C,E,F

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement would the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications? a. "Maintain tight glycemic control and prevent hyperglycemia." b. "Restrict your fluid intake to no more than 2 L a day." c. "Prevent hypoglycemia by eating a bedtime snack."

a. "Maintain tight glycemic control and prevent hyperglycemia."

After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "The lower abdomen is the best location because it is closest to the pancreas." b. "I can reach my thigh the best, so I will use the different areas of my thighs." c. "By rotating the sites in one area, my chance of having a reaction is decreased."

a. "The lower abdomen is the best location because it is closest to the pancreas."

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? 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 nurse assesses a client who has diabetes mellitus and notes that the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the client's signs and symptoms have not changed. What action would the nurse take next? a. Administer another half-cup (120 mL) of orange juice. b. Administer a half-ampule of dextrose 50% intravenously. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1 mg of glucagon intramuscularly.

a. Administer another half-cup (120 mL) of orange juice.

A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. b. Inform the spouse that the precautions are meant to keep other clients safe. c. Show the spouse how to follow the Isolation Precautions to avoid illness. d. Tell the spouse that he or she has already been exposed, so it's safe to visit.

a. Ask the spouse to explain the fear of visiting in further detail.

A nurse admits a client who is experiencing an exacerbation of heart failure. What actionwould the nurse take first? 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 client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin. The client is adamant about refusing the drug because "it's dangerous." What action by the nurse is best? a. Assess the reason behind the client's fear. b. Remind the client about laboratory monitoring. c. Tell the client that drugs are safer today than before. d. Warn the client about consequences of noncompliance.

a. Assess the reason behind the client's fear.

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity

a. Educating the client on adherence to the treatment regimen

A nurse cares for a client with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How would the nurse respond? a. "You need to start with multiple injections until you become more proficient at self-injection." b. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns." c. "A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates." d. "A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock."

b. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns."

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? 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 nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement would the nurse include in this client's teaching? a. "Change positions slowly when you arise or get out of bed" b. "Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)." c. "If you miss a dose of this drug, you can double the next dose." d. "Discontinue the medication if you develop a urinary infection."

b. "Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)."

A nurse teaches a client with heart failure about energy conservation. Which statement would the nurse include in this clients teaching? a. "Walk until you become short of breath, and 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 clinic nurse is reviewing care measures with a client who has asthma, Step 3. What statement by the client indicates the need to review the information? a. "I still will use my rapid-acting inhaler for an asthma attack." b. "I will always use the spacer with my dry powder inhaler." c. "If I am stable for 3 months, I might be able to reduce my drugs." d. "My inhaled corticosteroid must be taken regularly to work well."

b. "I will always use the spacer with my dry powder inhaler."

The nurse is caring for a client who is starting on propylthiouracil for hyperthyroidism. What statement by the client indicates a need for further teaching? a. "I will let my provider know if I have weight gain and cold intolerance." b. "I will let my provider know if I have a metallic taste or stomach upset." c. "I will avoid crowds and other people who have infection." d. "I am aware that if the drug changes the color of my urine, I should stop it."

b. "I will let my provider know if I have a metallic taste or stomach upset."

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? 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 pulmonary nurse cares for clients who have chronic obstructive pulmonary disease(COPD). Which client would the nurse assess first? a. A 46 year old with a 30-pack-year history of smoking b. A 52 year old in a tripod position using accessory muscles to breathe c. A 68 year old who has dependent edema and clubbed fingersd. A 74 year old with a chronic cough and thick, tenacious secretions

b. A 52 year old in a tripod position using accessory muscles to breathe

A client has been taking isoniazid for tuberculosis for 3 weeks. What laboratory results need to be reported to the primary health care provider immediately? a. Albumin: 5.1 g/dL (7.4 mcmol/L) b. Alanine aminotransferase (ATL): 180 U/L c. Red blood cell (RBC) count: 5.2/million/μL (5.2 × 1012/L) d. White blood cell (WBC) count: 12,500/mm3 (12.5 × 109/L)

b. Alanine aminotransferase (ATL): 180 U/L

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the assistive personnel (AP)? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the client's leg. d. Provide an ice pack.

b. Apply a warm moist pack.

A nurse cares for a client with arthritis who reports frequent asthma attacks. What action would the nurse take first? a. Review the client's pulmonary function test results. b. Ask about medications the client is currently taking. c. Assess how frequently the client uses a bronchodilator. d. Consult the primary health care provider and request arterial blood gases.

b. Ask about medications the client is currently taking.

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic action? a. Bronchodilator—stabilizes the membranes of mast cells and prevents the release of inflammatory mediators. b. Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system. c. Corticosteroid—relaxes bronchialar smooth muscles by binding to and activating pulmonary beta2 receptors. d. Cromone—disrupts the production of pathways of inflammatory mediators.

b. Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system.

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? 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 symptoms of hypokalemia.

b. Instruct the client to ask for assistance when rising from bed.

A nurse cares for a client who presents with bradycardia secondary to hypothyroidism. Which medication does the nurse prepare to administer? a. Atropine sulfate b. Levothyroxine c. Propranolol d. Epinephrine

b. Levothyroxine

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates that an important outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. V erbalizing risk factors

b. Oxygen saturation of 98%

The nurse is planning health teaching for a client starting on levothyroxine. What health teaching about this drug would the nurse include? a. The need to take the drug when the client feels fatigued and weak. b. The need to report chest pain and dyspnea when starting the drug. c. The need to check blood pressure and pulse every day. d. The need to rotate injection sites when giving self the drug.

b. The need to report chest pain and dyspnea when starting the drug.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question would the nurse ask first? a. "Do you have a strong support system?" b. "What do you understand about your disease?" c. "Do you experience shortness of breath with basic activities?" d. "What medications are you prescribed to take each day?"

c. "Do you experience shortness of breath with basic activities?"

The nurse is planning teaching for a client who is starting exenatide extended release (ER) for diabetes mellitus type 2. Which statement will the nurse include in the teaching? a. "Be sure to take the drug once a day before breakfast." b. "Take the drug every evening before bedtime. c. "Give your drug injection the same day every week."

c. "Give your drug injection the same day every week."

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? 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."

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates that the client comprehends the teaching? a. "I will carry this medication with me at all times in case I need it." b. "I will take this medication when I start to experience an asthma attack." c. "I will take this medication every morning to help prevent an acute attack." d. "I will be weaned off this medication when I no longer need it."

c. "I will take this medication every morning to help prevent an acute attack."

After teaching a client who is prescribed salmeterol, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I will be certain to shake the inhaler well before I use it." b. "It may take a while before I notice a change in my asthma." c. "I will use the drug when I have an asthma attack." d. "I will be careful not to let the drug escape out of my nose and mouth."

c. "I will use the drug when I have an asthma attack."

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that going out with friends is no longer enjoyable. How would the nurse respond? a. "There are a variety of support groups for people who have COPD." b. "I will ask your primary health care provider to prescribe an antianxiety agent." c. "I'd like to hear about thoughts and feelings causing you to limit social activities." d. "Friends can be a good support system for clients with chronic disorders."

c. "I'd like to hear about thoughts and feelings causing you to limit social activities."

A nurse cares for a client who has hypothyroidism as a result of Hashimotothyroiditis. The client asks, "How long will I need to take this thyroid medication?" How would the nurse respond? a. "You will need to take the thyroid medication until the goiter is completely gone." b. "Thyroiditis is cured with antibiotics. Then you won't need thyroid medication." c. "You'll need thyroid pills for life because your thyroid won't start working again." d. "When blood tests indicate normal thyroid, you can stop the medication."

c. "You'll need thyroid pills for life because your thyroid won't start working again."

A nurse plans care for a client with hypothyroidism. Which priority problem does the nurse address first for this client? a. Heat intolerance b. Body image problems c. Depression and withdrawal d. Obesity and water retention

c. Depression and withdrawal

A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. What action would the nurse take first? a. Document the finding in the client's chart. b. Assess tactile sensation in the client's hands. c. Examine the client's feet for signs of injury. d. Notify the primary health care provider.

c. Examine the client's feet for signs of injury.

A client is admitted with suspected pneumonia from the emergency department. The client went to the primary health care provider a "few days ago" and shows the nurse the results of what the client calls "an allergy test," as shown below: The reddened area is firm. What action by the nurse is best? a. Assess the client for possible items to which he or she is allergic. b. Call the primary health care providers office to request records. c. Immediately place the client on Airborne Precautions. d. Prepare to begin administration of intravenous antibiotics.

c. Immediately place the client on Airborne Precautions.

A nurse is assessing an obese client in the clinic for a follow-up after an episode of deep vein thrombosis. The client has lost 20 lb (9.09 Kg) since the last visit. What action by the nurse is best? a. Ask if the weight loss was intended. b. Encourage a high-protein diet. c. Measure for new compression stockings. d. Review a 3-day food recall diary.

c. Measure for new compression stockings.

After teaching a young adult newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? a. "At my age, I should continue seeing the ophthalmologist as I usually do." b. "I will see the eye doctor when I have a vision problem and yearly after age 40." c. "My vision will change quickly. I should see the ophthalmologist twice a year." d. "Diabetes can cause blindness, so I should see the ophthalmologist yearly."

d. "Diabetes can cause blindness, so I should see the ophthalmologist yearly."

A nurse teaches a client who is prescribed digoxin therapy. Which statement would 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."

A nurse assesses a client on the medical-surgical unit. Which statement made by the client alerts the nurse to assess the patient for hypothyroidism? a. "My sister has thyroid problems." b. "I seem to feel the heat more than other people." c. "Food just doesn't taste good without a lot of salt." d. "I am always tired, even with 12 hours of sleep."

d. "I am always tired, even with 12 hours of sleep."

After teaching a client who has diabetes mellitus with retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I have so many complications; exercising is not recommended." b. "I will exercise more frequently because I have so many complications." c. "I used to run for exercise; I will start training for a marathon." d. "I should look into swimming or water aerobics to get my exercise."

d. "I should look into swimming or water aerobics to get my exercise."

A nurse teaches a client with type 1 diabetes mellitus. Which statement would the nurse include in this client's teaching to decrease the client's insulin needs? a. "Limit your fluid intake to 2 L a day." b. "Animal organ meat is high in insulin." c. "Limit your carbohydrate intake." d. "Walk at a moderate pace for 1 mile daily."

d. "Walk at a moderate pace for 1 mile daily."

A nurse teaches a client who has a history of heart failure. Which statement would the nurse include in this client's discharge teaching? 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 daily while wearing the same amount of clothing."

d. "Weigh yourself daily while wearing the same amount of clothing."

A nurse reviews the laboratory test values for a client with a new diagnosis of diabetes mellitus type 2. Which A1C value would the nurse expect? a. 5.0% b. 5.7% c. 6.2% d. 7.4%

d. 7.4%

A nurse assesses a client who is prescribed levothyroxine for hypothyroidism. Which assessment finding alerts the nurse that drug therapy is effective? a. Thirst is recognized and fluid intake is appropriate. b. Weight has been the same for 3 weeks. c. Total white blood cell count is 6000 cells/mm3 (6 × 109/L). d. Heart rate is 76 beats/min and regular.

d. Heart rate is 76 beats/min and regular.