PN2 EXAM 2 Part 1

The nurse is teaching a female patient about her new prescription for spironolactone. Which statement indicates the teaching needs for further education?

"I will use salt substitutes to lower my sodium intake."

The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which finding requires further evaluation?

Ankle-brachial index of 0.65

The nurse is caring for a group of clients on a pulmonary unit. The nurse can delegate which task to unlicensed assistive personnel?

Assisting a client with adjusting his or her nasal cannula

When instructing a client on ways to lower his cholesterol levels, which of the following should the nurse include?

Consume less meat and eggs

A nurse suspects a client is experiencing chronic obstructive pulmonary disease when which of the following is assessed? (Select all that apply?

Cough, Dyspnea on exertion, Peripheral edema, Sputum production

Which of the following should the nurse instruct a client who is newly diagnosed with hypertension

It is a lifelong process

When a patient with hypertension who has a new prescription for atenolol returns to the health clinic after 2 weeks for a follow-up visit, the BP is unchanged from the previous visit. Which action should the nurse take first?

Question the patient about whether the medication is actually being taken.

A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan?

Red meat

. A client is admitted with arterial blood gas (ABGs) results of pH 7.30, PaCO2 60, HCO3 22. The nurse concludes this client has which acid-base imbalance??

Uncompensated Respiratory Acidosis

A nurse is assessing a client who is taking Lisinopril to treat hypertension. Which of the following findings is a priority to report?

swelling of the tongue

which of the following conditions is most commonly responsible for right heart failure?

C. Left heart failure

A client with atherosclerosis asks a nurse which factors are responsible for this condition. What is the nurse's best response?

"A combination of platelets and fats accumulate, narrowing the lumen of the artery, reducing blood flow."

A patient is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which of these statements by the patient is most consistent with the diagnosis?

"I can't get my shoes on at the end of the day."

Which intervention suggested to the client with Raynaud's disease is aimed at preventing worsening complications?

"Wear warm clothing when exposed to cool temperatures."

Which symptom is most characteristic of a factor VIII deficiency?

*a. Excessive bleeding from a cut

The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)?

*b. Blood pressure of 85/48 mmHg

A client is prescribed Lisinopril for control of hypertension. What health teaching will the nurse provide to this patient? (Select all that apply)

-"This medication can cause increased potassium levels." - "It's important to change positions slowly when you start this medication." - "This medication may cause you to develop a persistent, non-productive cough." - "Be sure to monitor your BP regularly while taking this medication."

A client is diagnosed with a venous stasis ulcer on the foot. Which of the following will be included in this client's plan of care? (Select all that apply)

-Administer oral antibiotics if infection is present -Cover the foot sores with a dressing -Provide pain medication with debridement

client is admitted with abdominal aortic aneurysm. For which of the following complications should the nurse be concerned?

-Aneurysm rupture

A home health nurse visits a client who has COPD and receives oxygen at 2L/min via nasal cannula. The client reports having difficulty breathing. Which of the following actions is the nurse's priority

-Assess the client's respiratory status

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure?

-B-type natriuretic peptide (BNP

A client has a history of heart failure and has been prescribed furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused, refusing to eat, and complaining of nausea. The nurse should assess the client for signs o

-Digoxin toxicity

Which of the following would the nurse most likely assess in a client diagnosed with right-sided heart failure?

-Distended neck veins

A client asks the nurse if there is an antihistamine that does not cause drowsiness. Which of the following medications would this client most likely prefer to treat allergic rhinitis? -

-Fexofenadine

A client with acute asthma is prescribed short-term corticosteroid therapy. Which is the expected outcome for the use of steroids in clients with asthma?

-Have an anti-inflammatory effect

A nurse is assessing a patient who has right heart ventricular failure. Which of the following findings should the nurse expect?

-Hepatomegaly

36. The nurse is assessing a client diagnosed with asthma. The client's initial breath sounds heard by the nurse consisted of wheezing but have diminishing until no audible sounds are heard. This has occurred due to which of the following?

-Increased airway constriction is blocking the airway

A nurse is assessing a male client who has a new diagnosis of peripheral artery disease (PAD). Which of the following findings should the nurse expect to find on the affected extremity? (Select all that apply)

-Pain, Pulselessness, Paresthesia, Paralysis, Pallor

A client comes into the ER with acute shortness of breath and a cough that produces pink, frothy sputum. Admission assessment reveals crackles and wheezes, a BP 85/46, a HR of 122 BPM, and a respiratory rate of 38 breaths/minute. The client's medical history included DM, HTN, and a heart failure. Which of the following disorders should the nurse suspect?

-Pulmonary edema

Which findings are significant data to gather from a client who has been diagnosed with pneumonia? (Select all that apply)

-Quality of breath sounds -Occurrence of chest pain -Color of nail beds

The RN and nursing assistant are working together to provide care for a group of clients. Which of these nursing activities could the ZRN delegate to the nursing assistant?

-Reinforce the use of slow expiration through pursed lips to maximize gas exchange for a client with COPD.

The nurse is assigned to a client who just arrived to the emergency room after a motor vehicle accident and has rib fractures. Knowing the client could potentially have a pneumothorax, what are the signs and symptoms the nurse would correlate with this condition?

-Respiratory distress

A nurse is reviewing the labs for a newly admitted heart failure patient and notes a K+ level of 5.6. Upon reviewing the patient's medications, the nurse realizes which of the following medications most likely contributed to this electrolyte imbalance?

-Spironolactone

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse take to specifically reduce the risk for ventilation associated pneumonia?

-Turn the client every 4 hours to facilitate mobilization of secretion

A nurse is caring for a client who has hemophilia A and hemarthrosis of the left knee. Which of the following actions should the nurse take?

. Assess client for s/s of bleeding

A patient is diagnosed with heart failure and is prescribed digoxin (Lanoxin) and furosemide (Lasix). Before administering the furosemide to the patient, which laboratory result should the healthcare provider to review?

. Serum potassium

. The nurse determines which client as at greatest risk for acidosis?

. The adult client with pneumonia

With which client does the nurse anticipate complications from obstructive sleep apnea following abdominal surgery?

28-year-old who is 80lbs (36.4 kg) overweight and has a short neck

Which client is at greatest risk for atherosclerosis?

A 65-year-old female who is obese with an LDL of 188

A client is having laboratory tests conducted to confirm a diagnosis of arteriosclerosis. Which of the following laboratory values would support this client's medical diagnosis? (Select all that apply)

A. Low- density lipoprotein (LDL) 145 mg/Dl C. Triglycerides 400 mg/d D. Serum cholesterol 300 mg/dL A. High-density lipoprotein (HDL) 25 mg /dL

The health care provider has just prescribed the client with a deep vein thrombosis (DVT) warfarin sodium. The nurse knows that this client is still receiving intravenous heparin. Which is the nurse's best action?

Administer the medications as prescribed.

The nurse should include which instruction when developing a teaching plan for a client who is receiving isoniazid and rifampin for treatment of tuberculosis?

Avoid Alcohol

A patient who has just been admitted with pneumococcal pneumonia has a temperature of 100.6 F with a frequent cough and is complaining of severe pleuritic chest pain. Which of these prescribed medications should the nurse give first?

Azithromycin

A client is undergoing diagnostic testing for infective endocarditis. Which of the following laboratory tests would be most useful in diagnosis?

Blood cultures

The nurse is assessing a client diagnosed with an abdominal aortic aneurysm. Which of the following sounds sis the nurse likely auscultates during the assessment?

Bruit

. Which assessment finding does the nurse expect in the client with mitral valve prolapse?

Chest pain and palpitations

Which finding requires immediate intervention when planning care for an adolescent with cystic fibrosis (CF)?

Chest pain with dyspnea

A nurse assesses a client in preparation for receiving a blood transfusion Pre-transfusion vitals are temperature 98.2 F, heart rate 82 beats/minute, respirations 18 breaths/minute, blood pressure 102/76 mm Hg, oxygen saturation 96% on room air. Fifteen minutes after starting the transfusion, the nurse measures the following vital signs. Which of the following is the highest priority for action?

D. Temperature 100.6F

A client diagnosed with heart failure is prescribed furosemide (Lasix). Which of the following should this client be monitored for because of this medication? (Select all that apply.)

Dehydration -Hyponatremia -Hypokalemia

A client is surprised to learn that she has high blood pressure. Which of the following should the nurse assess in this client? The presence or occurrence of:

Headache

The nurse notes that the international normalized ratio (INR) of a client with atrial fibrillation who is taking warfarin is 3.2. What is the priority intervention at this time?

Hold the next scheduled dose and notify the provider.

. You are educating a patient with newly diagnosed Vitamin B12 deficiency anemia. Which of the following statements indicate a need for further teaching?

I will limit my intake of dried beans and citrus fruit.

You are providing patient education on their new medication, Amlodipine (Norvasc). Which statement by the patient indicates patient understanding?

I will need to avoid grapefruit juice and grapefruit while taking this medication.

A nurse is reviewing the laboratory results of a male adult client who is at risk for peripheral arterial disease (PAD) caused by atherosclerosis. The nurse should identify that which of the following laboratory results places the client at further risk?

LDL of 162 mg/dL

The graduate nurse is assessing her newly admitted client's abdomen and notes a bruit upon auscultation. Which assessment technique by this nurse should be questioned in this client?

Palpate and document if artery is found to have doubled in size

A nurse completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for the client?

Peripherally inserted central catheter

The nurse is assessing a client for risks in the development of varicose veins. Which of the following findings would increase this client's risk?

Prolonged standing

34. A client receiving a heparin infusion is demonstrating of acute bleeding. Which of the following should the nurse prepare to administer to this client?

Protamine sulfate

A nurse is caring for a client who arrived at an emergency department with status asthmaticus. Based on the progress Note: BP 140/90, P 104, and Temp 98.4 F, RR 34, audible wheezing, ABG results pH 7.22, PaCO2 69, and HCO3-26. The nurse suspects that the client has what abnormality?

Respiratory acidosis

A patient who has a history of pulmonary valve stenosis tells the healthcare provider, "I don't have a lot of energy anymore, and both of my feet get swollen in the late afternoon." Which of these problems does the healthcare provider conclude is the likely cause of these clinical findings?

Right side heart failure

A client is admitted to the emergency department after a syncopal episode while exercising. All of the following symptoms are consistent with a diagnosis of Mitral Valve Prolapse except

Swelling of the feet and ankles

Of the following client assignments made by the charge nurse, which would you question?

The LPN with 20 years of experience caring for a diabetic client complaining of a headache and with blood pressure of 210/150

The post-anesthesia care nurse is caring for a client who just had a mitral valve replacement surgery. The client's blood gases are as follows: pH, 7.22; HCO3-, 21 mEq/L; PCO2, 65 mm Hg; and PO2 58 mm Hg. Which is the priority action by the nurse?

a. Assessing the client's airway

A nurse is caring for a client who arrived at an emergency department with status asthmaticus. Based on the Progress Note: BP 140/90, P 104, and T. 98.4 F, RR 34, diminishing wheezing. ABG results pH 7.22, PaCO2 69, and HCO3- 26. The nurse suspects that the client has what abnormality?

a. Uncompensated Respiratory acidosis.

Which ABG values are expected with anxiety induced hyperventilation?

pH 7.29; PaCO2 55 mm Hg

A nurse is assessing a client diagnosed with Buerger's disease. While assessing this client and extremities, the nurse correlates which clinical manifestations with this disease process?

ulcerations on digits and complaints of claudication