Practice Perfusion NCLEX Questions, clinical decision making practice questions, Inflammation NCLEX Questions, LPN to ADN Study Guide

A patient diagnosed with ulcerative colitis is prescribed the aminosalicylate sulfasalazine. When teaching the patient about this medication, which of the following statements is a priority for the healthcare provider include? Please choose from one of the following options. "Be sure to limit your intake of fluids during therapy." "Avoid exposure to sunlight while taking this medication." "Call our office immediately if your urine turns an orangish color." "You may crush the enteric-coated tablet and mix it with applesauce."

"Avoid exposure to sunlight while taking this medication"

metabolic acidosis

-buildup of acid in the body due to kidney disease or kidney failure -low pH, normal PaCO2, low HCO3

respiratory alkalosis

-condition marked by a low level of carbon dioxide in the blood due to breathing excessively -high pH, low CO2 -PaCO2 less than 40 and pH greater than 7.4 high HCO3

Hypocalcemia

-deficient calcium in the blood -blood levels less than 4

Hypercalcemia

-excessive calcium in the blood -blood levels greater than 13

Hyperkalemia

-high levels of potassium in the blood -blood level greater than 5.0

Hypernatremia

-high sodium -sodium blood levels greater than 145

Hypokalemia

-low potassium -blood level less than 3.5

Hyponatremia

-low sodium -sodium blood levels less than 135

metabolic alkalosis

-occurs when digestive issues disrupt the blood's acid-base balance -high pH, high HCO3, normal PaCO2

respiratory acidosis

-occurs when your lungs can't remove all of the carbon dioxide produced by your body. This causes the blood and other body fluids to become too acidic -low pH, high PaCO2 -ABG will show an elevated PCO2 (>45 mmHg), elevated HCO3- (>30 mmHg), and decreased pH (<7.35)

2) The nurse is prioritizing care for a client with several problems. List the order in which the nurse should address the client's needs. 1. Bleeding through nasogastric tube 2. Audible wheezes 3. Not understanding how to complete the menu 4. Requesting medication for arthritis pain 5. Dyspnea 6. Asking questions about teaching provided the other day

2,5,1,4,6,3

5) The nurse is prioritizing care activities that are to be completed for a group of clients. From highest to lowest priority, list the order in which the nurse should complete the listed activities. 1. Measure blood pressure before administering antihypertensive medication. 2. Request dietary consult for gluten-free diet. 3. Remove an intravenous access device infusing chemotherapy. 4. Change a dressing on an arm wound. 5. Call a family member to bring in shoes. 6. Ambulate to the bathroom using a walker.

3,1,4,6,2,5

3) The nurse is prioritizing care for a client based upon nursing diagnoses. If following Maslow's hierarchy of needs, list the order in which the nurse should provide care to the client. 1. Fatigue 2. Anxiety 3. Alteration in Perfusion 4. Self-Care Deficit 5. Deficient Knowledge 6. Diarrhea

3,6,4,2,1,5

1) During a health history a client becomes upset because the nurse is asking many questions. What should the nurse respond to the client? A) "I use the answers you provide to determine what your current health needs are." B) "I am sorry the questions disturb you." C) "I will skip the questions that bother you." D) "I cannot help you if you do not answer me."

A

10) A client asks the student nurse to explain the pathophysiology of diabetes. The student nurse does not know the answer to this question. What should the student respond to the client? A) "I do not know, but I will find out." B) "You'll have to ask the doctor that question." C) "Why do you need to know that?" D) "I do not know."

A

3) A goal of care for a client with congestive heart failure is for serum sodium levels to be within normal limits. What information should the nurse expect to see documented in the medical record? A) The client is experiencing dependent edema. B) The client experiences joint pain. C) The client is constipated. D) The client is experiencing wheezing respirations.

A

5) A client seen in an urgent care clinic is complaining of abdominal pain and believes that the food eaten the previous evening was tainted. What should the nurse do after the client states that the food was tainted? A) Ask the client open-ended questions to further assess the situation. B) Tell the client the physician does not need to assess the client. C) Call an ambulance before assessing the client any further. D) Advise the client to take an antacid.

A

5) An older client is experiencing confusion, a temperature of 101.5°F, bruising to the arms and legs, and decreased urine output. The medical diagnosis is a urinary tract infection. What is the most appropriate nursing diagnosis for this client? A) Risk for Injury B) Ineffective Breathing Pattern C) Activity Intolerance D) Impaired Memory

A

7) The home health nurse is visiting a client who is 2 weeks postoperative from a coronary artery bypass surgery. The client has lost 10 pounds, is continuing to experience pain, and is not eating. What should be the nurse's next action? A) Examine the current interventions for pain relief. B) Refer the client to social services. C) Contact Meals on Wheels so that the client will eat. D) Revise the goals in the current plan of care.

A

Diabetes Type 2

A chronic condition where the body does not use insulin properly and becomes insulin resistant.

3) The nursing instructor is evaluating a concept map created by a student for a client's plan of care. What characteristic or characteristics on the map indicate that the student created the map appropriately? Select all that apply. A) Legend created identifying nursing process phases and client information categories B) Lines drawn between assessment data and associated nursing diagnoses C) Different colors used to represent the phases of the nursing process D) A column entitled "evaluation" located on the outer edge of the document E) A checklist located at the bottom of the document

A,B,C

7) After receiving the morning report, the nurse prioritizes care needed by several clients. What factors should the nurse keep in mind when creating this priority list? Select all that apply. A) Client condition B) Safety C) Time available D) Client preferences E) Time of day

A,B,C,D

1) The nurse decides to use a standardized plan of care to address a client's health problems. What criterion differentiates this plan of care from other types? Select all that apply. A) Preprinted B) Has blank lines C) Has various shapes connected with lines D) Has checklists E) Includes different colors

A,B,D

12) The nurse is taking the time to reflect on a care situation in which a client sustained a cardiac arrest and died. On which area(s) should the nurse focus when performing this reflection? Select all that apply. A) Things that could have been done differently B) Gut reactions to the situation C) Things that were done well D) Resources that were used at the time E) Resources that were needed but not available

A,C,D,E

8) The nurse manager is concerned that a staff nurse is having difficulty prioritizing client care needs. What did the manager observe the nurse perform that caused these concerns? Select all that apply. A) Relying upon another nurse's assessment B) Reviewing the medication administration record C) Not completing an assessment D) Doing easiest tasks first E) Asking unlicensed assistive personnel to perform complicated care

A,C,D,E

1) The nurse is preparing to provide care to a group of clients. On which specific area(s) should the nurse focus in order to prioritize the clients' care needs? Select all that apply. A) Asking if any clients have complex issues B) Noting number of licensed staff assigned for the shift C) Noting time when the attending physicians make rounds D) Identifying clients with specific medication times E) Noting which clients have particular safety needs

A,D,E

10) A nurse enters a client's room to check on the client's response to IV pain medication she gave on request 20 minutes earlier. She finds the client on her side lying very still and not wanting to move, and asks the client about her current pain level. Which aspect(s) of the nursing process does this action represent? Select all that apply. A) Assessment B) Diagnosis C) Planning D) Implementation E) Evaluation

A,D,E

BPH (benign prostatic hyperplasia)

Age-associated prostate gland enlargement that can cause urination difficulty.

Which nursing action is most likely to detect early signs of infection in a patient who is taking immunosuppressive medications? a. Monitor white blood cell count. b. Check the skin for areas of redness. c. Check the temperature every 2 hours. d. Ask about fatigue or feelings of malaise.

Ask about fatigue or feelings of malaise

6) A client with aspiration pneumonia is diaphoretic, pale, and taking gasping breaths. What should the nurse do first? A) Notify the physician. B) Complete a thorough cardiopulmonary assessment. C) Administer 10 L of oxygen per face mask. D) Reposition the client to help with breathing.

B

11) A construction worker admitted to the unit with a chest injury and broken ribs from a fall from a ladder has nursing diagnoses of "Disturbed Sleep Pattern," "Ineffective Breathing Pattern," and "Risk for Infection." Because he also keeps saying "I've never been sick a day in my life and am really worried about how I can support my family while I'm out of work," the nurse also identifies "Anxiety" as another nursing diagnosis. Which diagnosis would receive priority for nursing intervention? A) Risk for Infection B) Ineffective Breathing Pattern C) Disturbed Sleep Pattern D) Anxiety

B

A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Sponge patient with cool water. b. Administer intravenous antibiotics. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).

B, D, A, C

4) The nurse is prioritizing care needed for a group of clients according to urgency. Which care should the nurse identify as being medium priority? Select all that apply. A) Instructing on changing ostomy appliance B) Performing passive range of motion every 4 hours C) Removing splints and providing complete skin care every 2 hours D) Administering 2 units of fresh frozen plasma E) Performing endotracheal suction

B,C

6) The nurse is preparing to triage victims of a train derailment who are being transported to the Emergency Department. Which victim(s) would need immediate care? Select all that apply. A) Holding broken arm, sitting in a chair B) Respiratory rate of 8 and irregular C) Bleeding from fractured limb with a blood pressure of 78/40 mmHg D) Bleeding from superficial facial wounds and talking to family E) Walking with a slight limp, asking for something to drink

B,C

9) Which statement or statements accurately reflect the distinction between nursing diagnoses arrived at as part of the nursing process and medical diagnoses? Select all that apply. A) A nursing diagnosis is determined following an assessment and analysis of data gathered only by registered nurses; a medical diagnosis is determined following an assessment and analysis of data gathered only by physicians. B) A nursing diagnosis changes as the client's responses to an illness or health situation change; a medical diagnosis remains the same as long as the disease process persists. C) A nursing diagnosis describes a client's physical, sociocultural, psychological, and spiritual responses to an illness or health condition; a medical diagnosis refers to disease processes. D) A nursing diagnosis considers the etiology of the health problem to give direction to required nursing care; a medical diagnosis does not consider the etiology of the health problem to give direction to medical care.

B,C

4) The nurse is selected to participate on a committee to write critical pathways for a specific set of medical diagnoses. What will be the advantage(s) of using this approach when providing client care? Select all that apply. A) Link nursing diagnoses with specific assessment data B) Sequence the care that is to be given on a particular day C) Identify interventions, time frames, and expected outcomes D) List medical treatments to be performed by other providers E) Provide specific columns for diagnosis, interventions, and evaluation

B,C,D

2) The nurse is creating a four-column plan of care for a client. For which area(s) should the nurse prepare to document when creating this care plan? Select all that apply. A) Medications B) Nursing diagnosis C) Goals D) Interventions E) Evaluation

B,C,D,E

8) A client who has just been diagnosed with diabetes mellitus is being instructed by the nurse regarding diet and exercise. Which client statement or statements indicate that further teaching is required? Select all that apply. A) "I should talk to the doctor about an exercise program." B) "I don't need to watch my diet as long as I take my insulin." C) "I need to limit the amount of fat in my diet." D) "I should eat a candy bar when my energy is low." E) "I will test my blood sugar before meals and at bedtime."

B,D

13) A client begins to vomit blood. The nurse immediately measures the blood pressure and prepares to insert a nasogastric tube while directing others to notify the physician and prepare to perform iced saline lavage. Which feature(s) of the Tanner Clinical Judgment Model did this nurse demonstrate? Select all that apply. A) Presencing B) Noticing C) Empowerment D) Interpreting E) Responding

B,D,E

11) A graduate nurse is planning care for an older client with a wound infection and systemic blood infection. The nurse completes the plan of care and decides to complete which action to enhance the skill of critical thinking? A) Discuss the plan with the physician. B) Request that the client review the plan. C) Request a review of the plan with the nurse's preceptor. D) Place the plan on the client's chart.

C

4) The nurse is assigned two clients. One client needs postoperative teaching in preparation for discharge and the other client with pneumonia has a PaCO2 of 85. Why does the nurse decide to see the client with pneumonia first? A) The nurse can delegate postoperative teaching to unlicensed assistive personnel (UAP). B) The client with pneumonia needs more care than the client needing postoperative teaching. C) The client with pneumonia may be experiencing respiratory distress. D) The room of the client with pneumonia is closer than that of the client needing postoperative teaching.

C

8) The nurse is caring for a female client with decreased energy who needs to get up to prevent the development of pressure ulcers. The client is unable to ambulate and wants to be alone. What should the nurse do? A) Notify the physician of the client's noncompliance. B) Leave the client alone until ready to get out of bed. C) Gain knowledge about the client from family to gain compliance. D) Proceed to get help to get the client out of bed.

C

9) The nurse is caring for a 10-year-old client who is sleeping when the menu choices for dinner are brought to the room. Which intervention should the nurse use to meet the dietary needs of this client? A) Wake the child to choose a meal for dinner. B) Order chicken nuggets because most children like this meal. C) Ask the dietary worker to come back later. D) Ask the parents to bring dinner from home for the client.

C

The nurse is teaching a client about clopidogrel (Plavix). What is important information to include? a. Constipation may occur. b. Hypotension may occur. c. Bleeding may increase when taken with aspirin. d. Normal dose is 25 mg tablet per day.

C

A patient who is confined to bed and who has a stage II pressure ulcer is being cared for in the home by family members. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to a. change the patient's bedding frequently. b. use a hydrocolloid dressing over the ulcer. c. record the size and appearance of the ulcer weekly. d. change the patient's position at least every 2 hours.

Change patient's position at least every two hours

A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). Which action by the nurse is most appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Give the prescribed PRN aspirin (Ascriptin) 650 mg. d. Check the patient's oral temperature again in 4 hours.

Check the patient's oral temperature again in 4 hours

acute renal failure

Condition that occurs when something, such as a blockage, toxins, or sudden loss of blood flow causes a change in the filtering function of the kidneys

1) A nurse has just received a shift report and is preparing to care for clients assigned on a medical-surgical unit. Which client should the nurse plan to assess first? A) The client who needs assistance with activities of daily living B) The client who needs help ambulating to the bathroom C) The client with a pain rating of 3/10 D) The client experiencing shortness of breath

D

2) A client with congestive heart failure is having difficulty breathing. Before leaving the room the nurse ensures the client has an over-bed table to lean on when awake if needed to ease breathing. Which technique did the nurse use to make this decision? A) Delegating a task B) Priority-setting C) Conflict resolution D) Critical thinking

D

2) The nurse is conducting a class for a group of expectant mothers regarding basic infant care techniques. Upon completion of the class, what should the nurse expect the participants to do? A) Set goals for the next class session. B) Pass a written test on how to bathe a newborn infant. C) Review the major points of the class. D) Provide a return demonstration of a bath on a newborn doll.

D

3) A postoperative client prescribed pain medication every 4 to 6 hours is requesting medication every 6 hours. At 4 hours the client's pain level is 8 on a rating scale of 1 to 10. The nurse decides to give the pain medication now. What does this nurse's action exemplify? A) Meeting a client goal B) Time management skills C) Prioritizing the client's care D) A response to a change in the client's condition

D

4) The nurse is collecting data about a client's current health status. Which statement would assist in gathering subjective data about the client? A) "Your eyelid is red and swollen." B) "Your skin appears to be dry and irritated." C) "I see that you have bruises on your legs." D) "Tell me why you have difficulty sleeping."

D

6) An older client with heart failure is experiencing activity intolerance due to dyspnea on exertion. Which nursing intervention is a priority for the client? A) Complete all nursing care at the end of the shift. B) Delegate care for the client to an aide. C) Complete all nursing care in the morning. D) Pace nursing care throughout the shift.

D

7) A client recovering from knee surgery is being prepared to ambulate for the first time. Prior to getting the client up, what should the nurse do? A) Ask the client about readiness to walk. B) Call for a wheelchair to start the process. C) Conduct a breathing assessment. D) Evaluate the client's level of pain.

D

The parent asks the nurse to explain which type of drugs will not be used in the medical treatment of their child's allergic reaction to bee stings. A. Diuretics and sedatives B. Antihistamines and salicylates C. Cardiotonics and anticholinergics D. Bronchodilators and corticosteroids

Diuretics and sedatives

The nurse assess a patient the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Obtain wound culture b. Document assessment c. Notify health care provide d. Assess the wound every 2 hours

Document assessment

A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is appropriate? a. Elevate the ankle above heart level. b. Remove the patient's shoe and sock. c. Apply a warm moist pack to the ankle. d. Assess the ankle's range of motion (ROM).

Elevate the ankle above the heart level

increases blood flow in the area of the injury.

Hyperemia

A patient diagnosed with inflammatory bowel disease experiences an obstruction in the small bowel. When assessing the patient, which of the following will the healthcare provider anticipate? Please choose from one of the following options. Scaphoid abdomen Hypovolemia Increased flatus Passage of melena

Hypovolemia

A patient is admitted to the hospital with a pressure ulcer on the left buttock. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer as stage a. I. b. II. c. III. d. IV.

III

The healthcare provider is assessing a patient diagnosed with ulcerative colitis. The patient has an altered level of consciousness, fever, and lower abdominal distension. Which of these additional findings would confirm a diagnosis of toxic megacolon? Please choose from one of the following options. Bradycardia Splenomegaly Leukocytosis Constipation

Leukocytosis

When caring for a diabetic patient who had abdominal surgery one week ago, the nurse obtains these data. Which finding should be reported immediately to the health care provider? a. Blood glucose 136 mg/dl b. Oral temperature 101° F (38.3° C) c. Patient complaint of increased incisional pain d. New 5-cm separation of the proximal wound edges

New 5-cm separation of the proximal wound edges

A patient diagnosed with ulcerative colitis is admitted to the medical unit. When assessing the patient, which of these findings would be of the most concern? Borborygmi Oral temperature of 99.0 F (37.2 C) Bloody diarrhea Rebound tenderness

Rebound tenderness

kidney stones

Solid crystalline masses formed in the kidney, resulting from an excess of insoluble salts or uric acid crystallizing in the urine; may become trapped anywhere along the urinary tract.

When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient states that the ulcers are very painful. b. The patient has had the heel ulcers for the last 6 months. c. The patient has several old incisions that have formed keloids. d. The patient takes corticosteroids daily for rheumatoid arthritis.

The patient takes corticosteriods daily for rheumatoid arthritis

The nurse has just received change-of-shift report about the following four patients. Which patient will the nurse assess first? a. The patient who has multiple black wounds on the feet and ankles. b. The newly admitted patient with a stage IV pressure ulcer on the coccyx. c. The patient who needs to be medicated with multiple analgesics before a scheduled dressing change. d. The patient who has been receiving immunosuppressant medications and has a temperature of 102° F.

The patient who has been receiving immunosuppressant medications and has a temperature of 102F

A patient with an inflammation has a high eosinophil count. The nurse recognizes that this finding most likely indicates that A. The inflammatory response has been stimulated by infection B. The inflammation has become chronic with persistent tissue damage C. Humoral and cell-mediated immunity is being stimulated D. Tissue damage has been caused by an allergen-antibody reaction

Tissue damage has been caused by an allergen-antibody reaction. Eosinophil= allergies

A nurse is caring for a client who is taking an angiotensin-converting enzyme inhibitor and develops a dry, nonproductive cough. What is the nurse's priority action? a. Call the health care provider to switch the medication. b. Assess the client for other symptoms of upper respiratory infection. c. Instruct the client to take antitussive medication until the symptoms subside. d. Tell the client that the cough will subside in a few days.

a. Angiotensin-converting enzyme inhibitors prevent the breakdown of bradykinin, frequently causing a nonproductive cough. Angiotensin receptor blocking agents do not block this breakdown, thus minimizing this annoying side effect. The client should be switched to a different medication if the side effect cannot be tolerated.

Which client assessment would assist the nurse in evaluating therapeutic effects of a calcium channel blocker? a. Client states that she has no chest pain. b. Client states that the swelling in her feet is reduced. c. Client states the she does not feel dizzy. d. Client states that she feels stronger.

a. The workload in the heart should be decreased with the vasodilatation from the calcium channel blocker. With less strain, the client should have fewer incidences of angina as afterload is decreased.

An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of: a. Left ventricular atrophy b. Irregular heartbeats c. Peripheral vascular occlusion d. Pacemaker placement

a. In older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden emotional or physical stress, the left ventricle is less able to respond to the increased demands on the myocardial muscle. Decreased cardiac output, cardiac hypertrophy, and heart failure are examples of the chronic conditions that may develop in response to inactivity, rather than in response to the aging process. Irregular heartbeats are generally not associated with an older sedentary adult's lifestyle. Peripheral vascular occlusion or pacemaker placement should not affect response to stress.

The nurse should understand that which of the following treatments for Second Degree Type II AV Block would be appropriate? (Select all that apply) a. Temporary pacemaker insertion b. Close monitoring without intervention c. Atropine to increase heart rate if symptomatic d. Coronary stent placement to improve blood flow to myocardium e. An implantable defibrillator surgically implanted

a. Temporary pacemaker insertion c. Atropine to increase heart rate if symptomatic d. Coronary stent placement to improve blood flow to myocardium Rationale: Rationale: a,c, and d are correct. Temporary pacing may be needed and atropine will temporarily improve heart rate cardiac output until the pacemaker can be inserted. b. is incorrect because Type II has a tendency to develop complete heart block where adequate cardiac output is not maintained and arrest is likely. Type I can be monitored and minimal treatment is needed unless unstable hemodynamics are present. e. is incorrect because a defibrillator is not called for since it is the ventricle that is trying to maintain the cardiac output from the decreased conduction between the atria and the ventricles. An implanted pacemaker may be needed permanently.

You are the charge nurse on the telemetry unit and are responsible for making client assignments. Which client would be appropriate to assign to the float RN from the medical-surgical unit? a. The 64-year-old admitted for weakness who has a first-degree heart block with a heart rate of 58 beats/min b. The 71-year-old admitted for heart failure who is short of breath and has a heart rate of 120 to 130 beats/min c. The 88-year-old admitted with an elevated troponin level who is hypotensive with a heart rate of 96 beats/min d. The 92-year-old admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min

a. The 64-year-old admitted for weakness who has a first-degree heart block with a heart rate of 58 beats/min Rationale: This client has a stable, asymptomatic dysrhythmia, which usually requires no treatment; this client can be managed by a nurse with less cardiac dysrhythmia training.

When planning care for a client receiving treatment for cardiac dysrhythmias, an appropriate client outcome would be: a. The client will avoid use of caffeine during therapy. b. The client will maintain heart rate below 60 beats per minute. c. The client will limit fluid intake to 1000 ml/day. d. The client will limit cigarettes to 15/day.

a. The client will avoid use of caffeine during therapy. Causes of dysrhythmias include electrolyte imbalance, hyperthyroidism, anxiety, caffeine ingestion, and tobacco use. The client should be taught to avoid caffeine and tobacco.

A client's serum lipids are cholesterol 197 mg/dl, low-density lipoprotein (LDL) 110 mg/dl, and high-density lipoprotein (HDL) 35 mg/dl. The nurse knows what about these values? a. Serum lipids are within desirable values. b. Cholesterol is within desirable value, but LDL and HDL are not. c. Cholesterol is not within desirable value, though LDL and HDL are. d. Cholesterol, LDL, and HDL are not within desirable values.

b

The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive highest priority? a. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles b. Confusion, urine output 15mL over the last 2 hours, orthopnea. c. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities. d. Weight gain of 1kg in 3 days, BP 130/80, mild dyspnea with exercise.

b. A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation there is a loss of atrial kick, but the blood pressure and heart rate are stable

A nurse who is auscultating a 56-year-old client's apical heart rate before administering digoxin (Lanoxin) notes that the heart rate is 52 beats/min. The nurse should make which interpretation about this information? a. Normal, because of the client's age b. Abnormal, requiring further assessment c. Normal, as a result of the effects of digoxin d. Normal, because this is the reason the client is receiving digoxin

b. Abnormal, requiring further assessment

The nurse is caring for a client with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first? a. Defibrillate the client at 200 J. b. Check the client for a pulse. c. Cardiovert the client at 50 J. d. Give the client IV lidocaine.

b. Check the client for a pulse. Rationale: The nurse needs to assess the client to determine stability before proceeding with further interventions. If the client has a pulse and is relatively stable, elective cardioversion or antidysrhythmic medications may be prescribed.

Which of the following is an expected outcome when a client is receiving an IV administration of furosemide? a. Increased blood pressure b. Increased urine output c. Decreased pain d. Decreased premature ventricular contractions

b. Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias

A client with a diagnosis of cardiac dysrhythmias and a history of type I diabetes mellitus is placed on propranolol therapy. The client asks the nurse if the drug will affect insulin needs. The best response by the nurse would be that: a. The drug will have no effect on insulin needs. b. The drug might cause hypoglycemia. c. The drug could cause hyperglycemia. d. The client should ask the physician this question.

b. The drug might cause hypoglycemia. There is increased incidence of hypoglycemia with type I diabetes mellitus, because propranolol can inhibit glycogenolysis.

The nurse explains that with the exposure to an antigen, the initiator of the inflammatory response is the presence of histamine, which is released by the: A. monocytes. B. neutrophils. C. basophils. D. eosinophils.

basophils

A client's blood pressure (BP) is 145/90. According to the guidelines for determining hypertension, the nurse realizes that the client's BP is at which stage? a. Normal b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension

c

A nurse who is giving a statin(Lipitor) realizes the importance of monitoring for which serious adverse reaction? a. Pharyngitis b. Rash/pruritus c. Rhabdomyolysis d. Agranulocytosis

c

A client taking spironolactone (Aldactone) [potassium-sparing diuretic] has been taught about the therapy. Which menu selection indicates that the client understands teaching related to this medication? a. Apricots b. Bananas c. Fish d. Strawberries

c. Spironolactone is a potassium-sparing diuretic that could potentially cause hyperkalemia. Fish is an appropriate dietary choice, because it is low in potassium. The other foods are high in potassium.

When a patient has long-term atrial fibrillation, the nurse would expect to include which drug in the plan of care to minimize the greatest risk that is commonly associated with atrial fibrillation? a. Beta blockers b. Digitalis c. Anticoagulants d. Antiarrhythmics

c. Anticoagulants Rationale: c. is correct because it reflects the greatest risk or complication of thrombi or emboli that occurs with long-term atrial fibrillation. Coumadin is often given prophylactically to prevent stroke, clots, or emboli from developing when hospitalizing a patient with long-term atrial fibrillation.

A 58-year-old female with a family history of CAD is being seen for her annual physical exam. Fasting lab test results include: Total cholesterol 198; LDL cholesterol 120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein (CRP) 4.2. The health care provider informs the client that she will be started on a statin medication and aspirin. The client asks the nurse why she needs to take these medications. Which is the best response by the nurse? a. "The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet." b. "The triglycerides are elevated and will not return to normal without these medications." c. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered." d. "The medications are not indicated since your lab values are all normal."

c. CRP is a marker of inflammation and is elevated in the presence of cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to evaluate cardiovascular risk. The family history, post-menopausal age, LDL above optimum levels and elevated CRP place the client at risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can reduce CRP and decrease the risk of MI and stroke.

Which laboratory test results may be associated with peaked or tall, tented T waves on a client's electrocardiogram (ECG)? a. Chloride level of 98 mEq/L b. Sodium level of 135 mEq/L c. Potassium level of 6.8 mEq/L d. Magnesium level of 1.6 mEq/L

c. Potassium level of 6.8 mEq/L

The nurse explains that medication being given to a client with a severe inflammatory response mimics a hormone secreted by the adrenal cortex. This hormone is: A. cortisol. B. aldosterone. C. histamine. D. testosterone.

cortisol

Captopril (Capoten) has been ordered for a client. The nurse teaches the client that ACE inhibitors have which common side effects? a. Nausea and vomiting b. Dizziness and headaches c. Upset stomach d. Constant, irritating cough

d

A client has developed uncontrolled atrial fibrillation with a ventricular rate of 150 beats/min. What manifestation should the nurse observe for when performing the client's focused assessment? a. Flat neck veins b. Nausea and vomiting c. Hypotension and dizziness d. Clubbed fingertips and headache

d. Hypotension and dizziness

The nurse is assessing clients at a health fair. Which client is at greatest risk for coronary artery disease? a. a 32-year-old female with mitral valve prolapse who quit smoking 10 years ago. b. a 43-year-old male with a family history of CAD and cholesterol level of 158 c. A 56-year-old male with an HDL of 60 who takes atorvastatin (Lipitor) d. A 65-year-old female who is obese with an LDL of 188

d. The woman who is 65-years-old, over weight and has an elevated LDL is at greatest risk. Total cholesterol >200, LDL >100, HDL <40 in men, HDL <50 in women, men 45-years and older, women 55-years and older, smoking and obesity increase the risk of CAD. Atorvastatin is a medication to reduce LDL and decrease risk of CAD. The combination of postmenopausal, obesity and high LDL cholesterol places this client at greatest risk.

Thyroid disease

disorders resulting from defects of the thyroid gland, can be genetic or acquired, results in either an increase or decrease in metabolism, controlled by drugs or surgery

chronic renal failure

gradual and progressive loss of kidney function

Increased metabolism at the inflammation site causes what?

heat

fluid volume excess

hypervolemia: water intoxication d/t excessive Na intake, IVF,CRF, CHF, SIADH, • S/s: ^HR, ^BP, distended neck veins, dysrthymias, ^RR, altered LOC, ^UO, pitting edema, diarrhea, • Rx: diuretics, restrict fluid/Na, monitor I&O, monitor daily weight

fluid volume deficit

hypovolemia, dehydration, diarrhea, DI. • S/s: ^HR, hypotension, dysrhythmias, ^RR, dyspnea, lethargic, weakness, decreased UO, tenting, constipation • Rx: IVF, O2

GI assessment

inspection, auscultation, percussion, palpation

Diabetes Type 1

no insulin produced

A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. The nurse anticipates that the next action will be to a. obtain wound cultures. b. start antibiotic therapy. c. redress the wound with wet-to-dry dressings. d. continue to monitor the wound for purulent drainage.

obtain wound culture

A 76-year-old patient has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep pink granulation tissue. The nurse documents the wound as a a. red wound. b. yellow wound. c. full-thickness wound. d. stage III pressure wound.

yellow wound