Cardio and Resp NCLEX questions

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, what does the nurse expect to identify? A. Hypertension B. Tenacious sputum C. Altered mental status D .Slow rate of breathing C. Altered mental status

Altered mental status is secondary to cerebral hypoxia, which accompanies acute respiratory distress syndrome (ARDS); cognition and level of consciousness are reduced. Hypotension occurs because of hypoxia. The sputum is not tenacious, but it may be frothy if pulmonary edema is present. Breathing will be fast and shallow.

A nurse teaches a client with a nose fracture about routine care after rhinoplasty surgery. Which statement of the client indicates the need for further teaching? I should not sniff upwards or blow my nose." 2 "I should take aspirin if I experience bleeding." 3 "I should move slowly and remain in the semi-Fowler's position whenever possible." 4 "I should not cough forcefully or strain during bowel movements."

I should take aspirin if i experience bleeding

A person is brought to the emergency department after prolonged exposure to cold weather. What clinical manifestations of hypothermia does the nurse expect? Select all that apply. 1 Stupor 2 Erythema 3 Increased anxiety 4 Rapid respirations 5 Paresthesia in affected body parts

stupor paresthesia in affected body parts

After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. What should the nurse conclude is the most likely cause of the pleural effusion?

Cancerous lesions in the pleural space increase the osmotic pressure, causing a shift of fluid to that space. Excessive fluid intake is usually balanced by increased urine output. Inadequate chest expansion results from pleural effusion and is not the cause of it. A bronchoscopy does not involve the pleural space.

A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock? Diuresis, irritability, and fever 2 Lethargy, cold skin, and hypertension 3 Thirst, cool skin, and orthostatic hypotension 4 Bounding pulse, restlessness, and slurred speech

Thirst, cool skin, and orthostatic hypotension

A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected, and a test for the human immunodeficiency virus (HIV) is performed. Which clinical responses are associated most commonly with this syndrome? (Select all that apply.) 1 Malaise 2 Confusion 3 Constipation 4 Swollen lymph glands 5 Oropharyngeal candidiasis

Development of HIV-specific antibodies (seroconversion) is accompanied by a flulike syndrome called acute retroviral syndrome. This syndrome includes malaise, swollen lymph glands, fever, sore throat, headache, nausea, diarrhea, muscle/joint pain, or a diffuse rash. It occurs one to three weeks after infection and may continue for several months. Acute retroviral syndrome over time is followed by the early-chronic, intermediate-chronic, and late-chronic stages of HIV infection. Development of HIV-specific antibodies, accompanied by flulike syndrome, includes swollen lymph glands. Confusion is associated with the intermediate-chronic and late-chronic stages of HIV infection when the individual develops AIDS-dementia complex or opportunistic infection that affects the neurological system. Diarrhea, not constipation, is associated with this syndrome. Oropharyngeal candidiasis occurs during the intermediate-chronic stage of HIV infection. answer is malaise and swollen lymph galnds

A nurse assesses that several clients have low oxygen saturation levels. Which client will benefit the most from receiving oxygen via a nasal cannula? Has an upper respiratory infection 2 Has many visitors while sitting in a chair 3 Has a nasogastric tube for gastric decompression 4 Has dry oral mucous membranes from mouth breathing

Has many visitors while sitting in a chair

An older client tells the nurse, "My legs begin to hurt after walking the dog for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition does the nurse consider as the most likely cause of the client's pain? 1 Spinal stenosis 2 Buerger disease 3 Rheumatoid arthritis interminnet caludation - answer

Pain that develops during exercise is a classic symptom of peripheral arterial occlusive disease; arterial occlusion prevents adequate blood flow to the muscles of the legs, causing ischemia and pain. Spinal stenosis is associated with chronic back pain. Buerger disease is associated with foot pain and cramping; rubor may be present, and pedal pulses may be absent. Rheumatoid arthritis is associated with joint pain, erythema, and swelling; pain may be present with or without activity, particularly when one is awakening.

The nurse is teaching a client who has asthma about using a peak flow meter. Which statement by the client reflects a correct understanding of the use of a peak flow meter? Select all that apply "Readings in the green zone mean that my asthma is under control." 2 "If I get a reading in the yellow zone, I need to stop what I'm doing and rest, then recheck in an hour." 3 "If I get a reading in the red zone, then I need to take my reliever drug and have my wife take me to the hospital." 4 "I should check the peak flow readings at least twice a day." 5 "I don't need to check my peak flow readings if I take a reliever drug.

Readings in the green zone mean that my asthma is under control. "If I get a reading in the red zone, then I need to take my reliever drug and have my wife take me to the hospital." "I should check the peak flow readings at least twice a day."

A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions? 1 Client no longer is infected. 2 Tuberculin skin test is negative. Correct 3 Sputum is free of acid-fast bacteria. 4 Client's temperature has returned to normal

The absence of bacteria in the sputum indicates that the disease can no longer be spread by the airborne route. Treatment is over an extended period; eventually the client may not have an active disease, but still remains infected. Once an individual has been infected, the test will always be positive. The client's temperature returning to normal is not evidence that the disease cannot be transmitted.

Following a laryngectomy a client experiences frequent coughing episodes and copious production of secretions. The nurse explains that the client's responses are related to:

The reaction of the mucous membranes to air that is dry and cool Air is moisturized and warmed as it passes through the nasopharynx. With a laryngectomy this area is bypassed and the tracheobronchial tree compensates by producing copious amounts of secretions. Irritation of the stoma by the tracheostomy tube will produce local irritation and a local response. Upper respiratory inflammation because of allergies is not a response to allergies but to the stress of the air that is entering the tracheobronchial tract. The air is no longer warmed or humidified by passing through the nose. Insufficient coughing and deep breathing do not create a response of coughing.

or which expected response should the nurse monitor a client after a cardiac catheterization? Correct 1 Marked increase in the volume of urine output 2 Decrease in blood pressure of 25% from the precatheterization blood pressure 3 Complaints of heart pounding with mild chest discomfort 4

There is increased urinary output as a result of the diuretic effect of the contrast medium. A decrease of 10% to 20% is expected because of the diuretic effect of the contrast medium; a decrease greater than 20% may be pathologic. Although heart pounding with mild chest discomfort may occur during the procedure because of trauma to the conduction system, it usually does not continue after the procedure. Respiratory distress may be an indication of a pulmonary embolus from a venous clot and should be reported immediately.

A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply. Correct 1 Dependent edema Correct 2 Swollen hands and fingers 3 Collapsed neck veins Correct 4 Right upper quadrant discomfort 5 Oliguria

With right-sided heart failure, signs of systemic congestion occur as the right ventricle fails; key features include dependent edema and swollen hands and fingers. Upper right quadrant discomfort is expected with right ventricular failure because venous congestion in the systemic circulation results in hepatomegaly. Jugular venous collapse and oliguria are key features of left-sided heart failure. Left-sided heart failure is associated with decreased cardiac output.

A client had thoracic surgery. The nurse should monitor for which clinical manifestations that may indicate acute pulmonary edema? Select all that apply. 1 Crackles 2 Cyanosis 3 Chest pain 4 Bradypnea 5 Frothy sputum

crackles, cyanosis frothy sputum

A client is admitted for an exacerbation of emphysema. The client has a fever, chills, and difficulty breathing on exertion. What is the priority nursing action based on the client's history and present status? Checking for capillary refill 2 Encouraging increased fluid intake 3 Suctioning secretions from the airway 4 Administering a high concentration of oxygen

encouraging increased fluid intake the reason becasue it decrease the suptum and increased the ciruclation

A spontaneous pneumothorax is suspected in a client with a history of emphysema. In addition to calling the healthcare provider, which action should the nurse take? 1 Place the client on the unaffected side 2 Administer 60% oxygen via a Venturi mask 3 Give oxygen at 2 L per minute via nasal cannula 4 Prepare for intravenous (IV) administration of electrolytes

give oxygen at 2 L per minute via nasal cannula

A client reports having a bad cold and chest pain that worsens when the client takes deep breaths. Where should the nurse place the stethoscope to determine the presence of a pleural friction rub? lower lateral

is the lower-lateral chest, which is the area of greatest thoracic excursion. With visceral and parietal pleural inflammation (pleurisy), a low-pitched, coarse, grating sound is heard when the client breathes, particularly when approaching the height of inspiration