Cardio Exam 2 Practice
A young woman is admitted to the ED after experiencing submersion at a local lake. She received rescue breathing at the site and now has spontaneous respirations. The nurse tells the patient that she will need to be observed for some time, primarily because she may yet experience 1. Hypernatremia 2. Pulmonary edema 3. Respiratory acidosis 4. Signs of head injury
2. Pulmonary edema
Which intervention should the nurse implement for a male client who has had a left-sided chest tube for six (6) hours and refuses to take deep breaths because it hurts too much? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain that deep breaths do not have to be taken at this time. 4. Tell the client that if he doesn't take deep breaths, he could die.
1. Medicate the client and have the client take deep breaths.
The client has a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse take is there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a stat chest x-ray. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client's pulse oximeter reading.
3. Check the tubing for kinks or clots.
The nurse is caring for a client diagnosed with pneumonia who is having shortness of breath and difficulty breathing. Which intervention should the nurse implement first? 1. Take the client's vital signs. 2. Check the client's pulse oximeter reading. 3. Elevate the client's head of the bed. 4. Notify the respiratory therapist STAT.
3. Elevate the client's head of the bed.
Which heart valve sound is heard best at the left midclavicular line at the level of the fifth ICS? a. Aortic b. Mitral c. Tricuspid d. Pulmonic
b. Mitral
During the respiratory assessment of a chest trauma patient with multiple rib fractures (flail chest) the nurse findings will include:
c. dyspnea and paradoxical chest movements
A patient diagnosed with active TB is started on initial drug therapy. The nurse plans to teach the patient about the uses and effects of:
c. isoniazid, rifampin, pyrazinamide, and ethambutol
A patient experiences a flail chest as a result of an automobile accident. During the respiratory assessment the nurse would expect to find:
c. paradoxic chest movement
An emergency department nurse is assessing a pediatric client suspected of having acute pericarditis. WHich assessment finding should the nurse conclude supports the diagnosis of acute pericarditis? 1. Bilateral lower extremity pain 2. Pain on expiration 3. Pleural friction rub 4. Pericardial friction rub
Ans: 4. Pericardial friction rub
An expected finding in the assessment of an 81-year-old patient is a. a narrowed pulse pressure. b. diminished carotid artery pulses. c. difficulty isolating the apical pulse. d. an increased heart rate in response to stress.
c. difficulty isolating the apical pulse.
Patient most at risk for pulmonary emboli
73 year-old with hip pinning one day post-op
When a person's blood pressure rises, the homeostatic mechanism to compensate for an elevation involves stimulation of A. baroreceptors that inhibit the sympathetic nervous system, causing vasodilation B. chemoreceptors that inhibit the sympathetic nervous system causing vasodilation C. baroreceptors that inhibit the parasympathetic nervous system, causing vasodilation D. chemoreceptors that stimulate the sympathetic nervous system, causing an increased heart rate
A. baroreceptors that inhibit the sympathetic nervous system, causing vasodilation
A client experiencing a pulmonary embolus has pleuritic pain and hemoptysis. The nurse would assesses the presence of hemoptysis as an indication of a. alveolar damage. b. hemorrhage in the sinuses. c. hemothorax. d. ruptured vessels in the trachea.
ANS: A Hemoptysis is an indication that the atelectasis has caused alveolar damage.
The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. O2 saturation is 88%. b. Blood pressure is 155/90 mm Hg. c. Respiratory rate is 24 breaths/min when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.
ANS: A O2 saturation should improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low O2 saturation is the priority.
How should the nurse document a loud humming sound auscultated over the patient's abdominal aorta? a. Thrill b. Bruit c. Murmur d. Normal finding
ANS: B A bruit is the sound created by turbulent blood flow in an artery. Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel. A murmur is the sound caused by turbulent blood flow through the heart. Auscultating a bruit in an artery is not normal and indicates pathology.
The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.
ANS: C A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given.
Which finding indicates to the nurse that the administered nifedipine (Procardia) was effective for a patient who has idiopathic pulmonary arterial hypertension (IPAH)? a. Heart rate is between 60 and 100 beats/min. b. Patient's chest x-ray indicates clear lung fields. c. Patient reports a decrease in exertional dyspnea. d. Blood pressure (BP) is less than 140/90 mm Hg.
ANS: C Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the therapy is not effective.
A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? a. Purpose of antibiotic therapy b. Ways to limit oral fluid intake c. Appropriate use of cough suppressants d. Safety concerns with home O2 therapy
ANS: C Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home O2 is not prescribed for acute bronchitis, although it may be used for chronic bronchitis.
Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be important to report to the health care provider before the MRI? a. The patient has an allergy to shellfish. b. The patient has a history of atherosclerosis. c. The patient has a permanent cardiac pacemaker. d. The patient took the prescribed heart medications today.
ANS: C MRI is contraindicated for patients with implanted metallic devices such as pacemakers. The other information does not affect whether the patient can have an MRI.
Which laboratory test result will the nurse review to determine the effects of therapy for a patient being treated for heart failure? a. Troponin b. Homocysteine (Hcy) c. Low-density lipoprotein (LDL) d. B-type natriuretic peptide (BNP)
ANS: D Increased levels of BNP are a marker for heart failure. The other laboratory results would assess for myocardial infarction (troponin) or risk for coronary artery disease (Hcy and LDL).
Z track
Air should be in syringe
A client is admitted with a diagnosis of acute infective endocarditis (IE). Which findings during a nursing assessment support this diagnosis? Select all that apply. 1. Skin petechiae 2. Crackles in lung bases 3. Peripheral edema 4. Murmur 5. Arthralgia 6. Decreased ESR
Ans: 1, 2, 3, 4, 5
A patient with COPD complains of a sudden onset of severe shortness of breath and pain in chest while watching TV at home. Based on the illustrations, your knowledge of this condition, your physical assessment findings will include:
B. tracheal deviation, air hunger, from tension pneumothorax
Postural drianage
Before meal
What is not a normal breath sound
Bronchovesicular sound in the 4th intercostal space
Advantage of mechanical valve?
Can last up to 20 years
What are the effects of rheumatic fever?
Causes mitral valve prolapse
Chest tube bottle with continuous bubble
Check for leak
Most effective cough
Cough twice on exhalation
R sided HF or cor pulmonale
Dependent edema
Incentive spirometer
Diaphragmatic breathing
S&S of pneumonia
Dull sound crackles
Patient with pneumonia best thing to do first
Find out what is causing the pneumonia
When a spontaneous pneumothorax is suspected in a patient with a history of emphysema, the nurse should call the physician and:
Give O2 and 2 L per minute via nasal cannula
HIV pt with duration of 7 mm with mantoux test
He is positive
Patient on streptomycin c/o taking so many meds and his ears are ringing
He needs to be further evaluated
Which of the following is contraindicated by INH?
Hepatitis C
TB primary drug used for prophylactic reason:
INH
Emphysema patient what diet?
Increase calories, and six small meals
Pt teaching for pericarditis
Leaning forward with arms on legs, or leaning on an overbed table
Technique for percussion
Light rhythmic cupping
Best prevention for pneumonia
Maintain general health & nutrition
A nurse should do what first when a patient comes from surgery with a chest tube?
Mark level with tube and observe amount of drainage
PaO2 84, PCO2 50, HCO3 Normal
Patient is going to increase respiration rate immediately
Patient with pleural rub everything except
Percussion over thorax
Tx for cardiac tamponade
Pericardiocentesis
Best test for TB
Positive sputum culture
Patient with TB & positive mantoux test
Pt is infected with TB
S/S of a Cardiac tamponade
Pulse paradoxus
Patient with lobectomy place the patient in any position except
Right side
Rimfampine
Urine body secretion and lacrimal should turn orange
Breathing exercises nurse should teach
Use abdominal muscles
Dx for pulmonary embolism
V/QSAN (ventilation perfusion)
A patient has a severe blockage in his right coronary artery. Which heart structures are most likely to be affected by this blockage? (select all that apply) a. AV node b. Left ventricle c. Coronary sinus d. Right ventricle e. Pulmonic valve
a. AV node b. Left ventricle d. Right ventricle
When assessing a patient, you note a pulse deficit of 23 beats. This finding may be caused by a. dysrhythmias b. heart murmurs c. gallop rhythms d. pericardial friction rubs
a. dysrhythmias
A P wave on an ECG represents an impulse arising at the a. SA node and repolarizing the atria. b. SA node and depolarizing the atria. c. AV node and depolarizing the atria. d. AV node and spreading to the bundle of His.
b. SA node and depolarizing the atria.
Which subjective data related to the cardiovascular system should be obtained from the patient? (select all that apply) a. Annual income b. Smoking history c. Religious preference d. Number of pillows used to sleep e. Blood for basic laboratory studies
b. Smoking history c. Religious preference d. Number of pillows used to sleep
A patient who has been diagnosed with TB of the bone tells the nurse that he thought TB was a lung disease. The nurse explains to the patient that:
b. The lungs are the most common site of TB infection that the microorganism can be spread to other organs through the blood and lymph systems.
Complete lung expansion before the removal of chest tubes is evaluated by
b. comparison of chest x-rays
The client was given a Mantoux PPD test for TB. The nurse recognizes that the injection is given:
b. intradermally 15 degrees
The nurse is caring for a patient newly admitted with heart failure secondary to dilated cardiomyopathy. Which intervention would be a priority? a. Encourage caregivers to learn CPR. b. Consider a consultation with hospice for palliative care. c. Monitor the patient's response to prescribed medications. d. Arrange for the patient to enter a cardiac rehabilitation program.
c. Monitor the patient's response to prescribed medications.
When a patient suffers a complete pneumothorax, there is a danger of a mediastinal shift. If such a shift occurs, it may lead to:
d. decrease filling of the right heart and cardiovascular compromise
A nurse evaluates that a client understands discharge teaching, following aortic valve replacement surgery with a synthetic valve, when the client states that he/she plans to: Select all that apply. 1. Use a soft toothbrush for dental hygiene 2. Floss teeth daily to prevent plaque formation 3. Wear loose-fitting clothing to avoid friction on the sternal incision 4. Use an electric razor for shaving 5. Report black, tarry stools 6. Consume foods high in Vitamin K, such as brocoli.
1, 3, 4, 5
In a 3 bottle system collection drainage system
1 bottle from patient - water seal suction
Following a thoracotomy to remove a lung tumor, a nurse is preparing a client to be discharged to home. Which are appropriate teaching points for the client? Select all that apply. 1. Avoid lifting greater than 20 pounds. 2. Build up exercise endurance. 3. Continue to build endurance even when dyspneic. 4. Expect to return to normal activity level and strength within 1 month. 5. Make time for frequent rest periods with activity.
1, 2, 5
A nurse evaluates that a client understands discharge teaching, following aortic valve replacement surgery with a synthetic valve, when the client states that he/she plans to: (Select all that apply) 1. Uses a soft toothbrush for dental hygiene 2. Floss teeth faily to prevent plaque formation 3. Wear loose-fitting clothing to avoid friction on the sternal incision 4. Use an electric razor for shaving 5. Report black, tarry stools 6. Consume foods high in vitamin K such as broccoli
1, 3, 4, 5
Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment? 1. Assess the client's bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. 3. Notify the health-care provider as soon as possible. 4. Document the findings in the client's chart.
1. Assess the client's bilateral lung sounds.
Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube and there is excessive bubbling in the water-seal compartment? 1. Check the amount of wall suction being applied. 2. Assess the tubing for any blood clots. 3. Milk the tubing proximal to distal. 4. Encourage the client to cough forcefully.
1. Check the amount of wall suction being applied.
The nurse observes the unlicensed nursing assistant (NA) entering an airborne isolation room and leaving the door open. Which action would be the nurse's best response? 1. Close the door and discuss the NA's action when the NA comes out of the room. 2. Make the NA come back outside the room and then reenter closing the door. 3. Say nothing to the NA but report the incident to the nursing supervisor. 4. Enter the client's room and discuss the matter with the NA immediately.
1. Close the door and discuss the NA's action when the NA comes out of the room.
The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs and symptoms would the nurse expect to find when assessing the client? 1. Confusion and lethargy. 2. High fever and chills. 3. Frothy sputum and edema. 4. Bradypnea and jugular vein distention.
1. Confusion and lethargy.
The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client? 1. Increase fluid intake to two (2) to three (3) liters a day. 2. Eat a low-cholesterol, low-fat diet. 3. Avoid being around loud crowds. 4. Receive pneumonia and flu vaccines.
1. Increase fluid intake to two (2) to three (3) liters a day.
The client diagnosed with pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client? 1. Increase fluid intake to two (2) to three (3) liters a day. 2. Eat a low-cholesterol, low-fat diet. 3. Avoid being around large crowds. 4. Receive pneumonia and flu vaccines.
1. Increase fluid intake to two (2) to three (3) liters a day.
Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply. 1. Keep protamine sulfate readily available. 2. Avoid applying pressure to venipuncture sites. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered.
1. Keep protamine sulfate readily available. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered.
A nurse is caring for a client following a coronary artery bypass graft. Which assessment finding in the immediate postoperative period should be most concerning to the nurse? 1. No chest tube output for 1 hour when previously it was copious. 2. Client temperature of 99.1 F. 3. ABG results show pH 7.32, PCO2 48, HCO3 28, PO2 80. 4. Urine output of 160 mL in the last 4 hours.
1. No chest tube output for 1 hour when previously it was copious.
The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply. 1. Place the client on oxygen by nasal cannula. 2. Plan for periods of rest during activities of daily living. 3. Place the client on a fluid restriction of 1000 mL per day. 4. Restrict the client's smoking to two (2) to three (3) cigarettes per day. 5. Monitor the client's pulse oximetry readings every four (4) hours.
1. Place the client on oxygen by nasal cannula. 2. Plan for periods of rest during activities of daily living. 5. Monitor the client's pulse oximetry readings every four (4) hours.
The client is suspected of having a pulmonary embolus. Which diagnostic test confirms the diagnosis? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray. 4. Magnetic resonance imaging (MRI).
1. Plasma D-dimer test.
The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms would the nurse look for when assessing the client? 1. Pleuritic chest discomfort and anxiety. 2. Asymmetrical chest expansion and pallor. 3. Leukopenia and CRT <3 seconds. 4. Substernal chest pain and diaphoresis.
1. Pleuritic chest discomfort and anxiety.
The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the physician is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? 1. Gather the needed supplies for the procedure. 2. Obtain a signed informed consent form. 3. Assist the client into a side-lying position. 4. Discuss the procedure with the client.
2. Obtain a signed informed consent form.
The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolus. Which action should the nurse implement first? 1. Administer oxygen ten (10) L via nasal cannula. 2. Place the client in a high Fowler's position. 3. Obtain a STAT pulse oximeter reading. 4. Auscultate the client's lung sounds.
2. Place the client in a high Fowler's position.
Which assessment data would support that the client has experienced a pulmonary embolus? 1. Calf pain with dorsiflexion of the foot. 2. Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade fever.
2. Sudden onset of chest pain and dyspnea.
The 56-year-old client diagnosed with tuberculosis (TB) is being discharged. Which statement made by the client indicates an understanding of the discharge instructions? 1. "I will take my medication for the full three (3) weeks prescribed." 2. "I must stay on the medication for months if I am to get well." 3. "I can be around my friends because I have started taking antibiotics." 4. "I should get a TB skin test every three (3) months to determine if I am well."
2. "I must stay on the medication for months if I am to get well."
The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. 1. Place the client in a low-Fowler's position. 2. Assess chest tube drainage system frequently. 3. Maintain strict bed rest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.
2. Assess chest tube drainage system frequently. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.
The unlicensed nursing assistant is assisting the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? 1. The client's chest tube is below the level of the chest. 2. The nursing assistant has the chest tube attached to suction. 3. The nursing assistant allowed the client out of the bed. 4. The nursing assistant uses a bedside commode for the client.
2. The nursing assistant has the chest tube attached to suction.
Which assessment data indicate that the chest tubes have been effective in treating the client with a hemothorax who has a right-sided chest tube? 1. There is gentle bubbling in the suction compartment. 2. There is no fluctuation (tidaling) in the water-seal compartment. 3. There is 250 mL of blood in the drainage compartment. 4. The client is able to deep breathe without any pain.
2. There is no fluctuation (tidaling) in the water-seal compartment.
While feeding the client diagnosed with aspiration pneumonia, the client becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention would the nurse implement first? 1. Suction the client's nares. 2. Turn the client to the side. 3. Place the client in the Trendelenburg position. 4. Notify the health-care provider.
2. Turn the client to the side.
The client is admitted to the emergency department with chest trauma. When assessing the client, which signs/symptoms would the nurse expect to find that support the diagnosis of pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy bloody sputum and consolidation. 4. Barrel chest and polycythemia.
2. Unequal lung expansion and dyspnea.
The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR 2.8. What action should the nurse implement? 1. Assess the client for abnormal breathing. 2. Prepare to administer vitamin K (AquaMephyton). 3. Administer the medication as ordered. 4. Notify the HCP to obtain an order to increase the dose.
3. Administer the medication as ordered.
Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select all that apply.) a. Age b. Blood pressure c. Respiratory rate d. O2 saturation e. Presence of confusion f. Blood urea nitrogen (BUN) level
ANS: A, B, C, E, F Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 years and older). The other information is also essential to assess but are not used for CURB-65 scoring.
The nurse is preparing to administer medications to the following clients. Which medication would the nurse question administering? 1. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9. 2. Regular insulin to a client with a blood glucose level of 218 mg/dL. 3. Hanging the heparin bag to a client with a PT/PTT of 12.9/98. 4. A calcium channel blocker to the client with a BP of 112/82.
3. Hanging the heparin bag to a client with a PT/PTT of 12.9/98.
The client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority? 1. Administer the oral antibiotic stat. 2. Order the meal tray to be delivered as soon as possible. 3. Obtain a sputum specimen for culture and sensitivity. 4. Have the unlicensed nursing assistant weigh the client.
3. Obtain a sputum specimen for culture and sensitivity.
The charge nurse on a surgical floor is making assignments. Which client should be assigned to the most experienced registered nurse (RN)? 1. The 36-year-old client who has undergone an antral irrigation for sinusitis yesterday and has moderate pain. 2. The six (6)-year-old client scheduled for a tonsillectomy and adenoidectomy this morning who will not swallow medication. 3. The 18-year-old client who had a Caldwell Luc procedure three (3) days ago and has purulent drainage on the drip pad. 4. The 45-year-old client diagnosed with a peritonsillar abscess who requires IVPB antibiotic therapy four (4) times a day.
3. The 18-year-old client who had a Caldwell Luc procedure three (3) days ago and has purulent drainage on the drip pad.
The day shift charge nurse on a medical unit is making rounds after report. Which client should be seen first? 1. The 65-year-old client diagnosed with tuberculosis who has a sputum specimen to be sent to the lab. 2. The 76-year-old client diagnosed with aspiration pneumonia who has a clogged feeding tube. 3. The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%. 4. The 39-year-old client diagnosed with bronchitis who has an arterial oxygenation level of 89%.
3. The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%.
The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis. Which statement indicates the need for radiological evaluation instead of skin testing? 1. The client's first skin test indicates a purple flat area at the site of injection. 2. The client's second skin test indicates a red area measuring four (4) mm. 3. The client's previous skin test was read as positive. 4. The client has never shown a reaction to the tuberculin medication.
3. The client's previous skin test was read as positive.
The client diagnosed with a pulmonary embolus is in the intensive care unit. Which assessment data would warrant immediate intervention from the nurse? 1. The client's ABGs are pH 7.36, PaO2 95, PaCO2 38, HCO3 24. 2. The client's telemetry exhibits occasional premature ventricular contractions. 3. The client's pulse oximeter reading is 90%. 4. THe client's urinary output for the 12-hour shift is 800 mL.
3. The client's pulse oximeter reading is 90%.
The nurse is presenting a class on chest tubes. Which statement describes a tension pneumothorax? 1. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during a central line placement.
3. The injury allows air into the pleural space but prevents it from escaping from the pleural space.
Which statement by the client indicates the discharge teaching for the client diagnosed with a pulmonary embolus is effective? 1. "I am going to use a regular bristle toothbrush." 2. "I will take antibiotics prior to having my teeth cleaning." 3. "I can take enteric-coated aspirin for my headache." 4. "I will wear a medic alert band at all times."
4. "I will wear a medic alert band at all times."
A client is diagnosed with Pneumocystis carinii pneumonia (PCP) secondary to AIDS. Upon assessment for the specific symptoms of PCP, the nurse should expect to find: 1. Dyspnea, fever, nonproductive cough and fatigue. 2. Weight loss, night sweats, persistent diarrhea, and hypothermia. 3. Dysphagia, yellow-white plaques in the mouth and sore throat. 4. Lung crackles, chest pain, and small, painless purple-blue skin lesions.
Ans: 1. Dyspnea, fever, nonproductive cough and fatigue.
The client is admitted with a diagnosis of rule out tuberculosis. Which type of isolation procedures should the nurse implement? 1. Standard precautions. 2. Contact precautions. 3. Droplet precautions. 4. Airborne precautions.
4. Airborne precautions.
The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of "impaired gas exchange." Which would be an expected outcome for this problem? 1. Performs chest physiotherapy three (3) times a day. 2. Able to complete activities of daily living. 3. Ambulates in the hall and back several times during each shift. 4. Alert and oriented to person, place, time, and events.
4. Alert and oriented to person, place, time, and events.
A client who experienced a pulmonary embolus is receiving heparin therapy. The client will now also start receiving sodium warfarin (Coumadin). When the client asks the nurse why both medications are being given, the best response by the nurse is a. "It takes several days for the warfarin to become therapeutic." b. "Most clients go home on both drugs for maximal treatment." c. "The heparin is not working to dissolve the blood clot, so we are adding warfarin." d. "You are right to ask. You are at increased risk of bleeding with both drugs."
ANS: A Administration of sodium warfarin is begun about 3 to 5 days before heparin is stopped to provide a transition to oral anticoagulants. Warfarin has a long half-life and if the heparin was stopped too early, the client would not be protected. It is important to note that heparin does not dissolve the blood clot.
The client has just been diagnosed with a pulmonary embolus. Which intervention should the nurse implement? 1. Administer oral anticoagulants. 2. Assess the client's bowel sounds. 3. Prepare the client for a thoracentesis. 4. Institute and maintain bed rest.
4. Institute and maintain bed rest.
The client has a right-sided chest tube. As the client is getting out of bed it is accidentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.
4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.
The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the LPN? 1. The client with pneumonia who has a pulse oximeter reading of 91%. 2. The client with a hemothorax who has Hgb of 9 mg/dL and Hct of 20%. 3. The client with chest tubes who has jugular vein distention and BP 96/60. 4. The client who is two (2) hours post-bronchoscopy procedure.
4. The client who is two (2) hours post-bronchoscopy procedure.
The client is diagnosed with a pulmonary embolus and is receiving a heparin drip. The bag hanging is 20,000 units /500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour?
880 units/hr
Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway? a. Weak cough effort b. Profuse green sputum c. Respiratory rate of 28 breaths/min d. Resting pulse oximetry (SpO2) of 85%
ANS: A The weak cough effort indicates that the patient is unable to clear the airway effectively. The other data suggest problems with gas exchange and breathing pattern.
A client experiencing severe chest pain from a pulmonary embolism has been medicated for pain but appears anxious and restless. The additional nursing measure that most likely would assist the client in dealing with fear is a. asking the client not to focus on the pain. b. explaining the monitoring devices to the client. c. reassuring the client the pain medication will work soon. d. remaining at the bedside with the client.
ANS: D Emotional support can reduce anxiety and lessen dyspnea. This helps reduce oxygen demand. The nurse should stay with the client and provide calm, efficient nursing care. The other measures are not necessarily wrong, and might work for some clients, but staying in the room and offering a comforting presence is the best alternative.
The nurse is assessing the lab work of a client with a pulmonary embolism. The client's INR is 5.8. The most appropriate action by the nurse is to a. call the physician and ask to increase the Coumadin. b. document the findings as normal and continue care. c. encourage the client to order green leafy vegetables for dinner. d. institute safety precautions for the client.
ANS: D The optimal INR ratio for heparin therapy is 2.5 to 3. A reading of 5.8 is much too high and puts the client at risk for bleeding episodes. The nurse should place the client on safety precautions. The next dose of Coumadin may need to be held or reduced. The client should not alter the amount of green leafy vegetables in the diet because they contain vitamin K, which works to antagonize the effects of Coumadin.
A nurse is drawing a blood sample from a client's central line and the client suddenly becomes dyspneic and complains of chest pain. The priority action by the nurse is to a. obtain blood pressure readings in both arms. b. notify the physician immediately. c. put the client in a left lateral Trendelenburg position. d. terminate the procedure and clamp the central line.
ANS: D This client is probably experiencing a venous air embolism from the open central line. The priority action is to stop the procedure and clamp the line. Then the nurse should position the client in Trendelenburg and rotate the client to the left side to trap the air in the apex of the heart. The nurse can attempt to aspirate the air from the distal port of the catheter. Someone else should notify the physician while the nurse remains with the client.
The nurse is caring for a client with a pulmonary embolism who is receiving heparin and must have an arterial blood gas (ABG) sample drawn. The nurse would arrange to remain in the room to be available to hold pressure on the puncture site for at least a. 1 minute. b. 2 minutes. c. 5 minutes. d. 10 minutes.
ANS: D When invasive studies such as ABGs are necessary, pressure is applied to the site for at least 10 minutes.
A nurse is caring for a hospitalized 10-year-old client who has chest contusions from a motor vehicle accident. The client is on room air and is being monitored by a pulse oximeter. When the nurse enters the room, the pulse oximeter monitor is alarming and is showing an oxygen saturation of 84%. The nurse should immediately: 1. call the physician for an order for arterial blood gases (ABGs). 2. assess the client's level of consciousness and skin color. 3. replace the machine and probe. 4. administer oxygen through a nasal cannula or by mask.
ANSWER: 2 By immediately evaluating the client's mental status and skin color, the nurse can quickly determine whether or not the signal tracing constitutes an emergency or if it is an artifact. An artifact in the pulse oximeter monitoring system can be caused by altered skin temperature, movement of the client's finger, or probe disconnection. Equipment malfunction can also occur. Calling the physician is necessary only if the reading is accurate. Replacing the machine is only necessary if the machine is malfunctioning. Applying oxygen may be necessary if the nurse is unable to determine the client's pulse oximeter reading within a few seconds.
A nurse is teaching a client who is 24 hours post-abdominal surgery how to use an incentive spirometer. Which instructions should the nurse include in the teaching? Select all that apply. 1. Inhale slowly and deeply through mouth. 2. Seal lips tightly around mouthpiece. 3. After inhaling, hold breath for 2-3 seconds. 4. Sit with head of bed down and bed almost flat. 5. Splint incision with pillows. 6. Exhale forcefully, fast, and hard.
Ans: 1, 2, 3, 5
A nurse is planning care for a client admitted with a new diagnosis of persistent atrial fibrillation with rapid ventricular response. Although the client has had no previous cardiac problems, the client has been in atrial fibrillation for more than 2 days. The nurse should anticipate that the HCP is likely to initially order: Select all that apply. 1. Oxygen 2. Immediate cardioversion 3. Administration of amiodarone (Cordarone) 4. Initiation of a IV heparin infusion 5. Immediate catheter-directed ablation of the AV node 6. Administration of a calcium channel antagonist such as diltiazem (Cardizem)
Ans: 1, 3, 4, 6
A nurse approaches a client who needs nasotracheal suctioning. The nurse explains the procedure to the client and washes hands. Which steps should be taken by the nurse when performing nasotracheal suctioning? Prioritize the nurse's actions by placing each step in the correct order. __ Prepare suction equipment; open water-soluble lubricant __ Place finger over suction control port of catheter and suction intermittently while withdrawing the catheter __ Put on sterile gloves __ Lubricate catheter, insert into nare, and advance into pharynx __ When client inhales, advance catheter into trachea __ Pick up suction catheter with dominant hand and attach it to connection tubing __ Place tip into sterile saline container while applying suction to clear secretions from the tubing
Ans: 1, 6, 2, 4, 5, 3, 7
A nurse receives a serum laboratory report for six different clients with admitting diagnoses of chest pain. After reviewing all of the lab reports, in which order should the nurse address each lab value? Prioritize the order in which the nurse should address each of the client's results. __ Troponin T 42 ng/mL (0.0-0.4 ng/mL) __ WBC 11,000 K/uL __ Hgb 7.2 g/dL __ SCr 2.2 mg/dL __ K 2.2 mEq/L __ Total cholesterol 430 mg/dL
Ans: 1, 6, 3, 4, 2, 5
A nurse is caring for a client with renal insufficiency. In addition to an ordered fluid restriction, the client needs strict monitoring of intake and output. Which actions should the nurse plan to include when caring for the client? Select all that apply. 1. Discussing with the client and family the plan of care and fluid restriction. 2. Documenting pureed foods as part of the client's liquid intake. 3. Eliminating counting ice chips as intake because this represents such a small amount of intake. 4. Providing a collection device for measuring the client's urine output. 5. Instructing the family to record any intake they provide to the client on the facility intake record. 6. Encouraging the family to bring favorite food items from home for the client to eat.
Ans: 1. Discussing with the client and family the plan of care and fluid restriction. 4. Providing a collection device for measuring the client's urine output.
A nurse is teaching a client newly diagnosed with chronic stable angina. Which instructions should the nurse incorporate in the teaching session on measures to prevent future angina? Select all that apply. 1. Increase isometric arm exercises to build endurance. 2. Wear a face mask when outdoors in cold weather. 3. Take nitroglycerin before a stressful situation even though pain is not present. 4. Perform most exertional activities in the morning. 5. Avoid straining at stool. 6. Eliminate tobacco use.
Ans: 2, 3, 5, 6
Following a normal chest x-ray for a client who had cardiac surgery, a nurse receives an order to remove the chest tubes. Which intervention should the nurse plan to implement first? 1. Auscultate the client's lung sounds 2. Administer 4 mg morphine sulfate intravenously 3. Turn off the suction to the chest drainage system 4. Prepare the dressing supplies at the client's bedside
Ans: 2. Administer 4 mg morphine sulfate intravenously
A 12-year-old child weighing 50 kg is hospitalized with bacterial pneumonia and an upper respiratory tract infection. The child is allergic to penicillin, azithromycin, and cefazolin sodium. A nurse is reviewing a serum laboratory report for the child before administering newly prescribed medications. Based on the findings of the serum laboratory report, which health-care provider prescription is most important for the nurse to question? 1. Dextrose 5% in 0.25 NaCl with 20 mEq/L KCL at 65 mL/hr 2. Amikacin sulfate (Amikin) 375 mg IVPB q12h 3. Guaifenesin (Robitussin) 50-100 mg q4h prn for cough 4. Acetaminophen (Tylenol) 325-650 mg q4h-6h prn, not to exceed five doses/24 hr
Ans: 2. Amikacin sulfate (Amikin) 375 mg IVPB q12h
A client is hospitalized for heart failure secondary to alcohol-induced cardiomyopathy. The client is started on milrinone (Primacor) and placed on a transplant waiting list. The client has been curt and verbally aggressive in expressing dissatisfaction with the medication orders, overall care, and the need for energy conservation. A nurse should interpret that the client's behavior is likely related to the client's: 1. Denial of the illness. 2. Reaction to milrinone (Primacor). 3. Fear of the diagnosis. 4. Response to cerebral anoxia.
Ans: 3
A nurse is preparing to discharge a 10 year-old male client who is hospitalized with the diagnosis of rheumatic fever. The nurse's top priority during the client's discharge teaching should be: 1. Providing an avenue for verbalization of feelings regarding illness. 2. Providing adequate and appropriate pain medications. 3. Ensuring that the client is aware of activity restrictions and the need for adherence. 4. Emphasizing the need for long-term prophylactic antibiotic therapy.
Ans: 3. Ensuring that the client is aware of activity restrictions and the need for adherence.
A client with a suspected pulmonary embolus receives a ventilation and quantification nuclear medicine (VQ) scan to evaluate regional lung ventilation of airflow and regional lung blood flow. In consulting with a physician, a nurse learns that there is a VQ mismatch. Based on this information, which action should be taken by the nurse? 1. Tell the client that tuberculosis treatment will be needed. 2. Reassure the client that he/she does not have a pulmonary embolus. 3. Explain to the client that further testing will be needed. 4. Inform the client that the test was normal.
Ans: 3. Explain to the client that further testing will be needed.
A nurse is interpreting an ECG rhythm strip for a 2 year-old child with heart failure secondary to a congenital heart defect. In analyzing the rhythm, the nurse notes the measurements of the PR interval is 0.26 seconds, the QRS is 0.08 seconds, and the QT is 0.28. The ventricular rate is 126 bpm. A nurse interprets the rhythm as: 1. Sinus bradycardia 2. Sinus rhythm with a bundle branch block. 3. Sinus rhythm with a first-degree AV block. 4. Sinus tachycardia with a first-degree AV block.
Ans: 3. Sinus rhythm with a first-degree AV block.
A nurse is preparing to admit a client with a confirmed case of tuberculosis. Which action is essential to infection control for this client? 1. Providing a positive-pressure airflow room 2. Wearing gown and gloves when handling the client's stool or urine 3. Using a national institute for occupational safety and health (NIOSH)- approved N95 respirator mask for staff and visitors 4. Keeping the client quarantined in the room until antibiotic therapy has been initiated.
Ans: 3. Using a national institute for occupational safety and health (NIOSH)- approved N95 respirator mask for staff and visitors
A nurse assessing a client hospitalized following a MI, obtains the following vital signs: blood pressure (BP) 78/38 mm Hg, heart rate (HR) 128, respiratory rate (RR) 32. For which life-threatening complication should the nurse carefully monitor the client? 1. Pulmonary embolism 2. Cardiac tamponade 3. Cardiomyopathy 4. Cardiogenic shock
Ans: 4
A client hospitalized for a severe case of pneumonia, is asking a nurse why a sputum sample is needed. The nurse should reply that the primary reason is to: 1. Complete the first of three samples to be collected. 2. Differentiate between pneumonia and atelectasis. 3. Encourage expectoration of secretions. 4. Help select the appropriate antibiotic.
Ans: 4. Help select the appropriate antibiotic.
An initial treatment regimen of isoniazid (Laniazid), rifampin (Rifadin), and ethambutol (Myambutol) are prescribed for a 16-year-old client who has a positive tuberculin skin test. The client confides that she thinks she may have become pregnant since she was diagnosed and asks if she should be taking the medication while pregnant. On which rational should a nurse base a response to the client's question? 1. These drugs cross the placental barrier and treatment should be withheld until the postpartum period. 2. The medications should be taken but the diagnosis is an indication for termination of the pregnancy. 3. The medications should be postponed because the risk is greatly increased in the intrapartum period. 4. The medications should be taken because untreated tuberculosis represents a far greater hazard to a pregnant woman and her fetus than does the treatment of the disease.
Ans: 4. The medications should be taken because untreated tuberculosis represents a far greater hazard to a pregnant woman and her fetus than does the treatment of the disease.
A 60 year-old homeless man has a cough, late-afternoon fever, and night sweats. The patient's response to a PPD skin test is 10 mm. The nurse recognizes that this response indicates that the patient:
d. Has class #3 clinically active tuberculosis
Which nursing actions would most likely help prevent the development of ventilator-associated pneumonia (VAP) in a client who is mechanically ventilated? (Select all that apply.) a. Oral hygiene every 2 hours. b. Elevation of the head of bed at least 20 degrees. c. Proper hand hygiene between clients. d. Routinely remove condensation from ventilator tubing. e. Change ventilator tubing every 12 hours.
Answer 1 is correct because frequent oral hygiene prevents the pooling of oral secretions, which may lead to aspiration. Answer 2 is incorrect because the head of the bed should be elevated to at least 30 to 45 degrees, unless contraindicated, to prevent gastric reflux, which can cause VAP. Answer 3 is correct because washing hands before and after every contact with clients prevents cross-contamination of microorganisms. Answer 4 is correct because draining the condensation prevents the potential for aspiration of the collected fluid. Answer 5 is incorrect because changing the ventilator tubing has not been shown to prevent VAP.
Which nursing measures are aspects of proper tracheostomy care? Select all that apply. a. Securing the twill tape ties on the side of the neck. b. Cleaning or changing the inner cannula at least once a day. c. Inflating the tracheostomy cuff before tracheostomy care. d. Using peroxide and sterile saline to clean around the stoma. e. Suctioning when secretions or adventitious breath sounds are present. f. Ensuring a means of communication with the client.
Answer 1 is correct because positioning the ties on the side of the neck makes it easier and safer to change. Answer 2 is correct because secretions will accumulate on the cannula and need daily cleaning. Answer 3 is incorrect because the cuff should have already been inflated to stabilize the tracheostomy tube. Answer 4 is correct because these solutions are effective in removing the remaining secretions, and reduce the risk of infection. Answer 5 is correct because accumulated secretions interfere with gas exchange. Answer 6 is correct because the inability to make credible speech sounds may be frustrating to the client and increase anxiety. If possible, it is best to establish an alternate means (flash cards, dry erase board) before the tracheostomy.
Assessment of an older adult with pneumonia will often reveal (Select all that apply) a. Anorexia and changes in behavior. b. Headache and difficulty breathing. c. Muscle aches and fever. d. Nonproductive cough and chest pain. e. Afebrile and productive cough.
Answer 1 is correct because the signs of pneumonia are more subtle and subjective and are related to developing sepsis. Answer 2 is incorrect because headache is not common; respiratory rate increases. Answer 3 is incorrect because the older adult typically has no fever with pneumonia. Answer 4 is incorrect because the client may have increased sputum and no chest (pleuritic) pain. Answer 5 is correct because sputum will be increased, causing a productive cough. The older adult often has a subnormal temperature, so that the temperature with an infection is often not elevated.
During the physical assessment of a client diagnosed with a right tension pneumothorax, a nurse would expect to find (Select all that apply.) a. Tracheal shift to the left. b. Tracheal shift to the right. c. Decreased breath sounds on the right side. d. Subcutaneous emphysema on the left chest. e. Increased breath sounds on the left side. f. Point of Maximum Impulse (PMI) shifted further to the left of midline.
Answer 1 is correct because, during a tension pneumothorax, thoracic structures are pushed toward the opposite side. Answer 2 is incorrect because thoracic structures are pushed toward the opposite side of the problem.Since Answer 1 is correct, this answer is wrong. Answer 3 is correct because pneumothorax causes partial or total collapse of the lung; therefore, breath sounds would be diminished or absent. Answer 4 is incorrect because, if present, the subcutaneous emphysema would be in the affected side (i.e., right side). Answer 5 is incorrect because the pressure on the non affected side might result in a decrease, or no change, in breath sounds. Answer 6 is correct because thoracic structures, including the heart, would shift to the left.
A nurse is concerned that the results of a client's recent arterial blood gas (ABG) analysis may be inaccurate. Which factors may affect the accuracy of ABG results? Select all that apply. a. Creatinine level of client that continues to rise. b. Client has been increasingly more confused. c. Sample was drawn 15 minutes after suctioning. d. Absence of an air bubble in the ABG. e. Sample returned to the lab an hour after it was drawn. f. Sample drawn from peripherally inserted central catheter (PICC).
Answer 1 is incorrect because kidney function would affect acid-base balance, but the technique for drawing the sample affects the accuracy of the results or values. Answer 2 is incorrect because confusion does not affect the accuracy of the sample. Answer 3 is correct because blood gases should be drawn at least 20 minutes after suctioning because suctioning removes oxygen. Answer 4 is incorrect because there should not be an air bubble in the sample. A bubble would affect the accuracy. Answer 5 is correct because the blood gas sample should be placed on ice and returned to the laboratory as quickly as possible. Answer 6 is correct because blood from a PICC line is venous blood, not arterial.
Which is the most important initial nursing action for a client with community-acquired pneumonia? a. Maintain IV site used for antibiotic therapy. b. Assess for indications of antibiotic effectiveness. c. Assist with client mobility. d. Assess for pain and treat as ordered.
Answer A is correct because antibiotic therapy is the most important aspect of treatment. Maintaining IV site patency and integrity is a key role for the RN and for the client's recovery. Answer B is incorrect because the antibiotics must be administered through a patent site before effectiveness can be evaluated. Answer C is incorrect because this is not the first action, although mobility is important in improving respiratory function. Answer D is incorrect because IV therapy is the first priority, but the client's comfort is important as pain will affect respiratory status.
While assessing the client who has just had a chest tube placed, the nurse notes fluctuations (tidaling) in the water-seal chamber. The nurse knows that this indicates :a. Expected fluid movement with respiration. b. An air leak. c. Presence of subcutaneous emphysema. d. Appropriate suction level.
Answer A is correct because fluid in the water-seal chamber should fluctuate and move up with inspiration and down with expiration on a newly inserted chest tube. The absence of fluctuations on a newly inserted chest tube must be identified and corrected because it indicates incorrect tube placement, or problems with the chest drainage system. A chest x-ray is always required to determine if the problem is due to incorrect tube placement or if the tube has become dislodged. The chest drainage system should be evaluated for: malfunction due to inappropriate setup, or obstruction of the tubing due to dependent loops filled with fluid, kinked tubing, or the client lying on the tubing. Answer B is incorrect because an air leak is present when there is continuous or intermittent bubbling in the water-seal chamber. Answer C is incorrect because presence of subcutaneous emphysema is assessed by palpating the client's chest around the chest tube insertion site for the presence of air under the skin, which indicates an air leak. Answer D is incorrect because the appropriate suction level is assessed on a wet suction unit by confirming that the fluid level is at the desired mark in the suction control chamber when the suction is turned off.
Following a left pneumonectomy, the optimal position for a client would be: a. In a high Fowler's position. b. Supine with a pillow under the right shoulder. c. Supine with a pillow under the left shoulder. d. Left side-lying to promote expansion of right lung.
Answer A is correct because high Fowler's and turned slightly on the operative side promotes ventilation in the remaining lung. Answer B is incorrect because the supine positioning is incorrect, although the pillow under the right shoulder is appropriate. Answer C is incorrect because supine does not facilitate ventilation of the remaining lung. The client can be positioned on the operative side with a pillow under the right shoulder. Answer D is incorrect because this positioning will contribute to mediastinal shift to the operative side.
Long-term follow-up care is being planned for a school-age child with rheumatic fever before discharge from the hospital. This must include: a. Indefinite antibiotic therapy. b. Immunization against future attacks. c. Cardiac rehabilitation program. d. Home schooling.
Answer A is correct because long-term follow-up care for children with rheumatic fever most frequently includes antibiotic therapy with penicillin or erythromycin on an exact schedule for an indefinite time. Answer B is incorrect because there is no way to immunize against future attacks. Answer C is incorrect because this child will be sent home on restricted activity, and cardiac rehabilitation programs are out of the question at this time. Answer D is incorrect because homeschooling would be fine, but it is not a priority at this time.
Which client has special risk factors that warrant testing for tuberculosis (TB)? a. A 45-year-old Caucasian man who has been homeless for 2 years. b. A 15-year-old Caucasian woman with asthma. c. A 72-year-old woman who is a recent immigrant from Russia. d. A 50-year-old Iowa farmer.
Answer A is correct because people who are homeless are at high risk for TB due to their lack of access to the health-care system and the difficulty health-care providers have in monitoring treatment. In addition, foreign-born individuals (particularly from Southeast Asia and Haiti), older adults, all socioeconomically disadvantaged and medically underserved populations, and individuals in prisons and nursing homes are at risk. Answer B is incorrect because young people with asthma are not necessarily at high risk for TB. Answer C is incorrect because people immigrating from Russia and Europe are not necessarily at high risk for TB. Answer D is incorrect because this person does not fit into a high-risk group.
A client, who is newly diagnosed with tuberculosis, is being seen in a clinic. Current treatment includes isoniazid (INH) and rifampin (Rifadia). During the assessment, the client states that there has been blood in the urine since starting treatment. The best response by a nurse would be: a. "One of your medications changes the color of body fluids." b. "This is expected. There is nothing to worry about." c. "I will send a urine specimen to the lab for analysis." d. "Have you had any pain on urination or more frequent urination?"
Answer A is correct because rifampin changes tears, sweat, saliva, and urine to an orange-red color. This is an expected effect. Answer B is incorrect because this response does not explain the cause or address the client's worry. Answer C is incorrect because this color change is normal. Answer D is incorrect because this change does not indicate a urinary tract infection.
To correctly administer a tuberculin skin test, the nurse would inject 5 TU (tuberculin units) of purified protein derivative (PPD) of tuberculin: a. Intradermally. b. Subcutaneously. c. Intramuscularly. d. Subdermally.
Answer A is correct because the PPD for the tuberculin skin test is injected intradermally on the polar aspect of the forearm. If the test is correctly administered, a pale elevation similar to a mosquito bite should be apparent. Answer B is incorrect because subcutaneous injection is not used for this test. Answer C is incorrect because intramuscular injection is not used for this test. Answer D is incorrect because subdermal injection is not used for this test.
The client comes to the emergency department with complaints of cough and difficulty breathing. The nurse assesses the client and notes decreased breath sounds in the right lower lobe, crackles in the right middle lobe, and exaggerated breath sounds on the left side. The client is most likely exhibiting symptoms of: a. Pneumonia. b. Cardiac tamponade. c. Pulmonary edema. d. Pleural friction rub.
Answer A is correct because the client is exhibiting assessment findings that are consistent with right lung pneumonia, including cough, difficulty breathing, crackles, and decreased breath sounds on the affected side, and increased breath sounds on the unaffected side. Diagnostic studies for pneumonia are: chest x-ray, sputum culture, and bronchoscopy if sputum culture is inconclusive. Answer B is incorrect because assessment findings that would be consistent with cardiac tamponade include decreased/muffled heart sounds, jugular vein distention, and hypotension. Answer C is incorrect because assessment findings that would be consistent with pulmonary edema include bilateral crackles, pink frothy sputum. Answer D is incorrect because assessment findings that would be consistent with pleural friction rub include sharp/stabbing pain and a crackling/rubbing sound on inspiration.
While assessing the client who has a chest tube, the nurse notes that the tubing is kinked between the bed rails. The nurse knows that this places the client at increased risk for: a. Tension pneumothorax. b. Air leak. c. Hemorrhage. d. Cardiac tamponade.
Answer A is correct because the kinked chest tube tubing does not allow for drainage of air or fluid from the pleural space. This will causes pressure to build up and push against the lung, collapsing the lung and shifting it to the unaffected side. The client will experience respiratory difficulty progressing to respiratory distress and tension pneumothorax. The tension pneumothorax causes a precarious drop in blood pressure as the large blood vessels in the thoracic cavity are compressed and the heart does not receive adequate blood volume to pump out. Answer B is incorrect because the kinked chest tube tubing does not allow for drainage of air or fluid from the pleural space, increasing the risk of pneumothorax, not air leak. Answer C is incorrect because kinked chest tube tubing does not allow for drainage of air or fluid from the pleural space, thus increasing the risk of pneumothorax, not hemorrhage. Answer D is incorrect because kinked chest tube tubing does not allow for drainage of air or fluid from the pleural space, increasing the risk of pneumothorax. Cardiac tamponade occurs when there is a fluid collection between the pericardial membrane and the heart muscle, which prevents the heart from pumping effectively.
Which signs and symptoms are often seen in a person with active tuberculosis? a. Fatigue, night sweats, low-grade fever. b. Weight gain, cough, purulent sputum. c. High fever; dry, hacking cough. d. Malaise, epistaxis, headache.
Answer A is correct because the presenting symptoms are vague and "flu-like." Initially, they are nagging and less acute. Answer B is incorrect because weight gain and purulent sputum are not characteristic of active tuberculosis (although cough would be a presenting symptom). Answer C is incorrect because the high fever would likely be associated with a more acute condition (although cough would be a tempting choice). Answer D is incorrect because the headache and nosebleed cannot be linked to the disease pathology.
Which finding should indicate to a nurse that a client has recovered from respiratory acidosis? a. Increasing respiratory rate. b. Increasing serum creatinine. c. Decreasing respiratory rate. d. Increasing serum bicarbonate.
Answer A is correct because the respiratory rate would increase as respiratory function improved. Respiratory acidosis occurs from slow and inadequate ventilation. Answer B is incorrect because an increase in creatinine and poor renal function would lead to metabolic acidosis. Answer C is incorrect because a slow respiratory rate causes CO2 to be retained, which will lead to respiratory acidosis. Answer D is incorrect because bicarbonate increases with respiratory acidosis.
A 65-year-old man with a 45-year history of smoking reports a change in his cough pattern, a nonproductive cough, and generally not feeling well. The chest x-ray reveals an infiltrate. A nurse should suspect: a. Pneumonia. b. Chronic obstructive pulmonary disease (COPD). c. Pulmonary edema. d. Tuberculosis.
Answer A is correct because the symptoms are characteristic of pneumonia. Answer B is incorrect because the client reports a "change." COPD is a chronic condition with sputum production. Answer C is incorrect because the development of pulmonary edema includes frothy sputum. The client indicates a nonproductive cough. Answer D is incorrect because tuberculosis includes a productive cough, fever, sweats, and weight loss.
The priority nursing action for a client admitted with a productive cough, weight loss, and a suspected diagnosis of tuberculosis is: a. Instruction on preventing disease transmission. b. Planning for frequent rest periods. c. Recording accurate intake and output. d. Reviewing current dietary patterns.
Answer A is correct because tuberculosis is an airborne infectious disease. Preventing further spread of the disease would be a priority for care. Covering the mouth when coughing, proper disposal of tissues, and hand washing must be reinforced. Answer B is incorrect because this is an important action after preventing disease transmission. Answer C is incorrect because this is an important action after preventing disease transmission. Answer D is incorrect because this is an important action after preventing disease transmission.
A school-age child experiences the following signs or symptoms of rheumatic fever. The nurse should plan any interventions based on the knowledge that the only one that may result in permanent damage is: a. Sydenham's chorea. b. Migratory polyarthritis. c. Carditis. d. Erythema marginatum.
Answer A is incorrect because Sydenham's chorea is transient and does not leave any permanent effects. Answer B is incorrect because migratory polyarthritis is transient and does not leave any permanent effects. Answer C is correct because carditis can lead to permanent, irreversible cardiac damage, specifically, mitral value stenosis. Answer D is incorrect because erythema marginatum is transient and does not leave any permanent effects.
A child is admitted to the hospital with a second attack of rheumatic fever. In doing an admission assessment on this child, which group of symptoms would the nurse most likely find? a. Petechiae, malaise, and joint pain. b. Chorea, anemia, and hypertension. c. Tachycardia, erythema marginatum, and fever in late afternoon. d. Subcutaneous nodules, dependent edema, and conjunctivitis.
Answer A is incorrect because a child with rheumatic fever does not usually have petechiae. Answer B is incorrect because a child with rheumatic fever does not usually have hypertension. Answer C is correct because the most common symptom in a child with rheumatic fever is tachycardia due to cardiac involvement; in addition, the child may develop a rash, "erythema marginatum," and a characteristic fever, which spikes in the late afternoon. Answer D is incorrect because a child with rheumatic fever does not usually have conjunctivitis.
Which assessment finding would the nurse expect in an 85-year-old with pneumonia? a. A temperature of 102 F. b. An oral temperature of 98 F to 99 F. c. Excessive sweating. d. Increased thirst.
Answer A is incorrect because a decreased or absent febrile response in infection is most likely. Answer B is correct because a normal oral temperature for an older adult is 96.9 F to 98 F. There would only be a slight elevation indicative of infection. Answer C is incorrect because there is less perspiration due to a decline in sweat glands. Answer D is incorrect because the thirst response is decreased due to age-related changes affecting the hypothalamus.
When would a client with community-acquired pneumonia be clinically stable enough to change from IV antibiotics to oral antibiotics? When the client has a(n): a. Temperature of 96.8 F or lower. b. O2 saturation of at least 80%. c. Systolic blood pressure that stays at 90 mm Hg or higher. d. Heart rate that remains at 120 beats/min or lower.
Answer A is incorrect because a temperature this low is subnormal and would not be an accurate indication of antibiotic effectiveness. Answer B is incorrect because the O2 saturation should be 90% or higher. Answer C is correct because a systolic BP of 90 mm Hg or higher signals stability of the client. Answer D is incorrect because a heart rate of 120 is high. A rate of 100 or lower would indicate client stability.
A client, newly diagnosed with active tuberculosis infection, is 12 weeks pregnant. In providing anticipatory guidance for this client, the nurse knows the physician will most likely recommend that: a. The client should have an abortion as soon as possible. b. The client should start isoniazid (INH) and rifampin after giving birth. c. The client should start INH and rifampin now. d. The client should start INH and pyrazinamide after the first trimester.
Answer A is incorrect because a therapeutic abortion is not indicated for a client with active tuberculosis infection. Answer B is incorrect because the client should start medication as soon as possible. Waiting for 6 months until birth is too long a time period. Answer C is correct because the client needs to start treatment immediately. These medications are the primary medications recommended for use in pregnancy. Answer D is incorrect because the client needs to begin medication as soon as the diagnosis is made, and pyrazinamide is not recommended in pregnancy.
When performing a cardioversion on a client who is unconscious and in ventricular tachycardia, it is most important to: a. Place alcohol pads on the client's chest to improve electrical conduction. b. Premedicate the client with diazepam so the cardioversion is less uncomfortable. c. Administer a bolus of lidocaine intravenously. d. Make sure all personnel, including the person doing the cardioversion, stand away from the client's bed to avoid electric shock.
Answer A is incorrect because alcohol can ignite when electric current is passed through it. Answer B is incorrect because it is inappropriate to further sedate a client who is unconscious. Answer C is incorrect because cardioversion is the first treatment of choice for a client who is unconscious. Answer D is correct because standing away from the bed while a shock is delivered prevents health-care personnel from receiving a shock.
The client returned from thoracic surgery 3 hours ago with two chest tubes placed at 20 cm suction. Which finding would be considered abnormal? a. Bubbling in the suction control chamber. b. 350 mL of sanguineous drainage in the drainage chamber over the last 3 hours. c. No fluctuation in the water-seal chamber. d. Small amount of sanguineous drainage on the chest tube dressing.
Answer A is incorrect because bubbling in the suction control chamber indicates that suction is present to remove air and fluid from the chest and is expected after thoracic surgery. Answer B is incorrect because sanguineous drainage from the chest tubes is expected after thoracic surgery, as long as it does not exceed 200 mL/hr. Answer C is correct because some fluctuation in the water-seal chamber is expected after thoracic surgery. Absence of fluctuation indicates a problem. Answer D is incorrect because a small amount of drainage on the dressing immediately after surgery is not unusual.
A client presents to an emergency department complaining of pain on the left side and shortness of breath. Vital signs are: BP 140/80 mm Hg; P 110, and R 44. The client's ABG results are: pH 7.5, PaCO 30 mm Hg and HCO3 22 mEq/L, SaO2 86%, PaO2 64 mm Hg. A nurse should recognize that these symptoms are consistent with: a. Possible trauma to the chest wall. b. Possible pneumonia. c. Possible pulmonary embolism. d. Possible acute pulmonary edema.
Answer A is incorrect because chest trauma would likely result in respiratory acidosis (pH below 7.35 and CO2 above 45), not alkalosis. Answer B is incorrect because pneumonia would likely result in respiratory acidosis (pH below 7.35 and CO2 above 45), not alkalosis. Answer C is correct because the ABGs show respiratory alkalosis (pH above 7.45 and CO2 below 35) and a problem with hypoxemia (O2 Sat below 96%) from rapid respirations. The vital signs and symptoms are consistent with a pulmonary embolism, which interferes with exchange of O2 Client hyperventilates, blowing off CO2. Answer D is incorrect because pulmonary edema would likely result in respiratory acidosis (pH below 7.35 and CO2; above 45), not alkalosis.
To safely transport a client who has chest tube drainage to the x-ray department to assess the degree of lung reexpansion, the nurse would: a. Remove the chest tubes, immediately covering the incision site with a sterile petrolatum gauze to prevent air from entering the chest. b. Disconnect the drainage bottles from the chest tubes, covering the catheter tip with a sterile dressing to prevent contamination. c. Send the client to x-ray with the chest tube clamped but still attached to the drainage system to prevent air from entering the chest wall if the bottles are accidentally broken. d. Send the client to x-ray with the chest tube attached to the drainage system, taking precautions to prevent interruption in the system.
Answer A is incorrect because chest tubes are not removed to facilitate transportation of the client; they are removed only after the physician is satisfied with the degree of reexpansion. Answer B is incorrect because removing the chest tubes from the suction drainage system will result in an equalization of intrapleural pressures with atmospheric pressures, thus increasing the risk of pneumothorax. Answer C is incorrect because current practice precludes the clamping of the chest tubes. It is believed that clamping increases the risk of a tension pneumothorax because air may enter the intrapleural space during inspiration but cannot escape during expiration. Answer D is correct because normal functioning of chest tubes is maintained, and the drainage system is transported below the level of the chest.
A client is admitted to a hospital for pneumonia and it is discovered that the client also has a stage II pressure ulcer. When planning a diet for this client, what foods should a nurse encourage the client to eat?a. Fruits and vegetables. b. Whole grains. c. Milk, yogurt, and cheese. d. Lean meats and low-fat milk.
Answer A is incorrect because fruits and vegetables are mostly carbohydrates. Answer B is incorrect because whole grains are not complete proteins. Answer C is incorrect because this choice has a lot of fats as well as carbohydrates. Answer D is correct because proteins help to repair and build cells.
The number one priority during the nurse's admission assessment of a school-age child with rheumatic fever is the child's: a. Weight. b. Apical pulse rate. c. Developmental level. d. ESR.
Answer A is incorrect because growth deserves secondary consideration after checking the apical pulse. Answer B is correct because carditis is the only manifestation of rheumatic fever that can lead to permanent damage; the best way to evaluate a child for the presence of carditis is to monitor the apical pulse at least q4h. Answer C is incorrect because development deserves secondary consideration after checking the apical pulse. Answer D is incorrect because the erythrocyte sedimentation rate (ESR) deserves secondary consideration after checking the apical pulse.
A nurse is reading the results of a tuberculosis (TB) skin test on a 72-year-old client who has never had a TB skin test. There is no induration around the injection site. The nurse should document the test as negative and: a. State that the client does not have TB. b. Have the client repeat the skin test in 2 weeks. c. Schedule the client for a follow-up chest x-ray. d. Start the client on prophylactic TB medications because the client is in a high-risk group.
Answer A is incorrect because hypersensitivity-type immune response diminishes as a normal consequence of aging, so the client who is elderly may test false negative. Answer B is correct because the client who is elderly may test as false negative because of diminished hypersensitivity-type immune response. It is best to do the two-step TB skin test and have the client repeat the test 1 to 3 weeks after the first test. If the second skin test is still negative, then the client can be informed that he or she does not have TB. If the second test is positive, then the client should receive a follow up chest x-ray and prophylactic treatment. Answer C is incorrect because it is not necessary to subject the client to the cost and risk of a chest x-ray after one skin test. A better response would be to have the client repeat the skin test in 1 to 3 weeks and base any follow-up on the results of the second skin test. Answer D is incorrect because, even though the client who is elderly may be at increased risk for TB, the client should not be started on medications until a second skin test or chest x-ray indicates a need.
The incidence of tuberculosis in the older adult is significantly increased among individuals who: a. Are physically inactive. b. Are cigarette smokers. c. Have received the BCG vaccine. d. Reside in institutions.
Answer A is incorrect because inactivity does not increase susceptibility. The client needs to be in close contact with someone who has the disease. Answer B is incorrect because smoking does not increase susceptibility, but the potential for lung damage may be greater. Answer C is incorrect because recipients of BCG should be less likely to contract the infection. Answer D is correct because the spread of the infection increases in crowded close living conditions since TB is spread from person to person by airborne droplets from talking, coughing, sneezing, laughing, or singing.
A client is in the emergency department with a pneumothorax secondary to a gunshot wound. The client complains of shortness of breath and exhibits tracheal and mediastinal shifts to the left. For what procedure should the nurse prepare? a. Intubation with an endotracheal tube. b. Insertion of a closed chest drainage tube. c. Paracentesis. d. MRI of the chest.
Answer A is incorrect because intubating the client is not yet necessary. The tracheal and mediastinal shifts should be managed first. Answer B is correct because tracheal and mediastinal shifts are hallmarks of tension pneumothorax, a life-threatening condition that requires immediate treatment with closed chest drainage. Answer C is incorrect because a paracentesis would be performed to drain the peritoneal cavity. Answer D is incorrect because the tracheal and mediastinal shifts indicate tension pneumothorax, which is an emergency and should be treated immediately.
The client is having a central line inserted into the right subclavian vein. Which assessment should be reported to the physician during the procedure? a. Dark red blood flowing briskly from the catheter hub just prior to attaching the IV tubing. b. Coughing. c. Mild pain at the insertion site. d. Sinus rhythm on the monitor.
Answer A is incorrect because it is expected that venous blood will flow briskly from the catheter hub just before the tubing is attached. This is an indicator that the catheter is correctly placed in a central vein. Answer B is correct because coughing may indicate pneumothorax from the insertion procedure. Answer C is incorrect because mild pain at the insertion site, particularly after the local anesthetic has worn off, is not unusual. Answer D is incorrect because sinus rhythm is normal.
Which nursing action is appropriate in the care of a client admitted with pneumonia who had a right mastectomy 3 years ago? a. Check right radial pulse every 4 hours. b. Start an IV on the left forearm. c. Keep the right arm below heart level. d. Avoid range of motion on right arm.
Answer A is incorrect because neither the mastectomy nor the pneumonia puts the client at risk for problems with arterial circulation. It is not necessary to do frequent pulse checks. Answer B is correct because, during breast surgery, lymph nodes are removed to rid the body of spreading cancer. This leaves the distal tissue at risk for swelling and infections. IV catheters, carrying a risk of infection, should be placed in the opposite arm. Answer C is incorrect because lymph nodes may have been removed from the right axillary area with the mastectomy; the client is at risk for arm swelling. Raising the arm is permitted and may help minimize swelling. Answer D is incorrect because movement of the right arm will help promote venous return in this arm with limited lymphatic damage.
When auscultating heart sounds, the nurse knows that the first heart sound is best heard: a. Using the bell of the stethoscope. b. With the client lying on the right side. c. At the second intercostal space, right sternal border. d. At the fifth intercostal space, left sternal border.
Answer A is incorrect because normal heart sounds are best heard using the diaphragm of the stethoscope. The bell is used when auscultating for extra heart sounds and murmurs. Answer B is incorrect because right side-lying is not an appropriate position for auscultating heart sounds.Answer C is incorrect because the second heart sound, is best heard at the second intercostal space, right sternal border. Answer D is correct because the closing of the mitral and tricuspid valves, which constitute the sound, is best heard at the fifth intercostal space, left sternal border.
A school-age child with rheumatic fever develops heart failure and is placed on digoxin, Lasix, and potassium. The chief purpose for giving potassium is to: a. Enhance the cardiogenic effect of digoxin. b. Potentiate the diuretic action of Lasix. c. Prevent hypokalemia. d. Pharmacologically induce hyperkalemia.
Answer A is incorrect because potassium supplements are not administered to enhance the cardiogenic effect of digoxin. Answer B is incorrect because potassium supplements are not administered to potentiate the diuretic action of Lasix. Answer C is correct because children receiving digoxin in addition to Lasix are particularly prone to developing hypokalemia, which can result in digoxin toxicity and potentially fatal cardiac dysrhythmias. Potassium supplements are frequently administered to avoid this problem rather than for any of the other reasons cited here. Answer D is incorrect because potassium supplements are not administered to pharmacologically induce hyperkalemia.
The most important information to include when teaching a client who recently began antituberculosis drugs for a tuberculosis (TB) skin test conversion is: a. Effect of prednisone on urine color. b. Use of the incentive spirometer tid for congestion. c. Importance of taking anti-TB drugs for several months. d. Repeating skin test 30 days after the start of therapy.
Answer A is incorrect because prednisone is not a drug of choice for TB and it has no effect on urine color. Answer B is incorrect because using the spirometer, if needed, is not the most important aspect of TB treatment. Answer C is correct because drug therapy is the only effective treatment for TB. Clients often discontinue medications when they begin to feel better. The client may appear to be symptom-free but the organism is still present. Answer D is incorrect because initial treatment is daily doses of combined drug therapy for a minimum of 6 to 12 months. Sputum culture, not a repeat skin test, and the absence of symptoms would be used to determine treatment effectiveness.
A nurse tells a client that a positive reaction to a tuberculosis (TB) test will be determined by: a. The appearance of redness after 24 hours. b. The size of the induration 48 hours after the test. c. The diameter of the reddened area at the site. d. The length of time it takes before redness or induration appears.
Answer A is incorrect because redness alone is not an indication of a positive test. Also, the reaction is assessed at 48 hours after testing, not after 24 hours. Answer B is correct because the presence of a positive TB test is determined by the size of the induration. Induration of 10 mm or more is a positive reaction. Answer C is incorrect because redness is not the indicator of a reaction. The diameter of the induration (raised area) is important. Answer D is incorrect because the test is not read before 48 hours regardless of when redness or induration appears.
Which side effect(s) from the combination therapy of isoniazid and rifampin should a client report immediately? a. Paleness of conjunctiva and oral mucosa. b. Dark urine and pale-colored stool. c. Blood in the urine. d. Decrease in hearing ability.
Answer A is incorrect because these symptoms would be indicative of anemia. Answer B is correct because antifungal agents can cause liver damage, which results in obvious jaundice and the disruption of normal bile flow. Answer C is incorrect because blood in the urine would indicate a bladder or kidney problem, which is not a side effect of these drugs. Answer D is incorrect because ototoxicity more often occurs from other antituberculosis drugs in the aminoglycoside classification (e.g., streptomycin), although ototoxicity can occur from isoniazid or rifampin.
A client with a past history of rheumatic heart disease is in the third trimester of her first pregnancy. She is asking the nurse what she should expect in labor. The best reply by the nurse would be: a. Plan on a natural childbirth because regional anesthesia in labor has significant cardiovascular risks. b. Because an episiotomy may cause excessive bleeding, she should prepare for strong pushing efforts. c. Excessive anxiety should be avoided in labor; therefore, she will be medicated and her family will stay in the waiting room. d. To reduce the burden on her cardiovascular system, she should practice breathing and relaxation exercises.
Answer A is incorrect because regional anesthesia is often used to avoid cardiovascular strain from painful contractions and pushing. Answer B is incorrect because excessive pushing is avoided in order to reduce cardiovascular strain. Answer C is incorrect because strong emotional support by the family is needed in labor to enhance relaxation and to reduce cardiovascular strain from excessive fear and anxiety. Answer D is correct because breathing and relaxation exercises are very important in reducing cardiovascular strain from fear and anxiety, and enhancing the ability to cope with contractions.
A client with chronic sinusitis has had pneumonia 3 times in the last year. The nurse should suggest: a. Saltwater gargle. b. Cool humidifier. c. Classic antihistamines such as diphenhydramine. d. Oral corticosteroids.
Answer A is incorrect because saltwater gargles are helpful for pharyngitis, but not sinusitis. Answer B is correct because humidification helps liquefy secretions in the sinus cavities, which reduces the risk for bacterial infection. Answer C is incorrect because classic antihistamines make secretions more viscous, and consequently more difficult to get rid of. Answer D is incorrect because corticosteroids in the form of nasal sprays are preferred for treating and preventing sinusitis.
Two hours ago the client had a left thoracotomy with a lobe resection. The sanguineous drainage in the chest tube collection chamber is 325 mL. The nurse recognizes that this is: a. Normal chest tube drainage. b. Indicative of a pneumothorax. c. Chyle drainage. d. A sign of hemorrhage.
Answer A is incorrect because sanguineous chest tube drainage in the client who is postoperative after a thoracotomy should be less than 100 mL/hr. Answer B is incorrect because pneumothorax occurs when there is air between the visceral and the parietal pleura, which causes compression of the lung and results in acute respiratory distress. Answer C is incorrect because chyle drainage is a milky color that results from disruption of the lymphatic drainage system. Answer D is correct because sanguineous drainage of greater than 100 mL/hr in the client who is in the immediate postoperative period following a thoracotomy indicates hemorrhage. The physician should be notified immediately.
The best roommate for a 9-year-old girl with rheumatic fever would be: a. An 8-year-old girl with impetigo. b. A 9-year-old girl with a tonsillectomy. c. A 10-year-old girl with a concussion. d. An 11-year-old girl with a fractured elbow in skeletal traction.
Answer A is incorrect because the child with impetigo, caused by streptococcus, would be a most unsatisfactory roommate for this child, because she might reinfect her with strep. Answer B is incorrect because the child with a tonsillectomy will most likely be in the hospital for a very short time and will be out of bed. Answer C is incorrect because the child with a concussion will most likely be in the hospital for a very short time and will be out of bed. Answer D is correct because a child with rheumatic fever will be in the hospital for a relatively longer time and will be confined to bed most of the time. The ideal roommate would be another child of the same sex and same developmental level who will also be in the hospital for some time and confined to bed. The best choice is the young girl with the fractured elbow, who will be in skeletal traction and also on bedrest.
he nurse caring for the client who has just undergone a left pneumonectomy knows that the client should be positioned on: a. The back with the head of the bed flat. b. The left side with the head of the bed flat. c. The left side with the head of the bed elevated. d. The right side with the head of the bed elevated.
Answer A is incorrect because the client should have the head of the bed elevated to facilitate ventilation. Answer B is incorrect because the client should have the head of the bed elevated to facilitate ventilation. Answer C is correct because this position facilitates ventilation of the remaining right lung. The client should be turned slightly to the left side with head elevated, but avoid extreme left lateral positioning as mediastinal shift may occur. Answer D is incorrect because the client should not be positioned with the remaining right lung dependent.
Client teaching on how long the medication for TB should be taken would include: a. Until the client feels better. b. Daily for at least 9 months. c. Until the sputum culture is negative. d. For the rest of the client's life.
Answer A is incorrect because the client will feel better soon after drug therapy is started, but must take the drug long after physical improvement results. Answer B is correct because total destruction of the infection takes at least 9 months, if not longer. Answer C is incorrect because a negative culture occurs in 2 months; however, the disease process can reactivate if drug therapy is stopped prematurely. Answer D is incorrect because, although some pathologic changes with TB may be difficult to treat, lifelong therapy is not required.
Discharge teaching for a client recently hospitalized with pneumonia who has a complement deficiency should include: a. "Take the full course of the prescribed diphenhydramine (Benadryl)." b. "Report early any signs of infection to the health-care provider." c. "Eat a diet high in protein to improve resistance." d. "Avoid meningococcal, pneumococcal, and influenza vaccinations."
Answer A is incorrect because the deficiency predisposes the client to infection or an autoimmune disease, not an allergic reaction. Answer B is correct because clients with complement deficiency typically have either an increased susceptibility to bacterial infections or increased likelihood of an autoimmune disease. Answer C is incorrect because no specific diet is known to improve complement deficiencies. Answer D is incorrect because it is important to protect from infection or the seriousness of the infection. Vaccinations would be one way to minimize the risk of infection.
A client with a spontaneous pneumothorax has had a chest tube for 3 days. On morning rounds, the physician clamped the chest tube to determine the client's readiness to have the chest tube discontinued. Two hours after having the chest tube clamped, the client began to have difficulty breathing. What action should the nurse take first? a. Notify the physician. b. Unclamp the chest tube. c. Assess the client for subcutaneous emphysema. d. Place the client on 2-L nasal cannula oxygen.
Answer A is incorrect because the first priority is to remain with the client and address the breathing difficulty by unclamping the chest tube clamp. The physician should be notified as priority number 4 in this answer sequence. Answer B is correct because the chest tube should be immediately unclamped. The client still has an air leak that is causing a buildup of air in the pleural space, collapsing part of the lung, and causing breathing difficulty. The clamp must be removed from the chest tube immediately to allow this air to escape and the lung to reexpand. Answer C is incorrect because the first priority is to address the breathing difficulty by unclamping the chest tube clamp. The client should then be assessed for the presence of new or expanded subcutaneous emphysema, which would indicate an air leak. This is priority number 3 in this answer sequence. Answer D is incorrect because the first priority is to address the breathing difficulty by unclamping the chest tube clamp. The client should be placed on 2-L nasal cannula oxygen as priority number 2 in this answer sequence.
If fluctuation (tidaling) in the water-seal compartment of a closed chest drainage system has stopped, a nurse should: a. Increase wall suction above 20 cm. b. Raise the apparatus above the chest to move the fluid. c. Ask the client to cough and deep breathe. d. Vigorously strip the tube to dislodge the clot.
Answer A is incorrect because the level of wall suction does not affect the water seal. This pressure enhances drainage. Answer B is incorrect because closed chest drainage should always remain below the level of the heart. Answer C is correct because this will change the intrapleural pressure and reestablish suctioning. Answer D is incorrect because stripping a chest tube may cause trauma to the lung.
A client with chest tubes returns to the unit. The first nursing measure concerning the closed chest drainage system is: a. Milking the tubing to prevent accumulation of fibrin and clots. b. Raising the bottle to bed height to accurately assess the meniscus level. c. Attaching the chest tubes to the bed linen to ensure that airflow and drainage are unhindered by kinks. d. Marking the time and the amount of drainage in the collection bottle.
Answer A is incorrect because the milking of chest tubes is a matter of debate at this time. Although the process of stripping or milking does assist in the removal of fibrin and clots from the chest tubes, compression of the tubes also increases intrapleural pressures by preventing the movement of air and fluid. Whether the chest tubes are milked or not will depend on institutional or individual physician's policies. Answer B is incorrect because the drainage system is always kept in a dependent position to maintain gravity flow of air and fluids. Answer C is incorrect because the nurse's second measure is to secure the tubes to the bed linen to prevent kinking or unnecessary looping of the drainage tubes, which would hinder the flow of air and fluid. Answer D is correct because the first nursing measure should be to mark the time and the amount of drainage in the collection bottle to ensure a baseline measurement for further observations.
When entering the client's room, the nurse notices a flat line on the client's electrocardiogram (ECG) monitor and the ECG alarm is sounding. What should the nurse do first? a. Call a code. b. Assess the client for responsiveness. c. Notify the physician STAT. d. Begin CPR.
Answer A is incorrect because the nurse should first assess the client before instituting emergency procedures. Answer B is correct because the nurse should first assess the client to determine if an emergency actually exists, or if one of the ECG leads has simply fallen off. Answer C is incorrect because the nurse has no pertinent data regarding the client's actual condition at this time. Answer D is incorrect because checking for responsiveness is always the first step in cardiopulmonary resuscitation (CPR).
When auscultating heart sounds, the nurse detects an irregular rhythm. The nurse should first: a. Call for a STAT electrocardiogram. b. Reposition the client to a left side-lying position, and auscultate further. c. Compare the apical pulse to the radial pulse. d. Prepare to administer lidocaine intravenously.
Answer A is incorrect because there is no apparent emergency in this situation. The nurse should continue with the assessment. Answer B is incorrect at this time. Auscultating heart sounds while the client is lying on the left side often provides useful information about extra heart sounds, but will not provide useful information about the irregularity. Answer C is correct because it is appropriate to compare apical and radial pulses when an irregular rhythm is detected to determine if there is a pulse deficit. Answer D is incorrect because the type of irregularity is unknown and it would be premature to treat until more data are gathered.
The nurse notes that the client's electrocardiogram (ECG) has a rate of 78 bpm, normal P waves that precede each QRS complex, P-R intervals of 0.16 seconds, and a regular pattern of shortening and lengthening of P-P and R-R intervals. The nurse should: a. Notify the physician STAT. b. Call for a STAT 12-lead ECG. c. Prepare the client for a cardiac catheterization. d. Document the client as having sinus arrhythmia.
Answer A is incorrect because there is no emergency in this situation. The characteristics described are consistent with sinus arrhythmia. Answer B is incorrect because there is no emergency in this situation. The characteristics described are consistent with sinus arrhythmia. Answer C is incorrect because the characteristics described do not warrant cardiac catheterization. Answer D is correct because the characteristics described are consistent with sinus arrhythmia, a common and non-life-threatening arrhythmia.
A nurse should anticipate that the chest tube for a client recovering from a pneumothorax will be removed when: a. Chest drainage decreases to 50 mL in 24 hours. b. Chest x-ray shows atelectasis has resolved. c. Water-seal chamber no longer fluctuates with breathing. d. Breath sounds are present bilaterally in apical lobes.
Answer A is incorrect because there may have been little drainage if the chest drainage system was removing air, not blood. There should be minimal drainage before removal also. Answer B is incorrect because a pneumothorax is a collapse of the lung, partial or complete, not a collapse of alveoli. Answer C is correct because the cessation of fluctuation in the water-seal chamber when the chest drainage system is no longer attached to suction is an indication of re-expansion. A chest x-ray would also be indicated. Answer D is incorrect because presence of breath sounds would need to be in all lobes, and particularly in the area of lung collapse.
A school-age child with rheumatic fever complains of severe joint pains in the knees and ankles. The best method to provide relief would be for the nurse to: a. Give a warm bath or shower. b. Apply splints to the affected joints. c. Refer the child to physical therapy. d. Place a bed cradle over the child's legs.
Answer A is incorrect because this child is most likely on bedrest, thus making a bath or shower out of the question. Answer B is incorrect because splints are unnecessary since this type of arthritis causes no permanent deformities. Answer C is incorrect because a referral to physical therapy is unnecessary since this type of arthritis causes no permanent deformities. Answer D is correct because, for a child experiencing migratory polyarthritis secondary to rheumatic fever, even the weight of a single sheet can cause excruciating pain; therefore, a bed cradle will help keep the linens off the child's joints and provide symptomatic relief.
A client with a tracheotomy just pulled out the tracheal tube. Which action by a RN is correct? a. Call the respiratory therapist to reinsert the tracheal tube. b. Get a hemostat to open the tracheotomy, and then try to reinsert the tube. c. Give 100% O2 by mask over the stoma opening. d. Place mouth to stoma and ventilate every 5 seconds.
Answer A is incorrect because this delays reestablishing the airway. Answer B is correct because keeping the airway open is most important. Concern for contamination of the tube can be addressed after a patent airway is established. Answer C is incorrect because keeping the airway open is most important. Answer D is incorrect because reinserting the tracheostomy tube is a more effective way to ventilate the client.
In doing a child's admission assessment, which signs and symptoms should a nurse recognize as most likely related to rheumatic fever? a. Vomiting and diarrhea. b. Arthralgia and muscle weakness. c. Conjunctivitis and red, cracked lips. d. Bradycardia and hypotension.
Answer A is incorrect because vomiting and diarrhea are not part of the diagnostic criteria for rheumatic fever and are symptoms common to many other illnesses. Answer B is correct because symptoms of rheumatic fever include muscle weakness and arthralgia. Answer C is incorrect because together these are symptoms of Kawasaki disease, not rheumatic fever. Answer D is incorrect because children with rheumatic fever are likely to experience tachycardia. In addition, hypotension is not part of the diagnostic criteria for rheumatic fever.
While a client is getting out of bed, the chest tube catches on the night stand and is pulled out. What should a nurse do first? a. Cover the opening with sterile gauze. b. Hold client's gown over opening. c. Put the client back to bed. d. Call the MD for help.
Answer A is incorrect because, although plausible, gauze is not occlusive and may not be readily available. Answer B is correct because the priority is to prevent air from entering the chest cavity with the most occlusive method. (Gloves might be available, but time is critical.) Answer C is incorrect because it would take too much time to reposition the client in bed. Cover the opening immediately, then put the client to bed. Answer D is incorrect because the best answer requires action by the nurse, not the physician.
Which person should be restricted from visiting a client with TB until at least 2 weeks of drug therapy has been completed? a. The client's 25-year-old son. b. The client's 3-year-old granddaughter. c. The client's 74-year-old mother. d. The client's middle-aged neighbor.
Answer A is incorrect because, unless the person is debilitated, is taking steroids, or is immunosuppressed, there is no restriction. Answer B is correct because infants and children under age 5 are susceptible to TB. Answer C is incorrect because, unless the person is debilitated, is taking steroids, or is immunosuppressed, there is no restriction. Answer D is incorrect because, unless the person is debilitated, is taking steroids, or is immunosuppressed, there is no restriction.
The nurse needs to take a client with active respiratory tuberculosis (TB) to radiology for a chest x-ray. Before leaving the client's room, the nurse should: a. Put on a HEPA mask. b. Put a HEPA mask on the client. c. Put a gown and gloves on the client. d. Call ahead to radiology to let them know the nurse is coming with the client.
Answer A is incorrect because, while HEPA masks are effective at blocking the transmission of TB, the mask should be placed on the client. Answer B is correct because placing a HEPA mask on the client will effectively prevent the transmission of TB while the client moves through the hospital. Answer C is incorrect because TB is transmitted via airborne droplets from the respiratory system. A gown and gloves will not prevent airborne transmission. Answer D is incorrect because, although it may be courteous to inform the radiology department that the client is coming, the best measure to prevent transmission of TB while in radiology is to place a HEPA mask on the client.
A male client confides to a clinic nurse that he is no longer dyspneic after receiving his new St. Jude's heart valve. He wants to have a vasectomy so that he can enjoy sexual intercourse again without the fear of his wife becoming pregnant. What is the nurse's best response? 1. "That's probably a good idea. The life expectancy after heart valve replacement is 10-15 years." 2. "You seem relieved that the heart valve replacement was successful and that you can enjoy a normal life again." 3. "If you have cardiac symptoms such as dyspnea during sexual intercourse you can take a nitroglycerin tablet before sexual activity to prevent symptoms." 4. "Be sure to inform the physician that you have an artificial heart valve so you are given antibiotics as a preventative measure before the procedure."A
Answer: 4
A patient with a tricuspid valve disorder will have impaired blood flow between the A. vena cava and right atrium. B. left atrium and left ventricle. C. right atrium and right ventricle. D. right ventricle and pulmonary artery.
C. right atrium and right ventricle.
A 61-year-old woman who is 5'3 and weighs 125 pounds (57 kg) tells the nurse that she has a glass of wine two or three times a week. The patient works for the post office and has a 5-mile mail-delivery route. This is her first contact with the health care system in 20 years. Which of these topics will the nurse plan to include in patient teaching about cancer? (Select all that apply) a. Alcohol use b. Physical activity c. Body weight d. Colorectal screening e. Tobacco use f. Mammography g. Pap testing h. Sunscreen use
D,F,G,H The patient's age, gender, and history indicate a need for teaching about or screening or both for colorectal cancer, mammography, pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy.
A teenage gang member came to the emergency room with occlusive dressing over the wound, having a hard time breathing
Remove dressing
Heparin
Should be on a pump
Patient was complaining of pain while coughing what should the nurse do?
Splint the abdomen with a pillow
Break in water seal in chest tube what should the nurse have handy?
Sterile water
The nurse recognizes that the goals of teaching regarding the transmission of TB have been met when the patient with TB: a. Covers the mouth and nose with a tissue when coughing or sneezing. b. Wears a mask when in contact with others. c. Boils dishes and personal items between use. d. Reports daily to the public health department.
a. Covers the mouth and nose with a tissue when coughing or sneezing.
Which nursing responsibilities are priorities when caring for a patient returning from a cardiac catheterization (select all that apply)? a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses c. Assisting the patient to ambulate to the bathroom to void d. Informing the patient that he will be sleepy from the general anesthesia e. Instructing the patient about the risks of the radioactive isotope injection
a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses
A patient is diagnosed with mitral stenosis and new-onset atrial fibrillation. Which interventions could the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) a. Obtain and record daily weight b. Determine apical-radial pulse rate c. Observe for overt signs of bleeding d. Teach the patient how to get a Medic Alert device e. Obtain and record vital signs, including pulse oximetry.
a. Obtain and record daily weight c. Observe for overt signs of bleeding e. Obtain and record vital signs, including pulse oximetry.
Which patients have the greatest risk for aspiration pneumonia? (Select all that apply) a. Patient with seizures. b. Patient with head injury. c. Patient who had thoracic surgery. d. Patient who had a myocardial infarction. e. Patient who is receiving nasogastric tube feeding.
a. Patient with seizures. b. Patient with head injury. e. Patient who is receiving nasogastric tube feeding.
The nurse notes tidaling of the water level in the water-seal chamber in a patient with closed chest tube drainage. The nurse should a. continue to monitor the patient. b. check all connections for a leak in the system. c. lower the drainage collector further from the chest. d. clamp the tubing at a distal point away from the patient.
a. continue to monitor the patient.
Which is a priority nursing intervention for a patient during the acute phase of rheumatic fever? a. giving IV antibiotics as prescribed b. managing pain with opioid analgesics c. encouraging of fluid intake for hydration d. performing frequent active range-of motion exercises
a. giving IV antibiotics as prescribed
The physician inserts a chest tube in a patient who has a stab wound in the chest and attaches it to a close-drainage system. When caring for the patient afterwards, nursing interventions will include:
a. observe for fluid fluctuations in the water seal chamber
A patient has a chest tube following a thoracotomy. Continuous bubbling in the suction chamber of the collection device would alert the nurse that
a. the unit is functioning normally
When teaching a patient about the long-term consequences of rheumatic fever, the nurse should discuss the possibility of a. valvular heart disease b. pulmonary hypertension c. superior vena cava syndrome d. hypertrophy of the right ventricle
a. valvular heart disease
A thoracentesis is performed. Following the procedure it is most important for the nurse to observe the patient for complications which can be exhibited by:
b. decreased respiratory rate
The nurse establishes the presence of a tension pneumothorax when assessment findings reveal
b. deviation of the trachea toward the side opposite the pneumothorax
A patient being treated for TB comes to the clinic after 2 months for a follow-up visit. Sputum smears for AFB are still positive. A sputum specimen is taken for culture and to determine whether the microorganism is sensitive to the drugs. The nurse questions the patient regarding the treatment regimen with the knowledge that:
b. directly observed therapy (DOT) will be necessary if the patient has been noncompliant.
The part of the vascular system responsible for hemostasis is the a. thin capillary vessels. b. endothelial layer of the arteries. c. elastic middle layer of the veins. d. smooth muscle of the arterial wall.
b. endothelial layer of the arteries.
A patient with emphysema experiences a sudden episode of shortness of breath. The physician diagnoses a spontaneous pneumothorax. The nurse is aware that the probable cause of the spontaneous pneumothorax is a:
b. rupture of a subpleural bleb
When planning care for a patient at risk for pulmonary embolism, the nurse prioritizes a. maintaining the patient on bed rest. b. using intermittent pneumatic compression devices. c. encouraging the patient to cough and deep breathe. d. teaching the patient how to use the incentive spirometer.
b. using intermittent pneumatic compression devices.
A patient with TB has been admitted to the hospital and is placed on airborne precautions and in an isolation room. What should the nurse teach the patient? (Select all that apply) a. Expect routine TB testing to evaluate the infection. b. No visitors will be allowed while in airborne isolation. c. Adherence to precautions includes coughing into a paper tissue. d. Take all medications for full length of time to prevent multi-drug-resistant TB. e. Wear a standard isolation mask if leaving the airborne infection isolation room.
c. Adherence to precautions includes coughing into a paper tissue. d. Take all medications for full length of time to prevent multi-drug-resistant TB. e. Wear a standard isolation mask if leaving the airborne infection isolation room.
After caring for a patient admitted with a fever and cough who was later diagnosed with TB, a nurse has a new positive TB skin test of 8 mm induration. A chest x-ray is negative, and the nurse is considered to have latent tuberculosis infection. The recommended intervention for the nurse includes:
c. administration of isoniazid (INH) daily for 6-9 months.
After a pneumonectomy, an appropriate nursing intervention is a. monitoring chest tube drainage and functioning. b. positioning the patient on the unaffected side or back. c. doing range-of-motion exercises on the affected upper limb. d. auscultating frequently for lung sounds on the affected side.
c. doing range-of-motion exercises on the affected upper limb.
The nurse identifies a flail chest in a trauma patient when a. multiple rib fractures are determined by x-ray. b. a tracheal deviation to the unaffected side is present. c. paradoxical chest movement occurs during respiration. d. there is decreased movement of the involved chest wall.
c. paradoxical chest movement occurs during respiration.
Your patient was the driver in a motor vehicle accident and suffered a chest trauma from the impact against the steering wheel. Symptoms include dyspnea, decreased breath sounds, dullness on percussion, shock, and hypovolemia. Your care will be based on the fact that the patient is exhibiting signs of:
d. hemothorax
The nurse emphasizes the need for especially close monitoring in the patient who is taking antitubercular drugs and has a history of:
d. liver disease
To monitor for the complication of subcutaneous edema after the insertion of chest tubes, the nurse should:
d. palpate around the chest tube insertion sites for crepitus
An appropriate nursing intervention to assist a patient with pneumonia manage thick secretions and fatigue would be to a. perform postural drainage every hour. b. provide analgesics as ordered to promote patient comfort. c. administer O2 as prescribed to maintain optimal O2 levels. d. teach the patient how to cough effectively and expectorate secretions.
d. teach the patient how to cough effectively and expectorate secretions.
The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. Which laboratory test result should be most helpful in indicating myocardial damage? a. Troponins b. Myoglobin c. Homocysteine (Hcy) d. Creatine kinase-MB (CK-MB)
ANS: A Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly specific to myocardium. They are the preferred diagnostic marker for myocardial infarction. Myoglobin rises in response to myocardial injury within 30 to 60 minutes. It is rapidly cleared from the body, thus limiting its use in the diagnosis of myocardial infarction. Creatine kinase (CK-MB) is specific to myocardial injury and infarction and increases 4 to 6 hours after the infarction occurs. It is often trended with troponin levels. Homocysteine (Hcy) is an amino acid that is made during protein catabolism. Elevated levels of Hcy are linked to a higher risk of CVD, peripheral vascular disease, and stroke.
The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Monitor for elevated white blood cell count.
ANS: A Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiography and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. White blood count elevation might indicate infection but is not expected with cor pulmonale.
The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation
ANS: A Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.
An older adult is receiving standard multidrug therapy for tuberculosis (TB). Which finding should the nurse report to the health care provider? a. Yellow-tinged sclera b. Orange-colored sputum c. Thickening of the fingernails d. Difficulty hearing high-pitched voices
ANS: A Noninfectious hepatitis is a toxic effect of isoniazid, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.
The nurse hears a murmur between the S1 and S2 heart sounds at the patient's left fifth intercostal space and midclavicular line. How will the nurse record this information? a. Systolic murmur heard at mitral area. b. Systolic murmur heard at Erb's point. c. Diastolic murmur heard at aortic area. d. Diastolic murmur heard at the point of maximal impulse.
ANS: A The S1 signifies the onset of ventricular systole. S2 signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur. The mitral area is the intersection of the left fifth intercostal space and the midclavicular line. The other responses describe murmurs heard at different landmarks on the chest and/or during the diastolic phase of the cardiac cycle.
The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which laboratory result is most important to communicate rapidly to the health care provider? a. High troponin I level b. Increased triglyceride level c. Very low homocysteine level d. Elevated C-reactive protein level
ANS: A The elevation in troponin I indicates that the patient has had an acute myocardial infarction. Further assessment and interventions are indicated. The other laboratory results are indicative of increased risk for coronary artery disease but are not associated with acute cardiac problems that need immediate intervention.
The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg." Which patient should the nurse call the health care provider about? a. Postoperative patient with a BP of 116/42 mm Hg. b. Newly admitted patient with a BP of 150/87 mm Hg. c. Patient with left ventricular failure who has a BP of 110/70 mm Hg. d. Patient with a myocardial infarction who has a BP of 140/86 mm Hg.
ANS: A The mean arterial pressure (MAP) is calculated using the formula MAP = (systolic BP + 2 diastolic BP)/3. The MAP for the postoperative patient is 67. The MAP in the other three patients is higher than 70 mm Hg.
Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB and has never had a positive TB skin test before. Which information should the occupational health nurse plan to teach the staff nurse? a. Use and side effects of isoniazid b. Standard four-drug therapy for TB c. Need for annual repeat TB skin testing d. Bacille Calmette-Guérin (BCG) vaccine
ANS: A The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for those who have already had a positive skin test result. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.
A patient who was admitted the previous day with pneumonia reports a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? a. Auscultate for breath sounds. b. Administer as-needed morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.
ANS: A The patient's statement indicates that pleurisy or a pleural effusion may have developed, and the nurse will need to listen for a pleural friction rub and decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.
The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every 8 hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.
ANS: A UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.
The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain the O2 saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.
ANS: A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done.
Which health promotion information should the nurse include when teaching a patient with a 42 pack-year history of cigarette smoking? (Select all that apply.) a. Resources for support in smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for cancer e. Importance of obtaining a yearly influenza vaccination
ANS: A, D, E Because smoking is the major cause of lung cancer, an important role for the nurse is teaching patients about the benefits of and means of smoking cessation. Screening for using low-dose CT is recommended for high-risk patients Encourage those at risk for pneumonia (e.g., those who smoke) to obtain both influenza and pneumococcal vaccines. Sputum cytology is a diagnostic test but does not prevent cancer or disease. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer.
The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse? a. The patient is offered a tissue from the box at the bedside. b. A surgical face mask is applied before visiting the patient. c. A snack is brought to the patient from the unit refrigerator. d. Hand washing is performed before entering the patient's room.
ANS: B A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient's room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.
A patient is scheduled for a cardiac catheterization with coronary angiography. What information should the nurse provide before the procedure? a. It will be important not to move at all during the procedure. b. A flushed feeling is common when the contrast dye is injected. c. Monitored anesthesia care will be provided during the procedure. d. Arterial pressure monitoring will be needed for 24 hours after the test.
ANS: B A sensation of warmth or flushing is common when the contrast material is injected, which can be anxiety producing unless it has been discussed with the patient. The patient may receive a sedative drug before the procedure but monitored anesthesia care is not used. Arterial pressure monitoring is not routinely used after the procedure to monitor blood pressure. The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths.
A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate? a. Adjust the dial on the wall regulator. b. Continue to monitor the collection device. c. Document the presence of a large air leak. d. Notify the surgeon of a possible pneumothorax.
ANS: B Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.
An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? a. Listening to the patient's lung sounds several times during the shift b. Placing the patient on droplet precautions in a private hospital room c. Monitoring patient serology results to identify the infecting organism d. Titrating the O2 flowrate as prescribed to keep the O2 saturation over 90%
ANS: B Fungal infections are not transmitted from person to person. Therefore, no isolation procedures are necessary. The other actions by the new nurse are appropriate.
How should the nurse listen to auscultate for S3 or S4 gallops in the mitral area? a. Use the diaphragm of the stethoscope with the patient lying flat. b. Use the bell of the stethoscope with the patient in the left lateral position. c. Use the diaphragm of the stethoscope with the patient in a supine position. d. Use the bell of the stethoscope with the patient sitting and leaning forward.
ANS: B Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher pitched sounds such as S1 and S2.
After receiving change-of-shift report on four patients, which patient should the nurse assess first? a. Patient with rheumatic fever who has sharp chest pain with a deep breath. b. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg. c. Patient with infective endocarditis who has a murmur and splinter hemorrhages. d. Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases.
ANS: B Hypotension in patients with acute aortic regurgitation may indicate cardiogenic shock. The nurse should immediately assess this patient for other findings such as dyspnea, chest pain or tachycardia. The findings in the other patients are typical of their diagnoses and do not indicate a need for urgent assessment and intervention.
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) suppository
ANS: B Initiating antibiotic therapy rapidly is essential, but it is important to obtain the cultures before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.
When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To obtain more information about the murmur, which action should the nurse take? a. Palpate the peripheral pulses. b. Determine the timing of the sound. c. Find the point of maximal impulse. d. Compare apical and radial pulse rates.
ANS: B Murmurs are caused by turbulent blood flow, such as occurs when blood flows through a damaged valve. Relevant information includes the position in which the murmur is heard best (e.g., sitting and leaning forward), the timing of the murmur in relation to the cardiac cycle (e.g., systole, diastole), and where on the thorax the murmur is heard best. The other information is important in the cardiac assessment but will not provide information that is relevant to the murmur.
The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 77-yr-old patient with tuberculosis (TB) who has four medications due b. A 46-yr-old patient on bed rest who reports sudden onset of shortness of breath c. A 35-yr-old patient with pneumonia who has a temperature of 100.2° F (37.8° C) d. A 23-yr-old patient with cystic fibrosis who has pulmonary function testing scheduled
ANS: B Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as O2 administration. The other patients should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.
The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement by the patient indicates a good understanding of the instructions? a. "I will call my health care provider if I still feel tired after a week." b. "I will continue to do deep breathing and coughing exercises at home." c. "I will schedule two appointments for the pneumonia and influenza vaccines." d. "I will cancel my follow-up chest x-ray appointment if I feel better next week."
ANS: B Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The pneumococcal and influenza vaccines can be given at the same time in different arms. A follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.
A registered nurse (RN) is observing a student nurse who is assessing a patient. Which action observed by the RN requires immediate intervention? a. The student nurse presses on the skin over the tibia for 10 seconds to check for edema. b. The student nurse palpates both carotid arteries simultaneously to compare pulse quality. c. The student nurse documents a murmur heard along the right sternal border as a pulmonic murmur. d. The student nurse places the patient in the left lateral position to check for the point of maximal impulse.
ANS: B The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected. However, they are not dangerous to the patient.
When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is important for the nurse to communicate to the health care provider before the test? a. The patient's pedal pulses are +1. b. The patient is allergic to shellfish. c. The patient had a heart attack 1 year ago. d. The patient has not eaten anything today.
ANS: B The contrast dye used for the procedure is iodine based, so patients who have shellfish allergies will require treatment with medications, such as corticosteroids and antihistamines before the angiogram. The other information may be communicated to the health care provider but will not require a change in the usual precardiac catheterization orders or medications.
The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse? a. The O2 saturation is 90%. b. The blood pressure is 98/56 mm Hg. c. The epoprostenol (Flolan) infusion is disconnected. d. The international normalized ratio (INR) is prolonged.
ANS: C The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion.
Which action should the nurse include in a community health program to decrease the incidence of rheumatic fever? a. Vaccinate high-risk groups in the community with streptococcal vaccine. b. Teach community members to seek treatment for streptococcal pharyngitis. c. Teach about the importance of monitoring temperature when sore throats occur. d. Teach about prophylactic antibiotics to those with a family history of rheumatic fever.
ANS: B The incidence of rheumatic fever is decreased by treatment of streptococcal infections with antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization that is effective in decreasing the incidence of rheumatic fever. Teaching about monitoring temperature will not decrease the incidence of rheumatic fever.
A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which is the best initial response by the nurse? a. "Are you ready to talk with family members about dying?" b. "Can you tell me what makes you think you will die so soon?" c. "Do you think that an antidepressant medication would be helpful?" d. "Would you like to talk to the hospital chaplain about your feelings?"
ANS: B The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data. The remaining answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.
An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take? a. Clamp the chest tube in two places. b. Administer the prescribed morphine. c. Milk the chest tube to remove any clots. d. Assist the patient with incentive spirometry.
ANS: B Treat the pain. The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Milking or stripping chest tubes is no longer recommended because these practices can dangerously increase intrapleural pressures and damage lung tissues. Position tubing so that drainage flows freely to negate need for milking or stripping. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax.
The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP? a. Teaching a patient about exercise electrocardiography b. Attaching ECG monitoring electrodes after a patient bathes c. Monitoring a patient after a transesophageal echocardiogram d. Checking the patient's catheter site after a coronary angiogram
ANS: B UAP can be educated in standardized lead placement for ECG monitoring. Assessment of patients who have had procedures where airway maintenance (transesophageal echocardiography) or bleeding (coronary angiogram) is a concern must be done by the registered nurse (RN). Patient teaching requires RN level education and scope of practice.
Which action should the nurse plan to prevent aspiration in a high-risk patient? a. Turn and reposition an immobile patient at least every 2 hours. b. Place a patient with altered consciousness in a side-lying position. c. Insert a nasogastric tube for feeding a patient with high-calorie needs. d. Monitor respiratory symptoms in a patient who is immunosuppressed.
ANS: B With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and O2 saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.
A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance? a. Restrict oral fluids during the day. b. Encourage pursed-lip breathing technique. c. Help the patient to splint the chest when coughing. d. Encourage the patient to wear the nasal O2 cannula.
ANS: C Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal O2 will improve gas exchange but will not improve airway clearance. Pursed-lip breathing can improve gas exchange in patients with chronic obstructive pulmonary disease but will not improve airway clearance.
A patient diagnosed with active tuberculosis (TB) is homeless and has a history of chronic alcohol use. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Repeat warnings about the high risk for infecting others several times. b. Give the patient written instructions about how to take the medications. c. Arrange for a daily meal and drug administration at a community center. d. Arrange for the patient's friend to administer the medication on schedule.
ANS: C Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen. Arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient's situation.
When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse? a. Patient reports feeling tired b. Sinus tachycardia at a rate of 110 beats/min c. Inversion of T waves on the electrocardiogram d. Blood pressure (BP) increase from 134/68 to 150/80 mm Hg
ANS: C ECG changes associated with coronary ischemia (such as T-wave inversions and ST segment depression) indicate that the myocardium is not getting adequate O2 delivery and that the exercise test should be stopped immediately. Increases in BP and heart rate are normal responses to aerobic exercise. Feeling tired is also normal as the intensity of exercise increases during the stress testing.
The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care? a. Bed rest for the first 24 hours b. Positioning only on the right side c. Frequent use of an incentive spirometer d. Chest tube placement to continuous suction
ANS: C Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space.
A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate? a. "Are you afraid that the surgery will be very painful?" b. "Did you have bad experiences with previous surgeries?" c. "Tell me what you know about the treatments available." d. "Surgery is the treatment of choice for stage I lung cancer."
ANS: C More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In non-small cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery.
A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness? a. Ask the patient about any visual changes in red-green color discrimination. b. Question the patient about experiencing shortness of breath, hives, or itching. c. Explain that orange discolored urine and tears are normal while taking this medication. d. Advise the patient to stop the drug and report the symptoms to the health care provider.
ANS: C Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occur when taking ethambutol, which is a different tuberculosis medication.
A patient has a chest wall contusion as a result of being struck in the chest with a baseball bat. Which initial assessment finding is of most concern to the emergency department nurse? a. Report of chest wall pain b. Heart rate of 110 beats/min c. Paradoxical chest movement d. Large bruised area on the chest
ANS: C Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.
The home health nurse is visiting a 30-yr-old patient recovering from rheumatic fever without carditis. Which statement by the patient indicates a need for further teaching? a. "I will need prophylactic antibiotic therapy for 5 years." b. "I can take aspirin or ibuprofen to relieve my joint pain." c. "I will be immune to future episodes of rheumatic fever after this infection." d. "I should call the health care provider if I am fatigued or have difficulty breathing."
ANS: C Patients with a history of rheumatic fever are more susceptible to a second episode. Patients with rheumatic fever withoutNcarRditisIreqGuirBe p.rCophMylaxis until age 20 years and for a USNT O minimum of 5 years. The other patient statements are correct.
An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease? a. Treat workers with pulmonary fibrosis. b. Teach about symptoms of lung disease. c. Require the use of protective equipment. d. Monitor workers for coughing and wheezing.
ANS: C Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation.
The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history focuses on a pertinent risk factor for rheumatic fever? a. "Do you use any illegal IV drugs?" b. "Have you ever injured your chest?" c. "Have you had a recent sore throat?" d. "Do you have a family history of heart disease?"
ANS: C Rheumatic fever occurs because of an abnormal immune response to a streptococcal infection. Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever, and it would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever.
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? a. Teach about the reason for the blood tests. b. Schedule an appointment for a chest x-ray. c. Teach the patient about providing specimens for 3 consecutive days. d. Instruct the patient to collect several separate sputum specimens today.
ANS: C Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for Mycobacterium tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used to test for tuberculosis. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? a. "I will take the bus instead of driving." b. "I will stay indoors whenever possible." c. "My spouse will sleep in another room." d. "I will keep the windows closed at home."
ANS: C Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation.
During a physical examination of an older patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. What would be the most focused follow-up action for the nurse to take? a. Ask about risk factors for atherosclerosis. b. Determine family history of heart disease. c. Assess for symptoms of left ventricular hypertrophy. d. Auscultate carotid arteries for the presence of a bruit.
ANS: C The PMI should be felt at the intersection of the fifth intercostal space and left midclavicular line. A PMI found outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy (LVH). The other assessments are part of a general cardiac assessment but do not represent follow-up for LVH. Cardiac enlargement is not necessarily associated with atherosclerosis or carotid artery disease.
After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Teach about drug-resistant TB. b. Schedule directly observed therapy. c. Ask the patient whether medications have been taken as directed. d. Discuss the need for an injectable antibiotic with the health care provider.
ANS: C The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.
Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? a. Providing supportive care to patients diagnosed with pertussis b. Teaching family members about the need for careful hand washing c. Teaching patients about the need for adult pertussis immunizations d. Encouraging patients to complete the prescribed course of antibiotics
ANS: C The increased rate of pertussis in adults is thought to be caused by decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made.
The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. Which assessment finding is of most concern? a. A large air leak in the water-seal chamber b. Report of pain with each deep inspiration c. 400 mL of blood in the collection chamber d. Subcutaneous emphysema at the insertion site
ANS: C The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.
A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 6000/μL. d. Increased tactile fremitus is palpable over the right chest.
ANS: C The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.
Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan? a. Insert an IV catheter. b. Administer oral sedative medications. c. Teach the patient about the procedure. d. Confirm that the patient has been fasting.
ANS: C The nurse will need to teach the patient that the procedure is rapid and involves little risk. None of the other actions are necessary.
A transesophageal echocardiogram (TEE) is planned for a patient hospitalized with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first? a. Start an IV line. b. Start O2 per nasal cannula. c. Place the patient on NPO status. d. Give lorazepam (Ativan) 1 mg IV.
ANS: C The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received. The other actions also will need to be accomplished but not until just before or during the procedure.
After change-of-shift report, which patient should the nurse assess first? a. A 40-yr-old with a pleural effusion who reports severe stabbing chest pain b. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet c. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion d. A 28-yr-old with a history of a lung transplant 1 month ago and a fever of 101° F (38.3° C)
ANS: C The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.
A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. The patient reports that joint discomfort prevents favorite activities such as taking a daily walk and sewing. What problem should be the focus of nursing interventions? a. Social isolation b. General anxiety c. Activity intolerance d. Altered body image
ANS: C The patient's joint pain will lead to difficulty with activity. Although acute joint pain will be a problem for this patient, joint inflammation is a temporary clinical manifestation of rheumatic fever and is not associated with permanent joint changes. This patient did not provide any data to support a problem with social isolation, anxiety, or altered body image.
The nurse notes that a patient who was admitted with heart failure has jugular venous distention (JVD) when lying flat. Which follow-up action should the nurse take? a. Encourage the patient to drink more liquids. b. Check the apical and radial pulse for a pulse deficit. c. Observe the neck veins with the patient elevated 45 degrees. d. Have the patient bear down to perform the Valsalva maneuver.
ANS: C When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not a clinically significant) finding. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. More fluids will further increase any fluid overload. JVD but is not confirmed based on the data given. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant.
Which action should the nurse take to prepare a patient with a pleural effusion for a thoracentesis? a. Remind the patient not to eat or drink 6 hours. b. Start a peripheral IV line to administer sedation. c. Position the patient sitting up on the side of the bed. d. Obtain a collection device to hold 3 liters of pleural fluid.
ANS: C When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema.
A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient is weak and needs assistance to get out of bed. Which patient problem should the nurse assign as the priority? a. Fatigue b. Hyperthermia c. Impaired mobility d. Impaired gas exchange
ANS: D All these problems are appropriate for the patient, but the patient's O2 saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.
A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? a. The Mantoux test had an induration of 7 mm. b. The chest x-ray showed infiltrates in the lower lobes. c. The patient has a cough that is productive of blood-tinged mucus. d. The patient is being treated with antiretrovirals for HIV infection.
ANS: D Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.
A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and severe pleuritic chest pain. Which prescribed medication should the nurse give first? a. Codeine b. Guaifenesin c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)
ANS: D Early initiation of antibiotic therapy has been shown to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.
Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? a. Assist the patient with chest physiotherapy and postural drainage. b. Teach the patient to avoid the use of over-the-counter expectorants. c. Notify the health care provider immediately about any bloody or foul-smelling d. Teach about the need for prolonged antibiotic therapy after discharge from the
ANS: D Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul-smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough.
The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates that the teaching has been effective? a. "I will make an appointment to see the doctor every year." b. "I will stop taking the prednisone if I experience a dry cough." c. "I will not worry if I feel a little short of breath with exercise." d. "I will call the health care provider right away if I develop a fever."
ANS: D Low-grade fever may indicate infection or acute rejection, so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team. Annual health care provider visits would not be sufficient. Home O2 use is not an expectation after lung transplant. Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough, and O2 desaturation are signs of rejection. Immunosuppressive therapy, including prednisone, needs to be continued to prevent rejection.
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is important for the nurse to ask before the skin test? a. "Do you take any over-the-counter (OTC) medications?" b. "Do you have any family members with a history of TB?" c. "How long has it been since you moved to the United States?" d. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"
ANS: D Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (e.g., chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.
Which statement by a patient with restrictive cardiomyopathy indicates that the nurse's discharge teaching about self-management has been effective? a. "I will avoid taking aspirin or other antiinflammatory drugs." b. "I can restart my exercise program that includes hiking and biking." c. "I will need to limit my intake of salt and fluids even in hot weather." d. "I will take antibiotics before my teeth are cleaned at the dental office."
ANS: D Patients with restrictive cardiomyopathy are at risk for infective endocarditis and should use prophylactic antibiotics for any procedure that may cause bacteremia. The other statements indicate a need for more teaching by the nurse. Dehydration and vigorous exercise impair ventricular filling in patients with restrictive cardiomyopathy. There is no need to avoid salt (unless ordered), aspirin, or nonsteroidal antiinflammatory drugs.
The nurse supervises unlicensed assistive personnel (UAP) providing care for a patient who has right lower lobe pneumonia. Which action by the UAP requires the nurse to intervene? a. UAP assists the patient to ambulate to the bathroom. b. UAP helps splint the patient's chest during coughing. c. UAP transfers the patient to a bedside chair for meals. d. UAP lowers the head of the patient's bed to 15 degrees.
ANS: D Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.
The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which patient statement indicates that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."
ANS: D Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis.
An older adult patient who has just arrived in the emergency department has a pulse deficit of 46 beats. The nurse should expect that the patient may require: a. cardiac catheterization. b. emergent cardioversion. c. hourly blood pressure checks. d. electrocardiographic monitoring.
ANS: D Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit.
A patient is hospitalized with active tuberculosis (TB). Which assessment finding indicates to the nurse that prescribed airborne precautions are likely to be discontinued? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Sputum smears for acid-fast bacilli are negative.
ANS: D Repeated negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment.
A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take? a. Keep the head of the patient's bed positioned flat. b. Cover the wound tightly with an occlusive dressing. c. Position the patient so that the left chest is dependent. d. Tape a nonporous dressing on three sides over the wound.
ANS: D The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.
A patient with a possible pulmonary embolism reports chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.
ANS: D The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be performed after the head is elevated and O2 is started. The health care provider may order a spiral CT to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.
A patient will be evaluated for rhythm disturbances with a Holter monitor. What should the nurse teach the patient to do? a. Connect the recorder to a computer once daily. b. Exercise more than usual while the monitor is in place. c. Remove the electrodes when taking a shower or tub bath. d. Keep a diary of daily activities while the monitor is worn.
ANS: D The patient is taught to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they should not take a shower or bath during Holter monitoring and that they should continue with their usual daily activities. The recorder stores the information about the patient's rhythm until the end of the testing, when it is removed and the data are analyzed.
A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy. Which information will the nurse plan to teach the patient? a. A heart transplant should be scheduled as soon as possible. b. Elevating the legs above the heart will help relieve dyspnea. c. Careful compliance with diet and medications will prevent heart failure. d. Notify the health care provider about symptoms such as shortness of breath.
ANS: D The patient should be instructed to notify the health care provider about any worsening of heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients with good compliance with therapy may have recurrent episodes of heart failure. Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with hypertrophic cardiomyopathy). The patient with terminal or end-stage cardiomyopathy may consider heart transplantation.
The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall c. Bronchodilator administration d. Chest tube connected to suction
ANS: D The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.
The nurse is reviewing the 12-lead electrocardiograph (ECG) for a healthy older adult patient who is having an annual physical examination. What finding should be of most concern to the nurse? a. A right bundle branch block. b. The PR interval is 0.21 seconds. c. The QRS duration is 0.13 seconds. d. The heart rate (HR) is 41 beats/min.
ANS: D The resting HR does not change with aging, so the decrease in HR needs further investigation. Bundle branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, bundle of His, and bundle branches.
Which action could the nurse delegate to unlicensed assistive personnel (UAP) trained as electrocardiogram (ECG) technicians working on the cardiac unit? a. Select the best lead for monitoring a patient with an admission diagnosis of Dressler syndrome. b. Obtain a list of herbal medications used at home while admitting a new patient with pericarditis. c. Teach about the need to monitor the weight daily for a patient who has hypertrophic cardiomyopathy. d. Watch the heart monitor for changes in rhythm while a patient who had a valve replacement ambulates.
ANS: D Under the supervision of registered nurses (RNs), UAPs check the patient's cardiac monitor and obtain information about changes in heart rate and rhythm with exercise. Teaching and obtaining information about home medications (prescribed or complementary) and selecting the best leads for monitoring patients require more critical thinking and should be done by the RN.
While doing the hospital admission assessment for a thin older adult, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take next? a. Teach the patient about aneurysms. b. Notify the hospital rapid response team. c. Instruct the patient to remain on bed rest. d. Document the finding in the patient chart.
ANS: D Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals. The nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary.
The nurse is obtaining a health history from a 24-yr-old patient with hypertrophic cardiomyopathy (CMP). Which information obtained by the nurse is most important in planning care? a. The patient had a recent upper respiratory infection. b. The patient has a family history of coronary artery disease. c. The patient reports using cocaine "a few times" as a teenager. d. The patient's 29-yr-old brother died from a sudden cardiac arrest.
ANS: DAbout half of all cases of hypertrophic CMP have a genetic basis, and it is the most common cause of sudden cardiac death in otherwise healthy young people. The information about the patient's brother will be helpful in planning care (e.g., an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against the use of stimulant drugs, but the limited past history indicates that the patient is not currently at risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy but not for hypertrophic CMP.
