EXAM 1 practice quiz

The nurse teaches a client who has recently been diagnosed with hypertension about following a low-calorie, low-fat, low-sodium diet. Which menu selection would best meet the client's needs?

baked chicken, an apple, and a slice of white bread

A nurse is reviewing a client's medical history. Which factor indicates the client is at risk for candidiasis?

corticosteroids use A small quantity of the fungus Candida albicans commonly exists in the vagina. Because corticosteroids decrease host defense, they increase the risk of candidiasis. Candidiasis is rare before menarche and after menopause. Using hormonal contraceptives, not spermicidal jelly, and pregnancy, not nulliparity, increase the risk of candidiasis.

A client is placed on a low-sodium (1500 mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has been effective?

"I chose broiled chicken with a baked potato for dinner."

A teenage client with heart failure is prescribed carvedilol. The client asks the nurse, "What is this drug supposed to do?" Which responses by the nurse are correct? Select all that apply.

"Improve the way your heart works" "Lower your blood pressure" "Slow your heart rate" Carvedilol is an antihypertensive, beta-adrenergic blocker. It has been shown to increase left ventricular function and reduce the symptoms of heart failure. It reduces cardiac output. Carvedilol will not prevent infection.

An obese male client with history of heart failure is prescribed a beta blocker. Which of the following is important to teach regarding home drug therapy? Select all that apply.

"Take your medication at the same time daily." "Contact the health care provider if you have difficulty getting or maintaining an erection." "Change positions between sitting and standing carefully." "Check your pulse for a full minute before administering your medication." Beta blockers treat a variety of conditions including hypertension, heart failure, glaucoma, and migraines. Beta blockers are used to slow the heartbeat, to reduce the force of the heart's contractions, and reduce blood vessel contraction. Important client instructions include taking the medication at the same time daily, daily weights, changing positions daily due to hypotension, and apical pulses for a full minute. A side effect of the medication is sexual difficulties, such as difficulty getting an erection. Monitor the blood pressure, not blood glucose, each morning

A client has been prescribed corticosteroids. The nurse would also anticipate an order for

blood glucose checks every 6 hours Corticosteroids cause elevated blood glucose levels; insulin may be necessary to maintain normal blood glucose levels. Corticosteroids can cause edema, but fluid restrictions are generally unnecessary unless the client also has renal or cardiac disease. Lactulose is given for constipation and to treat hepatic encephalopathy. Platelet count every 12 hours is not necessary when monitoring clients undergoing corticosteroid therapy.

An older adult is admitted to the emergency department (ED) at 2000 hours with syncope, shortness of breath, and reported palpitations (see nurse's notes below). At 2015, the nurse places the client on the electrocardiogram (ECG) monitor and identifies the following rhythm (see below). What should the nurse do? Select all that apply.

apply oxygen monitor vital signs have the client consent for cardioversion as prescribed

The nurse obtains a pulse rate of 116 (bpm) before administering digoxin to a client with heart failure who has been receiving digoxin for 2 weeks. What should the nurse do next?

Evaluate the client's cardiac rhythm. Before administering the medication, the nurse should evaluate the possibility of digitalis toxicity. Sign of digitalis toxicity include tachycardia and atrial fibrillation, sometimes with a heart rate of more than 100 bpm. The appropriate action by the nurse is to evaluate the cardiac rhythm of the client. The cardiac rhythm is a higher assessment priority than the client's respiratory rate.

A client has a chest tube inserted for the treatment of a pneumothorax. While turning in the bed, the client dislodges the tube and it is found in the bed. As the registered nurse is directing the healthcare team, place the actions of the registered nurse in the correct order. All options must be used.

Apply an occlusive dressing over the puncture site. Tape the dressing on three sides. Assess the client's respiratory status. Assess the client's vital signs. Direct the licensed practical/vocational nurse (LPN/VN) to remain with the client. Notify the healthcare provider and obtain further orders.

The nurse notices on the cardiac monitor that the client has started having premature ventricular contractions every other beat. What should the nurse do first?

Assess the client's orientation and vital signs. The priority action is to assess the client and determine whether the rhythm is life-threatening. More information, including vital signs, should be obtained, and the nurse should notify the HCP. A bolus of lidocaine may be prescribed to treat this arrhythmia. This is not a code-type situation unless the client has been determined to be in a life-threatening situation.

After having a lobectomy for lung cancer, a client receives a chest tube connected to a three-chamber chest drainage system. The nurse observes that the drainage system is functioning correctly when noting which findings? Select all that apply.

Fluctuations in the water-seal chamber occur when the client breathes. Intermittent bubbling occurs in the water-seal chamber. Gentle bubbling occurs in the suction control chamber. Drainage is collecting in the drainage chamber. Fluctuations in the water-seal compartment (or tidal movements) indicate normal function of the system as the pressure in the tubing changes with the client's respirations. There also should be intermittent bubbling in the water-seal chamber, indicating that air is being removed from the pleural cavity by the system. Gentle bubbling in the suction control chamber indicates that the proper suction level has been reached. Drainage is expected to collect in the drainage chamber after a lobectomy. Crepitus indicates that air is leaking into the subcutaneous tissues. The physician should be notified of this finding.

A critically ill 4-year-old child is in the pediatric intensive care unit. Telemetry monitoring reveals junctional tachycardia. Identify where this arrhythmia originates.

In junctional tachycardia, the atrioventricular node fires rapidly. The atria are depolarized by retrograde conduction; however, conduction through the ventricles remains normal.

A client is admitted to the emergency department with atrial fibrillation and does not recall how long the rapid pulse and irregular heart rate have been occurring. The nurse should include which goal(s) of care at this time? Select all that apply.

Maintain bed rest Maintain a ventricular response below 100 bpm. Prevent an embolic stroke. Clients who experience atrial fibrillation for more than 48 hours are at an increased risk for developing blood clots due to stasis of blood in the atria. Initially, it will be important to maintain a ventricular heart rate of less than 100 bpm and prevent complications related to clot formation, including an embolic stroke. It is not necessary to limit activities; the client can resume normal activities and slowly increase exercise tolerance. Treating the atrial fibrillation and decreasing the heart rate will help to help to increase exercise tolerance. Atrial fibrillation causes a decrease in cardiac output, and a goal of therapy would be to increase cardiac output. It is imperative to determine the length of time a client has been in atrial fibrillation before performing a cardioversion. If a client has been in atrial fibrillation longer than 48 hours and a cardioversion is performed, a clot may be dislodged and become lodged in vessels of the brain, lungs, or coronary arteries.

A client is admitted to the telemetry unit with atrial fibrillation. What is the appropriate action of the nurse? Select all that apply.

administer warfarin Apply sequential compression device Apply continuous cardiac monitoring assess for changes in level of consciousness For clients who have atrial fibrillation, oral anticoagulation using warfarin has shown to be effective in the prevention of stroke. Assessment for pulmonary embolism (PE), deep vein thrombosis (DVT), and prevention of venous thromboembolism with the use of sequential compression device is also appropriate. The client should be on continuous cardiac monitoring while being treated for atrial fibrillation. Assessing for change in level of consciousness is necessary for stroke prevention. The client with an embolic stroke usually remains conscious, although may have a headache. Symptoms include changes in mentation, speech, sensory function, and motor function. Treatment for atrial fibrillation should not impact deep tendon reflexes.

A physician orders digoxin elixir for a client with heart failure. Immediately before administering this drug, the nurse must check the client's

apical pulse Because digoxin may reduce the heart rate and heart failure may cause a pulse deficit, the nurse should measure the client's apical pulse before administering the drug to prevent further slowing of the heart rate. The serum sodium level doesn't affect digoxin's action. For a client with heart failure, the nurse should check urine output and measure weight regularly, but not necessarily just before digoxin administration.

While auscultating the apical heart rate, the nurse notes an irregular heart rhythm at a rate of 120 beats/min. What is the nurse's next action?

assess for a pulse deficit The correct landmark for obtaining the apical pulse is the left fifth intercostal space in the midclavicular line. The nurse measures the apical-radial pulse for a deficit; apical rate minus radial rate. A deficit is present during atrial fibrillation, and premature ventricular contractions because some heart beats do not perfuse to distal areas. The client should not perform the Valsalva maneuver without electrocardiographic monitoring and the healthcare provider at the bedside; assessment of the underlying disorder should be made first to direct the proper intervention. Prior to calling healthcare providers, the nurse should report vital signs and presence of pulse deficit.

The nurse administers lisinopril to a client. What assessment findings does the nurse document as evidence of a positive therapeutic response?

blood pressure 118/74 mmHg Lisinopril is an angiotensin-converting-enzyme (ACE) inhibitor that lowers the blood pressure through inhibition of the renin angiotensin system. A therapeutic effect is shown as the medication vasodilates to bring down the blood pressure. The apical heart rate and total cholesterol levels are not affected by lisinopril. Potassium can become elevated due to the blocking of aldosterone with ACE inhibitors, but this is a side effect and not a therapeutic effect.

A client has a malignant pleural effusion. The nurse should conduct a focused assessment to determine if the client has which sign(s) or symptom(s)? Select all that apply.

chest pain dyspnea A malignant pleural effusion is an accumulation of excessive fluid within the pleural space that occurs when cancer cells irritate the pleural membrane. Dyspnea can result from increased pressure, which may contribute to increased anxiety and fear of suffocation. Pain is caused by pleural irritation. Hiccups are usually associated with pericardial effusions. Weight gain and peripheral edema may occur with peritoneal effusion.

The nurse is caring for a client with a chest tube. When assessing the client, which situation does the nurse recognize as an immediate emergency situation?

disconnection of the tubing from the drainage apparatus

A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. Which history finding is a major risk factor for infective endocarditis?

history of aortic valve replacement A heart valve prosthesis such as an aortic valve replacement is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, I.V. drug abuse, and immunosuppression. Although race, age, and a history of diabetes mellitus may predispose a person to cardiovascular disease, they aren't major risk factors for infective endocarditis.

A nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?

low serum potassium level Furosemide is a potassium-wasting diuretic. The nurse must monitor the serum potassium level and assess for signs of low potassium. As water and sodium are lost in the urine, blood pressure decreases, blood volume decreases, and urine output increases.

A child with suspected infective endocarditis arrives at the emergency department. Which assessment findings would the nurse anticipate in this child? Select all that apply.

murmur low-grade fever malaise headache Symptoms may include a low-grade intermittent fever, decrease in hemoglobin level, tachycardia, anorexia, weight loss, malaise, headache, joint and muscle pain, and decreased activity level. Bacteremia leads to these signs of an infection. The murmur is due to damage to the cardiac valves or myocardium.

A client is taking hydrochlorothiazide to treat heart failure. Which adverse effect should the nurse instruct the client to report to the health care provider?

muscle weakness Hydrochlorothiazide is a thiazide diuretic. Muscle weakness can be an indication of hypokalemia. Polyuria is associated with this diuretic, not urinary retention. Confusion and diaphoresis are not side effects of hydrochlorothiazide.

A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure?

potassium Diuretics, such as furosemide, are commonly used to treat acute heart failure. Most diuretics increase the renal excretion of potassium. The nurse should check the client's potassium level before administering diuretics, and obtain an order to replace potassium if the level is low. Other medications commonly used to treat heart failure include angiotensin-converting enzyme inhibitors, digoxin, and beta-adrenergic blockers. Although checking the platelet count, calcium level, and WBC count are important, these values don't affect medication administration for acute heart failure.

A client with acute pulmonary edema has been taking an angiotensin-converting enzyme (ACE) inhibitor. The nurse explains that this medication has been ordered to

reduce blood pressure ACE inhibitors are given to reduce blood pressure by inhibiting aldosterone production, which in turn decreases sodium and water reabsorption. ACE inhibitors also reduce production of angiotensin II, a potent vasoconstrictor. Diuretics are given to increase urine production. Vasodilators increase cardiac output. Negative inotropic agents decrease contractility.

An older adult client has been treated for stage 4 left-sided heart failure for several days. New laboratory results indicate serum sodium of 130 mEq/L (130 mmol/L), TCO2 36 mEq/L (36 mmol/L), and potassium 3.4 mEq/L (3.4 mmol/L). The nurse suspects these results are related to one of the client's medications prescribed to treat heart failure and its complications. The nurse prioritizes assessing what systems prior to contacting the healthcare provider about reassessing the medication?

respiratory status and fluid balance This client's laboratory results indicate hyponatremia, hypokalemia, and elevated bicarbonate levels (TCO2). The medication used to treat complications of heart failure that causes these symptoms is a loop diuretic such as furosemide. Before contacting the healthcare provider about the current dose of furosemide, the nurse assesses the most relevant parameters related to the diuresis for which furosemide is prescribed. This means the nurse checks for evidence of pulmonary edema such as decreased oxygen saturation and crackles upon lung auscultation. A medication that would affect heart rate and rhythm such as a beta blocker or other anti-arrythmia medication is not as likely to contribute to the lab results demonstrated as a loop diuretic would be. Decreased cerebral perfusion in late heart failure could contribute to neurological changes but this is not likely to be related to typical pharmacological treatments. Furosemide may also affect creatinine levels and urine output but these values are not as critical to assessing the need for a loop diuretic as fluid balance status and the ongoing presence of pulmonary edema.

Considering a client's atrial fibrillation, a nurse must administer digoxin with caution because it

stimulates the parasympathetic division of the autonomic nervous system, increasing tone A nurse must administer digoxin with caution in a client with atrial fibrillation because digoxin stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. The vagal effect slows the heart rate, increases the refractory period, and slows conduction through the atrioventricular node and junctional tissue, increasing the potential for new arrhythmias to develop. Digoxin doesn't constrict arteries. Although digoxin can trigger proarrhythmias, it does so by increasing vagal tone (not stroke volume).

A nurse is teaching a client with adrenal insufficiency about corticosteroids. Which statement by the client indicates a need for additional teaching?

"I may stop taking this medication when I feel better" The client requires additional teaching because they state that they may stop taking corticosteroids when they feel better. Corticosteroids should be gradually tapered by the physician. Tapering the corticosteroid allows the adrenal gland to gradually resume functioning. Corticosteroids increase the risk of infection and may mask the early signs of infection, so the client should avoid people who are sick. Corticosteroids cause muscle wasting in the extremities, so the client should increase their protein intake by eating foods such as chicken and dairy products. Corticosteroids have been linked to glaucoma and corneal lesions, so the client should visit their ophthalmologist regularly.

The nurse is caring for a client receiving digoxin who has begun vomiting and reports seeing colorful halos around the lights in the room. Which actions should the nurse implement? Select all that apply.

Discontinue administration of digoxin. Begin continuous electrocardiographic monitoring. Determine serum digoxin and electrolyte levels. Symptoms of digoxin toxicity include severe sinus bradycardia, colorful halos around lights, nausea, anorexia, and vomiting. If digoxin toxicity is suspected, the steps the nurse should implement include discontinue administration of drug; begin continuous electrocardiographic monitoring for cardiac dysrhythmias; administer any appropriate antidysrhythmic drugs as ordered; determine serum digoxin and electrolyte levels; administer potassium supplements for hypokalemia if indicated, as ordered; institute supportive therapy for gastrointestinal symptoms (nausea, vomiting, or diarrhea); and administer digoxin antidote (digoxin immune fab) if indicated, as ordered. Inserting a nasogastric tube or administering oxygen is not appropriate for digoxin toxicity.

The client has been prescribed lisinopril to treat hypertension. The nurse should assess the client for which electrolyte imbalance?

hyperkalemia Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor. Hyperkalemia can be a side effect of ACE inhibitors. Because of this side effect, ACE inhibitors should not be administered with potassium-sparing diuretics.