Exam 2 Chapter Questions
A patient presents to the ED and is diagnosed with an acute MI. The patient's spouse asks what type of damage has been caused by the "heart attack." What is the appropriate nursing response?
"A heart attack evolves over several hours. We won't know the extent of the damage immediately."
A client admitted to a telemetry unit with a new diagnosis of atrial fibrillation (AF) tells the nurse, "I feel fine, there's nothing wrong with me." Which nursing response is appropriate?
"AF can cause clots to form from irregular blood flow in the heart."
A client who is 9 days post-coronary artery bypass graft presents to a follow-up appointment. Which client statement requires nursing action?
"I have a bandage on my sternum to collect the drainage."
A patient is being discharged to home on warfarin (Coumadin) therapy to manage an acute pulmonary embolism. Which patient response indicates a need for further teaching by the nurse?
"I should eat more green leafy vegetables like spinach."
The primary health care provider prescribes warfarin for a client with atrial fibrillation. Which client statement indicates that additional education is needed?
"I'm glad I don't need to change my diet. Salads are my favorite food."
A client with COPD has just been reclassified for disease severity from a GOLD 2 to a GOLD 3. Which client statement about changes in management or lifestyle indicate to the nurse that more teaching is needed to prevent harm?
"Now I will try to rest as much as possible and avoid any unnecessary exercise."
The nurse is preparing to discharge a client who recently experienced a STEMI. Which client statement indicates understanding of nitroglycerin use?
"The nitroglycerin should tingle when I put it in my mouth."
A nurse interviewing an 82-year-old, somewhat confused client who is becoming a nursing home resident today asks the client's daughter if she would consent for the client to receive an
"The virus causing influenza often changes each year, and a new influenza vaccination is needed every flu season."
A client newly diagnosed with stage I nonsmall cell lung cancer (NSCLC) who is getting ready for curative surgery asks the nurse whether the oncologist might consider this new drug he has seen on television, pembrolizumab, instead of surgery. What is the nurse's best response?
"This drug is approved for use in clients whose lung cancer has metastasized not for early-stage cancers."
The nurse is caring for an 80-year old client with progressive fatigue, shortness of breath, and headaches. What assessment question will the nurse ask? Select all that apply.
"What medications do you routinely take?" "Could you tell me about your dietary habits?"
A nursing home client who has completed a 2-week course of antibiotics for bacterial pneumonia asks whether he can go out to a restaurant to celebrate his grandson's high school graduation if he uses a wheelchair. What is the nurse's best response?
"Yes, if you want to and feel that you could tolerate a couple of hours of sitting."
Which adults are at higher risk for development of active tuberculosis? Select all that apply.
38-year-old with HIV-III (AIDS) who stopped taking antiretroviral therapy 42-year-old injection drug user 50-year-old Guatemalan migrant farm worker 62-year-old incarcerated in prison for 20 years
On a telemetry monitor, the nurse observes that a patient's heart rhythm is sustained ventricular tachycardia (VT). Upon assessment, the patient is alert and oriented with no reports of chest pain, but expresses feeling slightly short of breath. His blood pressure is 108/70. What is the nurse's first action?
Administration of IV amiodarone (Cordarone) and dextrose
A client who 3 days ago underwent extensive abdominal surgery for cancer reports having a difficult time "catching her breath" and feeling very scared. After assessing the client, what is the nurse's best action or response to prevent harm?
Apply oxygen and initiate the Rapid Response Team
An attempt by a primary health care provider to intubate a client for mechanical ventilation is unsuccessful after 45 seconds. What is the nurse's priority action?
Applying oxygen with a bag-valve-mask device
A client in the telemetry unit is on a cardiac monitor. The monitor technician alerts the nurse that there are no ECG complexes, and the alarm is sounding. What is the first action by the nurse?
Assess the client and check lead placement.
The client, who is 24 hours postoperative after a right lower lobectomy for stage II lung cancer and has two chest tubes in place, reports intense burning pain in his lower chest. On assessment, the nurse notes there is no bubbling on exhalation in the water seal chamber. What action will the nurse perform first?
Assist the client to a side-lying position and reassess the water seal chamber for bubbling.
The nurse understands that patients with which dysrhythmia constitute the largest group of those hospitalized with dysrhythmias?
Atrial fibrillation
Which precaution has the highest priority for prevention of harm when the nurse teaches the client about home care after a bone marrow aspiration?
Avoid taking any aspirin or aspirin-containing products.
What is the most important precaution to prevent harm that a nurse will teach a client who is prescribed to take the anticoagulant drug warfarin?
Avoid taking aspirin or any aspirin-containing product unless prescribed.
A client who has been taking the four first-line drugs for tuberculosis treatment for a month reports all of the following changes. Which changes would cause the nurse to collaborate quickly with the health care provider? Select all that apply.
Blurry vision Yellowing of the sclera
You are contributing to the assessment of a client with chest pain. Which symptoms would be most indicative of an myocardia infarction (MI)? Select all that apply.
Chest pain associated with ECG changes Chest pain relieved only by opioids Chest pain associated with shortness of breath
When performing a medication reconciliation for a newly admitted client before planned abdominal surgery, the nurse notes that the client is prescribed salmeterol and fluticasone daily for asthma control. What is the priority action for the nurse to take regarding this information to prevent harm?
Collaborate with the surgeon to arrange for continuation of this therapy in the perioperative period.
The nurse understands that which of the following is the most common manifestation of pneumonia in the older adult patient?
Confusion
A client with primary pulmonary arterial hypertension (PAH) receiving treprostinil by continuous IV infusion now has a fever of 101.6°F (38.7°C). Which actions will the nurse perform to prevent harm? Select all that apply.
Culture the IV site Increase the treprostinil flow rate Initiate a second IV access and administer prescribed antibiotic
A client being mechanically ventilated has all of the following changes. Which changes are most relevant in helping the nurse determine whether suctioning is needed at this time? Select all that apply.
Decreased SpO 2 Crackles auscultated over the trachea High-pressure ventilator alarm sounds Presence of fluid within the endotracheal tube
The nurse is providing community education regarding myocardial infarction. What teaching will the nurse include? Select all that apply.
Denial is common reaction to chest pain. Age is a significant risk factor in the development of CAD. Women are more likely to experience atypical chest pain. Atherosclerosis is a primary factor in the development of CAD.
Which symptom or change in assessment of a client with four broken ribs on the right side indicates to the nurse the possibility of a tension pneumothorax?
Distended neck veins
Which condition, sign, or symptom does the nurse consider most relevant in assessing a client suspected to have ARDS? Select all that apply.
Dyspnea Intercostal retractions PaO 2 84% on oxygen at 6 L/min
Which client history information is most relevant for the nurse to document when assessing for a possible hematologic problem? Select all that apply.
Eats a vegan diet Mother has pernicious anemia Sprays fertilizers and weed killers for a lawn care company
Which precaution is a priority for the nurse to teach a client prescribed the gene therapy combination of ivacaftor/tezacaftor in order to prevent harm from this therapy?
Examine your skin and the whites of your eyes daily for a yellow appearance.
Which actions does the nurse ensure are performed for a client being mechanically ventilated to prevent ventilator-associated pneumonia (VAP)? Select all that apply.
Getting the patient out of bed as soon as prescribed Keeping the head of the bed elevated to 30 degrees or above Providing meticulous mouth care every 12 hours
The nurse is assessing a client who had a coronary artery bypass graft yesterday. Which assessment finding indicates the client is at risk for decreased perfusion?
Heart rate of 50 beats/min
The nurse is caring for client who is experiencing occasional premature ventricular contractions. What assessment data are most concerning to the nurse?
History of smoking
A nurse assessing an older adult client with pneumonia notes the client is now confused and the oxygen saturation has dropped since the last assessment 1 hour ago from 90% to 84%. The nurse also notes the respiratory rate has increased from 26 to 32. What is the nurse's best first action?
Increase her O2 flow rate by 2 L and reassess in 5 minutes.
Which response or health problem does the nurse expect to be present in a client who has a lifelong deficiency of antithrombin III?
Increased risk for clot formation and disruption of perfusion
When reviewing the laboratory results for a client in the emergency department, which finding does the nurse report immediately to prevent harm?
International normalized ratio (INR) is 5.2
A client is being transitioned from IV heparin to oral warfarin. Which laboratory finding does the nurse identify confirming that warfarin treatment is effective?
International normalized ratio (INR) of 2.5
The nurse assesses a client who had a coronary artery bypass graft yesterday. Which assessment finding will cause the nurse to suspect cardiac tamponade?
Muffled heart sounds with the presence of JVD
The nurse is assessing the client's cardiac rhythm and notes the following: HR 64, regular rhythm, PR interval 0.20; QRS 0.10. How will the nurse document this rhythm interpretation in the electronic health record?
Normal sinus rhythm
Upon entering a client's room, the nurse finds the client unresponsive. In what order will the nurse provide care?
Notify the Rapid Response Team Get the crash cart/AED Check carotid pulse Begin chest compressions Provide rescue breaths
Identify appropriate interventions for a patient experiencing inadequate oxygenation and tissue perfusion as a result of coronary artery disease. (Select all that apply.)
Notify the physician Maintain or initiate an IV line Apply oxygen via nasal cannula Administer nitroglycerin sublingually
A client with COPD has all of the following ABG changes from earlier today. Which change alerts the nurse to take immediate action to prevent harm?
Paco2 from 45 mm Hg to 68 mm Hg
The spouse of a 78-year-old client who was discharged to home 1 day ago after hospitalization for seasonal influenza calls to report the fever has returned and is now 103.4°F (39.7°C). What is the nurse's primary concern for this client?
Pneumonia may be present
Which statement about the genetics of cystic fibrosis is true?
Recessive disorder affecting chloride transport
The nurse is caring for a client with bleeding gums that reports increased fever, fatigue, malaise, and "chills." What is the priority nursing intervention?
Review laboratory data and prepare to obtain blood cultures
The nurse is caring for a client with chest pain. What assessment data would cause the nurse to suspect unstable angina? Select all that apply.
ST changes Pain lasts 15 to 25 minutes Increased number of angina attacks The intensity of the chest pain has increased
A 48-year old female asks about her chance of developing an MI. You discuss risk factors with her. Which modifiable risk factors will you assess to guide the client's teaching plan? Select all that apply.
Smoking Obesity Diet
While suctioning a client with a tracheostomy, the client becomes diaphoretic and nauseous and the heart rate decreases to 37 beats/min. What is the priority nursing action?
Stop suctioning the patient.
Which specific information will the nurse teach to the client with eosinophilic asthma newly prescribed benralizumab therapy?
The drug can only be given by a health care professional.
Which statement regarding erythrocytes is true?
The lack of a nucleus in a mature erythrocyte increases its life span.
A 45-year-old male client having an annual physical asks the nurse about his risk for developing a myocardial infarction (MI). Which modifiable risk factors will the nurse assess to guide the client's teaching plan? Select all that apply.
Tobacco use Diet Weight
The client, a woman who is 5 feet 11 inches tall and 176 lb (80 kg), has been mechanically ventilated at a tidal volume of 400 mL and a respiratory rate of 12 breaths/min for the past 24 hours. The most recent arterial blood gas (ABG) results for this client are pH = 7.32; PaO 2 = 84 mm Hg; PaCO 2 = 56 mm Hg. What is the nurse's interpretation of these results?
Ventilation inadequate; respiratory acidosis present.
The nurse teaching clients precautions to use with drug therapy for primary pulmonary arterial hypertension (PAH) instructs the female clients to use two reliable forms of contraception while taking which drugs? Select all that apply.
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