hesi evolve questions (respiratory, cardio)
When teaching a client with hypertension about a 2-gram sodium diet, which foods would the nurse instruct the client to avoid? Select all that apply. One, some, or all responses may be correct. - canned chili - ground beef - fresh salmon - luncheon meat - cooked broccoli
- canned chili - luncheon meat (55% nationwide answered correctly)
When teaching a client with heart failure about signs and symptoms that indicate a need to contact the primary health care provider, which clinical manifestations would the nurse include? Select all that apply. One, some, or all responses may be correct. - weight loss - extreme fatigue - coughing at night - excessive urination - difficulty breathing
- extreme fatigue - coughing at night - difficulty breathing (rationale: fatigue is caused by lack of oxygenation from decreased CO. as CO decreases, pulmonary congestion increases) (44% nationwide answered correctly)
Which diagnostic test is most important to obtain rapidly when caring for a client who has just arrived in the emergency department with possible acute coronary syndrome (ACS)? - chest radiograph - troponin T (cTnT) - creatine kinase MB (CK-MB) - 12-lead electrocardiogram (ECG)
12-lead electrocardiogram (ECG) (65% nationwide answered correctly)
Which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema (& COPD)? - prevents bronchial spasm - decreases air trapping in lung - improves alveolar surface area - strengthens diaphragmatic contraction
decreases air trapping in lung (rationale: provides positive pressure in airways during expiration, prolonging expiration & decreasing the air trapping which is a characteristic of emphysema) (64% nationwide answered correctly)
Which statement by a client is consistent with a diagnosis of heart failure? - "I see spots before my eyes." - "I am tired at the end of the day." - "I feel bloated when I eat a large meal." - "I have trouble breathing when I climb a flight of stairs."
"I have trouble breathing when I climb a flight of stairs." (rationale: dyspnea on exertion occurs with HF because of the heart's inability to meet the O2 needs) (87% nationwide answered correctly)
When a client is diagnosed with left-sided congestive heart failure, which assessment findings would the nurse expect? Select all that apply. One, some, or all responses may be correct. - dyspnea - crackles - frequent cough - peripheral edema - jugular distention
- dyspnea - crackles - frequent cough (LVF leads to pulmonary congestion) (62% nationwide answered correctly)
Which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? Select all that apply. One, some, or all responses may be correct. - fatigue - orthopnea - pitting edema - dry hacking cough - 4-pound weight gain
- fatigue - orthopnea - pitting edema - dry hacking cough - 4-pound weight gain (rationale: signs of worsening HF include fatigue, weakness, & orthopnea. other manifestations include pitting edema, weight gain, & dry hacking cough) (42% nationwide answered correctly)
Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? Select all that apply. One, some, or all responses may be correct. - mold - cold air - pet dander - air pollution - cigarette smoke
- mold - cold air - pet dander - air pollution - cigarette smoke (75% nationwide answered correctly)
Which information is needed to determine oxygen administration for a client with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of 87%? Select all that apply. One, some, or all responses may be correct. - level of orientation - arterial blood gases - bilateral lung sounds - complete blood count - pulmonary function test
arterial blood gases (rationale: to determine how much O2 to administer bc too much O2 can decrease breathing & lower respiratory drive) (21% nationwide answered correctly)
When caring for a client who has had a bronchoscopy in the ambulatory surgery unit, which action would the nurse take? - offer ice chips to decrease throat pain - avoid turning the head from side to side - keep the client in the semi-Fowler position - suggest medicated lozenges for sore throat.
keep the client in the semi-Fowler position (rationale: prevents fluid collecting in the interstitial spaces around the trachea) (73% nationwide answered correctly)
After an admission for acute coronary syndrome (ACS), a client is asked to notify the nursing staff before getting out of bed. After finding the client up walking alone in the hallways an hour later, which response by the nurse is best? - "Please go get back into your bed immediately." - "It must be frustrating to lose your independence." - "Sometimes after ACS, people feel dizzy and fall." - "The primary health care provider wants you to rest."
"Sometimes after ACS, people feel dizzy and fall." (rationale: provides the client with the rationale for the activity restriction and is more likely to lead to patient compliance) (65% nationwide answered correctly)
After the nurse has taught a client with asthma about use of a peak flow meter, which client statements indicate that the teaching has been effective? Select all that apply. One, some, or all responses may be correct. - "Readings in the green zone mean that my asthma is under control." - "If I get a reading in the yellow zone, I need to stop what I'm doing and rest for a while." - "If I get a reading in the red zone, then I need to use the quick relief inhaler and have my family take me to the hospital." - "I should check the peak flow readings at least twice a day until my baseline is established." - "I don't need to check my peak flow readings if I use the quick relief medication."
- "Readings in the green zone mean that my asthma is under control." - "If I get a reading in the red zone, then I need to use the quick relief inhaler and have my family take me to the hospital." - "I should check the peak flow readings at least twice a day until my baseline is established." (32% nationwide answered correctly)
For which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? Select all that apply. One, some, or all responses may be correct. - weight loss - unusual fatigue - dependent edema - nocturnal dyspnea - increased urinary output
- unusual fatigue - dependent edema - nocturnal dyspnea (rationale: unusual fatigue r/t decreased CO. dependent edema occurs with RVF because of hypervolemia. dyspnea at night is a sign of LVF) (57% nationwide answered correctly)
To avoid complications in a client who has developed severe bone marrow depression after receiving chemotherapy for cancer, which actions by the nurse are appropriate? Select all that apply. One, some, or all responses may be correct. - monitor for signs of alopecia - encourage an increase in fluids - wash hands before entering the client's room - advise use of a soft toothbrush for oral hygiene - report an elevation in temperature immediately - teach the client to avoid eating raw fruits or vegetables
- wash hands before entering the client's room - advise use of a soft toothbrush for oral hygiene - report an elevation in temperature immediately (rationale: bone marrow depression causes neutropenia putting pt at risk for infection. thrombocytopenia occurs with chemo induced bone marrow depression. temperature elevation indicates infection) (22% nationwide answered correctly)
Which modifiable risk factor would the nurse include in a community presentation on cardiovascular risk factors? Select all that apply. One, some, or all responses may be correct. - weight - inactivity - cholesterol - tobacco use - homocysteine
- weight - inactivity - cholesterol - tobacco use - homocysteine (46% nationwide answered correctly)
Which of these clients seen at a health fair will be most at risk for hypertension? - 23-year-old white man - 44-year-old white woman - 50-year-old Mexican-American woman - 62-year-old African American man
62-year-old African American man (94% nationwide answered correctly)
To determine whether a client is experiencing acute coronary syndrome (ACS), which component of the electrocardiogram would the nurse analyze? - P wave - PR interval - QRS complex - ST segment
ST segment (rationale: elevation or depression of the ST segment is indicative of ACS because of changes in electrical activity occurring in ischemia and injury) (66% nationwide answered correctly)
After a client has had bronchoscopy, which finding indicates that the client's gag reflex has returned? - alert and oriented - able to swallow saliva - speaks without difficulty - denies sore throat
able to swallow saliva (rationale: ability to swallow indicates intact gag reflex. pt can be alert and able to speak & still have diminished gag reflex. pt denying sore throat may have ongoing numbness & decreased gag reflex) (93% nationwide answered correctly)
A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), which would the nurse do? - initiate pulmonary hygiene to clear air passages of trapped mucus - instruct to deep-breathe slowly with inhalation longer than exhalation - encourage continuous rapid panting to promote respiratory exchange - administer oxygen at a low concentration to maintain respiratory drive
administer oxygen at a low concentration to maintain respiratory drive (rationale: with chronically high CO2 levels, it is believed that decreased O2 levels become the stimulus to breathe) (64% nationwide answered correctly)
How can the nurse describe heart failure to a client? - a cardiac condition caused by inadequate circulating blood volume - an acute state in which the pulmonary circulation pressure decreases - an inability of the heart to pump blood in proportion to metabolic needs - a chronic state in which the systolic blood pressure drops below 90 mm Hg
an inability of the heart to pump blood in proportion to metabolic needs (rationale: as the heart fails, CO decreases eventually reaching a level where there is very poor tissue perfusion) (79% nationwide answered correctly)
When an older client with heart failure is transferred from the emergency department to the medical service, which would the nurse on the unit do first? - interview the client for a health history - assess the client's heart and lung sounds - monitor the client's peripheral pulse quality - obtain the client's blood specimen for electrolytes.
assess the client's heart and lung sounds (85% nationwide answered correctly)
When admitting a client with acute coronary syndrome (ACS) to the telemetry unit after cardiac catheterization and percutaneous intervention (PCI), which action would the nurse take first? - attach the cardiac monitor - auscultate the heart sounds - check the intravenous fluid rate - assess alertness and orientation
attach the cardiac monitor (rationale: fatal dysrhythmias may occur within the first hours after MI, cardiac monitoring is a priority) (54% nationwide answered correctly)
Which action will the nurse include in the plan for care for a client after a bronchoscopy examination? - check for the gag reflex - send the client for a chest x-ray examination - assess breathing every 30 minutes - have the client avoid the Valsalva maneuver
check for the gag reflex (61% nationwide answered correctly)
Which action would the clinic nurse take when a client with chronic obstructive pulmonary disease (COPD) has a 10-mm area of induration after Mantoux testing? - document the result as a negative finding - teach the client about need for a chest x-ray - discuss latent tuberculosis with client - notify the local public health department
document the result as a negative finding (rationale: if induration was 15mm+ for this patient, a CXR would be indicated) (19% nationwide answered correctly)
Which parameter would the nurse assess in a client with right-sided heart failure? Select all that apply. One, some, or all responses may be correct. - fluid volume - lung sounds - mental status - respiratory rate - peripheral pulses
fluid volume (rationale: JVD, edema, ascites, & weight gain would be expected in right sided heart failure) (9% nationwide answered correctly)
Which finding for a client who has just returned to the nursing unit after bronchoscopy and lung biopsy would be most important to report to the health care provider? - client arousable, but lethargic - cough productive of bloody mucus - heart rate 126 beats per minute - client report of dry and sore throat
heart rate 126 beats per minute (rationale: tachycardia may indicate hemorrhage, a possible complication, & should immediately reported to HCP) (55% nationwide answered correctly)
Which finding in a client with asthma exacerbation requires the most rapid action by the nurse? - report of chest tightness - heart rate of 112 beats per minute - expiratory wheezes in both lungs - markedly decreased breath sounds
markedly decreased breath sounds (rationale: may indicate very limited airflow and life threatening asthma exacerbation. immediately check O2 & anticipate possible need for mechanical ventilation) (66% nationwide answered correctly)
When a nurse needs to administer oxygen at a fraction of inspired oxygen (FiO2) of about 40% to keep a client's oxygen saturation greater than 94%, which method would be best? - face tent - venturi mask - nasal cannula - simple face mask
nasal cannula (rationale: all of these are able to deliver FiO2 of 40%, but nasal cannula is most comfortable & least intrusive) (29% nationwide answered correctly)
When a client with acute coronary syndrome (ACS) is admitted to the coronary intensive care unit, which topic is a priority to include in teaching? - symptoms of worsening heart failure - use of daily low dose aspirin after discharge - need to report any chest discomfort to the nurses - importance of starting a walking and exercise program
need to report any chest discomfort to the nurses (59% nationwide answered correctly)
Which method of oxygen delivery would the nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? - face tent - venturi mask - nasal cannula - nonrebreather mask
nonrebreather mask (rationale: will deliver high O2 concentrations at a liter flow of 10-15 L/min) (73% nationwide answered correctly)
When the nurse manager is evaluating the care of a client receiving oxygen through a nasal cannula, which finding indicates a need for more staff education about oxygen therapy? - oxygen flow rate is set to 8 L/min - there is bubbling present in the humidifier - pressure areas of tubing along the ears are padded - smoking and open flame prohibited signs are clearly posted.
oxygen flow rate is set to 8 L/min (rationale: nasal cannula flow rates shouldn't exceed 6 L/min, higher flows don't increase FiO2, & high O2 flow increases drying & irritation of mucous membranes) (88% nationwide answered correctly)
Which diagnostic testing is most useful in evaluating the effectiveness of treatment for asthma? - chest x-ray - pulmonary function tests - serum eosinophil counts - immunoglobulin E levels
pulmonary function tests (rationale: PFT measures airflow. CXR can check for complications of asthma.) (89% nationwide answered correctly)
When a client with a history of hypertension that is usually successfully treated with medications has a blood pressure of 160/100 mm Hg during a clinic appointment, which action would the nurse take next? - teach the client about the need for a low sodium diet - ask the client when blood pressure medications were taken last - question the client about symptoms such as headache or chest pain - call for an ambulance to transport the client to the emergency department
question the client about symptoms such as headache or chest pain (rationale: the nurse's initial action would be to determine if the client is having symptoms indicating acute complications like stroke or ACS) (19% nationwide answered correctly)
A client with chronic obstructive pulmonary disease (COPD) is breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. Which action would the nurse take? - encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula - place the client in a side-lying position and perform chest physiotherapy using clapping and vibration - raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula - assist the client in assuming a position of comfort and perform postural drainage
raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula (rationale: sitting facilitates breathing by increasing lung expansion) (83% nationwide answered correctly)
Which dietary choice reflects the recommendations of the Dietary Approaches to Stop Hypertension (DASH) diet? Select all that apply. One, some, or all responses may be correct. - salami - pickles - salmon - french fries - canned soup
salmon (rationale: DASH includes fruits, veggies, low-fat or fat-free foods, fish, poultry, & reduced sugar) (61% nationwide answered correctly)
A client is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). Which action would the nurse take to prevent client fatigue? - provide small, frequent meals - encourage pursed-lip breathing - schedule nursing activities to allow for rest - encourage bed rest until energy level improves.
schedule nursing activities to allow for rest (rationale: rest limits muscle contractions, diminishes O2 needs, & decreases fatigue) (58% nationwide answered correctly)
Which instruction would the nurse include when teaching a client with asthma how to use a peak flow meter? - sit up straight in a firm chair - check peak flow early in the morning - take the deepest breath you can, then blow out hard and fast - calculate the average of 3 readings to obtain your peak flow
take the deepest breath you can, then blow out hard and fast (rationale: client is taught to stand for best readings, taken between 12-2pm when peak flow is highest, and reading is done 3x with highest reading recorded) (57% nationwide answered correctly)
Which laboratory value will be most important for the nurse to monitor to determine whether a client with chest pain has acute coronary syndrome (ACS)? - troponin T (cTnT) - C-reactive protein (CRP) - low-density lipoprotein (LDL) - B-type natriuretic protein (BNP)
troponin T (cTnT) (rationale: troponin are released into circulation within hours after myocardial injury or infarction and elevation in troponin helps determine the client is experiencing ACS) (79% nationwide answered correctly)
Which action by a client with asthma indicates that the client teaching about use of a peak flow meter has been effective? - calls the health care provider when peak flows are in the green zone - does deep breathing and relaxation exercises when peak flow is in the red zone - uses a quick relief inhaled medication when peak flow is in the yellow zone - stops taking the daily inhaled corticosteroid when peak flow is in the yellow zone
uses a quick relief inhaled medication when peak flow is in the yellow zone (rationale: peak flow in yellow zone are 50-80% of personal best and indicate need for quick relief inhaler like albuterol) (69% nationwide answered correctly)