Kelly's Q's

A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this client's teaching? (Select all that apply.) A) "Do not walk around barefoot." B) "Soak your feet in a tub each evening." C) "Trim toenails straight across with a nail clipper." D) "Treat any blisters or sores with Epsom salts." E) "Wash your feet every other day."

A) "Do not walk around barefoot." C) "Trim toenails straight across with a nail clipper." AC Clients who have diabetes mellitus are at high risk for wounds on the feet secondary to peripheral neuropathy and poor arterial circulation. The client should be instructed to not walk around barefoot or wear sandals with open toes. These actions place the client at higher risk for skin breakdown of the feet. The client should be instructed to trim toenails straight across with a nail clipper. Feet should be washed daily with lukewarm water and soap, but feet should not be soaked in the tub. The client should contact the provider immediately if blisters or sores appear and should not use home remedies to treat these wounds

After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? A) "The lower abdomen is the best location because it is closest to the pancreas." B) "I can reach my thigh the best, so I will use the different areas of my thighs." C) "By rotating the sites in one area, my chance of having a reaction is decreased." D) "Changing injection sites from the thigh to the arm will change absorption rates."

A) "The lower abdomen is the best location because it is closest to the pancreas." The abdominal site has the fastest rate of absorption because of blood vessels in the area, not because of its proximity to the pancreas. The other statements are accurate assessments of insulin administration.

A nurse cares for a client with DM who is visually impaired. The client asks, "Can I ask my niece to prefill my syringes and then store them for later use when I need them?" How should the nurse respond? A) "Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up." B) "Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light." C) "Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes." D) "No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container."

A) "Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up." Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled plastic syringes are stable for up to 3 weeks. They should be stored in the refrigerator in the vertical position with the needle pointing up to prevent suspended insulin particles from clogging the needle.

A nurse assesses clients at a health fair. Which clients should the nurse counsel to be tested for diabetes? (Select all that apply.) A) 56-year-old African-American male B) Female with a 30-pound weight gain during pregnancy C) Male with a history of pancreatic trauma D) 48-year-old woman with a sedentary lifestyle E) Male with a body mass index greater than 25 kg/m2 F) 28-year-old female who gave birth to a baby weighing 9.2 pounds

A) 56-year-old African-American male D) 48-year-old woman with a sedentary lifestyle E) Male with a body mass index greater than 25 kg/m2 F) 28-year-old female who gave birth to a baby weighing 9.2 pounds A D E F Risk factors for type 2 diabetes include certain ethnic/racial groups (African Americans, American Indians, Hispanics), obesity and physical inactivity, and giving birth to large babies. Pancreatic trauma and a 30-pound gestational weight gain are not risk factors.

A nurse collaborates with the interdisciplinary team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members should the nurse include in this interdisciplinary team meeting? (Select all that apply.) A) A registered dietitian B) Clinical pharmacist C) Occupational therapist D) Health care provider E) Speech-language pathologist

A) A registered dietitian B) Clinical pharmacist D) Health care provider A B D When planning care for a client newly diagnosed with diabetes mellitus, the nurse should collaborate with a registered dietitian, clinical pharmacist, and health care provider. The focus of treatment for a newly diagnosed client would be nutrition, medication therapy, and education. The nurse could also consult with a diabetic educator. There is no need for occupational therapy or speech therapy at this time.

A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the client's clinical manifestations have not changed. Which action should the nurse take next? A) Administer another half-cup of orange juice. B) Administer a half-ampule of dextrose 50% intravenously. C) Administer 10 units of regular insulin subcutaneously. D) Administer 1 mg of glucagon intramuscularly.

A) Administer another half-cup of orange juice. This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse should administer oral glucose in the form of orange juice. If the symptoms do not resolve immediately, the treatment should be repeated. The client does not need intravenous dextrose, insulin, or glucagon.

A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.) A) Advanced age B) Diabetes C) Ethnic background D) Medication use E) Smoking

A) Advanced age B) Diabetes C) Ethnic background E) Smoking ABCE Age, diabetes, ethnic background, and smoking are all risk factors for developing CAD; medication use is not.

A 72-year-old patient is diagnosed with hypothyroidism and levothyroxine (Synthroid) is prescribed. Which assessment is most important for the nurse to make during initiation of thyroid replacement? A) Apical pulse rate B) Nutritional intake C) Intake and output D) Orientation and alertness

A) Apical pulse rate In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina or dysrhythmias. The medication also is expected to improve mental status and fluid balance and will increase metabolic rate and nutritional needs, but these changes will not result in potentially life-threatening complications.

Which assessment finding for a patient who takes levothyroxine (Synthroid) to treat hypothyroidism indicates that the nurse should contact the health care provider before administering the medication? A) Increased thyroxine (T4) level B) Blood pressure 102/62 mm Hg C) Distant and difficult to hear heart sounds D) Elevated thyroid stimulating hormone level

A) Increased thyroxine (T4) level An increased thyroxine level indicates the levothyroxine dose needs to be decreased. The other data are consistent with hypothyroidism and the nurse should administer the Synthroid.

A nurse assesses a client with nephrotic syndrome. For which clinical manifestations should the nurse assess? (Select all that apply.) A) Proteinuria B) Hypoalbuminemia C) Dehydration D) Lipiduria E) Dysuria F) Costovertebral angle (CVA) tenderness

A) Proteinuria B) Hypoalbuminemia D) Lipiduria

A nurse provides diabetic education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? (Select all that apply.) A) Stroke B) Kidney failure C) Blindness D) Respiratory failure E) Cirrhosis

A) Stroke B) Kidney failure C) Blindness A B C Complications of diabetes mellitus are caused by macrovascular and microvascular changes. Macrovascular complications include coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Microvascular complications include nephropathy, retinopathy, and neuropathy. Respiratory failure and cirrhosis are not complications of diabetes mellitus.

A patient with Graves' disease is admitted to the emergency department with thyroid storm. Which of these prescribed medications should the nurse administer first? A) propranolol (Inderal) B) propylthiouracil (PTU) C) methimazole (Tapazole) D) iodine (Lugol's solution)

A) propranolol (Inderal) b-adrenergic blockers work rapidly to decrease the cardiovascular manifestations of thyroid storm. The other medications take days to weeks to have an impact on thyroid function.

A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this client's teaching? A) "When ill, avoid eating or drinking to reduce vomiting and diarrhea." B) "Monitor your blood glucose levels at least every 4 hours while sick." C) "If vomiting, do not use insulin or take your oral antidiabetic agent." D) "Try to continue your prescribed exercise regimen even if you are sick."

B) "Monitor your blood glucose levels at least every 4 hours while sick." When ill, the client should monitor his or her blood glucose at least every 4 hours. The client should continue taking the medication regimen while ill. The client should continue to eat and drink as tolerated but should not exercise while sick.

A nurse prepares to administer prescribed regular and NPH insulin. Place the nurse's actions in the correct order to administer these medications. 1. Inspect bottles for expiration dates. 2. Gently roll the bottle of NPH between the hands. 3. Wash your hands. 4. Inject air into the regular insulin. 5. Withdraw the NPH insulin. 6. Withdraw the regular insulin. 7. Inject air into the NPH bottle. 8. Clean rubber stoppers with an alcohol swab. A) 1, 3, 8, 2, 4, 6, 7, 5 B) 3, 1, 2, 8, 7, 4, 6, 5 C) 8, 1, 3, 2, 4, 6, 7, 5 D) 2, 3, 1, 8, 7, 5, 4, 6

B) 3, 1, 2, 8, 7, 4, 6, 5 After washing hands, it is important to inspect the bottles and then to roll the NPH to mix the insulin. Rubber stoppers should be cleaned with alcohol after rolling the NPH and before sticking a needle into either bottle. It is important to inject air into the NPH bottle before placing the needle in a regular insulin bottle to avoid mixing of regular and NPH insulin. The shorter-acting insulin is always drawn up first.

Which action should the nurse take first when caring for a patient who has just arrived on the unit after a thyroidectomy? A) Check the dressing for bleeding. B) Assess respiratory rate and effort. C) Take the blood pressure and pulse. D) Support the patient's head with pillows.

B) Assess respiratory rate and effort. Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany, and the priority nursing action is to assess the airway. The other actions also are part of the standard nursing care post-thyroidectomy but are not as high in priority.

A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client? A) Urine specific gravity of 1.033 B) Presence of protein in the urine C) Elevated capillary blood glucose level D) Presence of ketone bodies in the urine

B) Presence of protein in the urine Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result of renal dysfunction. Specific gravity is elevated with dehydration. Elevated capillary blood glucose levels and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function.

A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the client's diet should the nurse decrease? A) Carbohydrates B) Proteins C) Fats D) Total calories

B) Proteins Restriction of dietary protein to 0.8 g/kg of body weight per day is recommended for clients with microalbuminuria to delay progression to renal failure. The client's diet does not need to be decreased in carbohydrates, fats, or total calories.

While assessing a patient who has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy, the nurse obtains these data. Which information is most important to communicate to the surgeon? A) The patient is sleepy and hard to arouse. B) The patient has increasing swelling of the neck. C) The patient is complaining of 7/10 incisional pain. D) The patient's cardiac monitor shows a heart rate of 112.

B) The patient has increasing swelling of the neck.

A 78-year-old patient in a long-term care facility has these medications prescribed. After the patient is diagnosed with hypothyroidism, the nurse will need to consult with the health care provider before administration of A) docusate (Colace). B) diazepam (Valium). C) ibuprofen (Motrin). D) cefoxitin (Mefoxin).

B) diazepam (Valium). Worsening of mental status and myxedema coma can be precipitated by the use of sedatives, especially in older adults. The nurse should discuss the diazepam with the health care provider before administration. The other medications may be given safely to the patient

After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? A) "I should increase my intake of vegetables with higher amounts of dietary fiber." B) "My intake of saturated fats should be no more than 10% of my total calorie intake." C) "I should decrease my intake of protein and eliminate carbohydrates from my diet." D) "My intake of water is not restricted by my treatment plan or medication regimen."

C) "I should decrease my intake of protein and eliminate carbohydrates from my diet." The client should not completely eliminate carbohydrates from the diet, and should reduce protein if microalbuminuria is present. The client should increase dietary intake of complex carbohydrates, including vegetables, and decrease intake of fat. Water does not need to be restricted unless kidney failure is present.

A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the client's breath has a "fruity" odor. Which action should the nurse take? A) Encourage the client to use an incentive spirometer. B) Increase the client's intravenous fluid flow rate. C) Consult the provider to test for ketoacidosis. D) Perform meticulous pulmonary hygiene care.

C) Consult the provider to test for ketoacidosis. The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a "fruity" odor to the breath. Documentation should occur after all assessments have been completed. Using an incentive spirometer, increasing IV fluids, and performing pulmonary hygiene will not address this client's problem.

When planning teaching for a patient who was admitted with myxedema coma and diagnosed with hypothyroidism, which strategy will be best for the nurse to use? A) Delay teaching until patient discharge. B) Ensure privacy by asking visitors to leave. C) Provide written handouts of all information. D) Offer multiple options for management of therapies.

C) Provide written handouts of all information. Written instructions will be helpful to the patient because initially the hypothyroid patient may be unable to remember to take medications and other aspects of self-care. Since the treatment regimen is somewhat complex, teaching should be initiated well before discharge. Family members or friends should be included in teaching because the hypothyroid patient is likely to forget some aspects of the treatment plan. A simpler regimen will be easier to understand until the patient is euthyroid.

After teaching a client who has DM and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? A) "I have so many complications; exercising is not recommended." B) "I will exercise more frequently because I have so many complications." C) "I used to run for exercise; I will start training for a marathon." D) "I should look into swimming or water aerobics to get my exercise."

D) "I should look into swimming or water aerobics to get my exercise." Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury. Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury. The client should not exercise too vigorously.

A nurse cares for a client who has type 1 DM. The client asks, "Is it okay for me to have an occasional glass of wine?" How should the nurse respond? A) "Drinking any wine or alcohol will increase your insulin requirements." B) "Because of poor kidney function, people with diabetes should avoid alcohol." C) "You should not drink alcohol because it will make you hungry and overeat." D) "One glass of wine is okay with a meal and is counted as two fat exchanges."

D) "One glass of wine is okay with a meal and is counted as two fat exchanges." Under normal circumstances, blood glucose levels will not be affected by moderate use of alcohol when diabetes is well controlled. Because alcohol can induce hypoglycemia, it should be ingested with or shortly after a meal. One alcoholic beverage is substituted for two fat exchanges when caloric intake is calculated. Kidney function is not impacted by alcohol intake. Alcohol is not associated with increased hunger or overeating.

A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this client's teaching to prevent injury? A) "Examine your feet using a mirror every day." B) "Rotate your insulin injection sites every week." C) "Check your blood glucose level before each meal." D) "Use a bath thermometer to test the water temperature."

D) "Use a bath thermometer to test the water temperature." Clients with diminished sensory perception can easily experience a burn injury when bathwater is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and checking blood glucose levels will not prevent injury

A nurse teaches a client with type 1 diabetes mellitus. Which statement should the nurse include in this client's teaching to decrease the client's insulin needs? A) "Limit your fluid intake to 2 liters a day." B) "Animal organ meat is high in insulin." C) "Limit your carbohydrate intake to 80 grams a day." D) "Walk at a moderate pace for 1 mile daily."

D) "Walk at a moderate pace for 1 mile daily." Moderate exercise such as walking helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for clients with type 1 diabetes mellitus. Restricting fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least 130 grams of carbohydrates each day.

A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. Which action should the nurse take? A) Apply ice to the site to reduce inflammation. B) Consult the provider for a new administration route. C) Assess the client for other signs of cellulitis. D) Instruct the client to rotate sites for insulin injection.

D) Instruct the client to rotate sites for insulin injection. The client's tissue has been damaged from continuous use of the same site. The client should be educated to rotate sites. The damaged tissue is not caused by cellulitis or any type infection, and applying ice may cause more damage to the tissue. Insulin can only be administered subcutaneously and intravenously. It would not be appropriate or practical to change the administration route.

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately? A) Serum chloride level of 98 mmol/L B) Serum calcium level of 8.8 mg/dL C) Serum sodium level of 132 mmol/L D) Serum potassium level of 2.5 mmol/L

D) Serum potassium level of 2.5 mmol/L Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.

Which assessment finding for a 24-year-old patient admitted with Graves' disease requires the most rapid intervention by the nurse? A) BP 166/100 mm Hg B) Bilateral exophthalmos C) Heart rate 136 beats/minute D) Temperature 104.8° F (40.4° C)

D) Temperature 104.8° F (40.4° C) The patient's temperature indicates that the patient may have thyrotoxic crisis and that interventions to lower the temperature are needed immediately. The other findings also require intervention but do not indicate potentially life-threatening complications.

At a clinic visit, the nurse provides dietary teaching for a 56-year-old woman who was recently hospitalized with an exacerbation of chronic heart failure. The nurse determines that teaching is successful if the patient makes which statement? A) "I will limit the amount of milk and cheese in my diet." B) "I can add salt when cooking foods but not at the table." C) "I will take an extra diuretic pill when I eat a lot of salt." D) "I can have unlimited amounts of foods labeled as reduced sodium ."

"I will limit the amount of milk and cheese in my diet." Milk products should be limited to 2 cups per day for a 2500-mg sodium-restricted diet. Salt should not be added during food preparation or at the table. Diuretics should be taken as prescribed (usually daily) and not based on sodium intake. Foods labeled as reduced sodium contain at least 25% less sodium than regular.

The nurse prepares to administer digoxin (Lanoxin) 0.125 mg to an 82-year-old man admitted with influenza and a history of chronic heart failure. What should the nurse assess before giving the medication? A) Prothrombin time B) Urine specific gravity C) Serum potassium level D) Hemoglobin and hematocrit

C) Serum potassium level Serum potassium should be monitored because hypokalemia increases the risk for digoxin toxicity. Changes in prothrombin time, urine specific gravity, and hemoglobin or hematocrit would not require holding the digoxin dose.

After the nurse teaches the patient about the use of atenolol (Tenormin) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? A) "It is important not to suddenly stop taking the atenolol." B) "Atenolol will increase the strength of my heart muscle." C) "I can expect to feel short of breath when taking atenolol." D) "Atenolol will improve the blood flow to my coronary arteries."

A) "It is important not to suddenly stop taking the atenolol." Patients who have been taking b-blockers can develop intense and frequent angina if the medication is suddenly discontinued. Atenolol (Tenormin) decreases myocardial contractility. Shortness of breath that occurs when taking b-blockers for angina may be due to bronchospasm and should be reported to the health care provider. Atenolol works by decreasing myocardial oxygen demand, not by increasing blood flow to the coronary arteries.

A patient who is diagnosed with nephrotic syndrome has 3+ ankle and leg edema and ascites. Which nursing diagnosis is a priority for the patient? A) Excess fluid volume related to low serum protein levels B) Activity intolerance related to increased weight and fatigue C) Disturbed body image related to peripheral edema and ascites D) Altered nutrition: less than required related to protein restriction

A) Excess fluid volume related to low serum protein levels The patient has massive edema, so the priority problem at this time is the excess fluid volume. The other nursing diagnoses also are appropriate, but the focus of nursing care should be resolution of the edema and ascites.

A 70-year-old woman with chronic heart failure and atrial fibrillation asks the nurse why warfarin (Coumadin) has been prescribed for her to continue at home. Which response by the nurse is accurate? A) "The medication prevents blood clots from forming in your heart." B)"The medication dissolves clots that develop in your coronary arteries." C) "The medication reduces clotting by decreasing serum potassium levels." D) "The medication increases your heart rate so that clots do not form in your heart."

A) "The medication prevents blood clots from forming in your heart." Chronic heart failure causes enlargement of the chambers of the heart and an altered electrical pathway, especially in the atria. When numerous sites in the atria fire spontaneously and rapidly, atrial fibrillation occurs. Atrial fibrillation promotes thrombus formation within the atria with an increased risk of stroke and requires treatment with cardioversion, antidysrhythmics, and/or anticoagulants. Warfarin is an anticoagulant that interferes with hepatic synthesis of vitamin K-dependent clotting factors.

When admitting a patient with acute glomerulonephritis, it is most important that the nurse ask the patient about A) Recent sore throat and fever. B) history of high blood pressure. C) frequency of bladder infections. D) family history of kidney stones.

A) Recent sore throat and fever. Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by hypertension, urinary tract infection (UTI), or kidney stones.

The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important? A) Assess vital signs. B) Don a mask and gown. C) Gather needed supplies. D) Perform hand hygiene.

D) Perform hand hygiene. To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority

After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition? A) "I must decrease my intake of fat." B) "I will increase my intake of protein." C) "A decreased intake of carbohydrates will be required." D) "An increased intake of vitamin C is necessary."

B) "I will increase my intake of protein."

A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? A) "Fish oil is contraindicated with most drugs for CAD." B) "The best source is fish, but pills have benefits too." C) "There is no evidence to support fish oil use with CAD." D) "You can reverse CAD totally with diet and supplements."

B) "The best source is fish, but pills have benefits too." Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The best source is fish three times a week or some fish oil supplements. The other options are not accurate.

A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best? A) "The t-PA didn't dissolve the entire coronary clot." B) "The heparin keeps that artery from getting blocked again." C) "Heparin keeps the blood as thin as possible for a longer time." D) "The heparin prevents a stroke from occurring as the t-PA wears off."

B) "The heparin keeps that artery from getting blocked again." After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a "blood thinner," although laypeople may refer to it as such.

A few days after experiencing a myocardial infarction (MI), the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which response should the nurse make? A) "Where are you planning to go for your vacation?" B) "What do you think caused your chest pain episode?" C) "Sometimes plans need to change after a heart attack." D) "Recovery from a heart attack takes at least a few weeks."

B) "What do you think caused your chest pain episode?" When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff

A patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole (Bactrim) for 3 days. Which action will the nurse plan to take? A) Remind the patient about the need to drink 1000 mL of fluids daily. B) Obtain a midstream urine specimen for culture and sensitivity testing. C) Teach the patient to take the prescribed Bactrim for at least 3 more days. D) Suggest that the patient use acetaminophen (Tylenol) to treat the symptoms.

B) Obtain a midstream urine specimen for culture and sensitivity testing. Since uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Tylenol would not be as effective as other over-the-counter (OTC) medications such as phenazopyridine (Pyridium) in treating dysuria. The fluid intake should be increased to at least 1800 mL/day. Since the UTI has persisted after treatment with Bactrim, the patient is likely to need a different antibiotic.

For a patient who has been admitted the previous day to the coronary care unit with an acute myocardial infarction (AMI), the nurse will anticipate teaching about A) typical emotional responses to AMI. B) when patient cardiac rehabilitation will begin. C) discharge drugs such as aspirin and b-blockers. D) the pathophysiology of coronary artery disease.

B) when patient cardiac rehabilitation will begin. Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will prevent good understanding of complex information such as coronary artery disease (CAD) pathophysiology. Teaching about discharge medications should be done when the time for discharge is closer. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional response to myocardial infarction (MI).

A nurse cares for a middle-aged female client with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, "What can I do to help prevent these infections?" How should the nurse respond? A) "Test your urine daily for the presence of ketone bodies and proteins." B) "Use tampons rather than sanitary napkins during your menstrual period." C) "Drink more water and empty your bladder more frequently during the day." D) "Keep your hemoglobin A1c under 9% by keeping your blood sugar controlled."

C) "Drink more water and empty your bladder more frequently during the day."

Which of these statements made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? A)"I will switch from whole milk to 1% or nonfat milk." B)"I like fresh salmon and I will plan to eat it more often." C) "I will miss being able to eat peanut butter sandwiches." D) "I can have a cup of coffee with breakfast if I want one."

C) "I will miss being able to eat peanut butter sandwiches." Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from mono-saturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet.

Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider? A) Foul-smelling urine B) Complaint of flank pain C) Blood pressure 88/45 mm Hg D) Temperature 100.1° F (57.8° C)

C) Blood pressure 88/45 mm Hg The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported. The other findings are typical of pyelonephritis.

A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? A) Assess the client's pupillary responses. B) Request a neurologic consultation. C) Stop the infusion and call the provider. D) Take and document a full set of vital signs.

C) Stop the infusion and call the provider. A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.

The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom(s)? A) Muscle aches B) Constipation C) Pounding headache D) Anorexia and nausea

D) Anorexia and nausea S/S of dig toxicity: Confusion, Irregular pulse, Loss of appetite, nausea, vomiting, diarrhea, Palpitations/ Vision changes (unusual), including blind spots, blurred vision, changes in how colors look, or seeing spots.

The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) for a patient with cystitis has been effective when the patient states, A) "I can use vaginal sprays to reduce bacteria." B) "I will drink a quart of water or other fluids every day." C) "I will wash with soap and water before sexual intercourse." D) "I will empty my bladder every 3 to 4 hours during the day."

D) "I will empty my bladder every 3 to 4 hours during the day." Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is dis- couraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.

After the nurse teaches a patient with chronic stable angina about how to use the prescribed short-acting and long-acting nitrates, which statement by the patient indicates that the teaching has been effective? A) "I will put on the nitroglycerin patch as soon as I develop any chest pain." B) "I will check the pulse rate in my wrist just before I take any nitroglycerin." C) "I will be sure to remove the nitroglycerin patch before using any sublingual nitroglycerin." D) "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue."

D) "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue." The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates.

To prevent the recurrence of renal calculi, the nurse teaches the patient to A) use a filter to strain all urine. B) avoid dietary sources of calcium. C) drink diuretic fluids such as coffee. D) have 2000 to 3000 mL of fluid a day.

D) have 2000 to 3000 mL of fluid a day. A fluid intake of 2000 to 3000 mL daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.

When assessing the patient who has a lower urinary tract infection (UTI), the nurse will initially ask about A) nausea. B) flank pain. C) poor urine output. D) pain with urination

D) pain with urination Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI.

The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if A) the patient is restless and agitated. B) the blood pressure is 190/110 mm Hg. C) the patient complains about feeling anxious. D) the cardiac monitor shows a heart rate of 45.

D) the cardiac monitor shows a heart rate of 45. Patients taking b-blockers should be monitored for bradycardia. Because this category of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects.

A patient admitted with heart failure appears very anxious and complains of shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety (select all that apply)? A) Administer ordered morphine sulfate. B) Position patient in a semi-Fowler's position. C) Position patient on left side with head of bed flat. D) Instruct patient on the use of relaxation techniques. E) Use a calm, reassuring approach while talking to patient.

A) Administer ordered morphine sulfate. B) Position patient in a semi-Fowler's position. D) Instruct patient on the use of relaxation techniques. E) Use a calm, reassuring approach while talking to patient.

When admitting a patient with acute glomerulonephritis, it is most important that the nurse ask the patient about A) recent sore throat and fever. B) history of high blood pressure. C) frequency of bladder infections. D) family history of kidney stones.

A) recent sore throat and fever. Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by hypertension, urinary tract infection (UTI), or kidney stones.

A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? A) "Continue to educate the client on possible healthy changes." B) "Emphasize complications that can occur with noncompliance." C) "Tell the client that denial is normal and will soon go away." D) "You need to make sure the client understands this illness."

A) "Continue to educate the client on possible healthy changes." Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client.

A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? A) "Do you have any concerns about sexuality?" B) "I'm glad to hear you are sleeping well now." C) "Sleep near your spouse in case of emergency." D) "Why would you move into the guest room?"

A) "Do you have any concerns about sexuality?" Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse should investigate the reason for the move. The other two responses are likely to cause the client to be defensive.

After teaching a client with hypertension secondary to renal disease, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? A) "I can prevent more damage to my kidneys by managing my blood pressure." B) "If I have increased urination at night, I need to drink less fluid during the day." C) "I need to see the registered dietitian to discuss limiting my protein intake." D) "It is important that I take my antihypertensive medications as directed."

A) "I can prevent more damage to my kidneys by managing my blood pressure."

A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) A) Accompanied by shortness of breath B) Feelings of fear or anxiety C) Lasts less than 15 minutes D) No relief from taking nitroglycerin E) Pain occurs without known cause

A) Accompanied by shortness of breath B) Feelings of fear or anxiety D) No relief from taking nitroglycerin E) Pain occurs without known cause ABDE The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion.

A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? A) Allow family members to remain at the bedside. B) Ask the family if the client would like a fan in the room. C) Keep the television tuned to the client's favorite channel. D) Speak loudly to the client in case of hearing problems.

A) Allow family members to remain at the bedside. Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more.

A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A) Assist the client to the chair for meals and to the bathroom. B) Encourage the client to use the spirometer every 4 hours. C) Ensure the client wears TED hose or sequential compression devices. D) Have the client rate pain on a 0-to-10 scale and report to the nurse. E) Take and record a full set of vital signs per hospital protocol.

A) Assist the client to the chair for meals and to the bathroom. C) Ensure the client wears TED hose or sequential compression devices. E) Take and record a full set of vital signs per hospital protocol. The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done.

Which nursing action will be most helpful in decreasing the risk for hospital-acquired infection (HAI) of the urinary tract in patients admitted to the hospital? A) Avoid unnecessary catheterizations. B) Encourage adequate oral fluid intake. C) Test urine with a dipstick daily for nitrites. D) Provide thorough perineal hygiene to patients.

A) Avoid unnecessary catheterizations. Since catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful, but are not as useful as decreasing urinary catheter use.

A patient who has chest pain is admitted to the emergency department (ED), and all the following diagnostic tests are ordered. Which one will the nurse arrange to be completed first? A) Electrocardiogram (ECG) B) Computed tomography (CT) scan C) Chest x-ray D) Troponin level

A) Electrocardiogram (ECG) The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion. Troponin levels will increase after about 3 hours. Data from the CT scan and chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing a myocardial infarction (MI).

Four days after having a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with all the daily activities, saying, "I am too nervous to take care of myself." Based on this information, which nursing diagnosis is appropriate? A) Ineffective coping related to anxiety B) Activity intolerance related to weakness C) Denial related to lack of acceptance of the MI D) Social isolation related to lack of support system

A) Ineffective coping related to anxiety The patient data indicates that ineffective coping after the MI caused by anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or social isolation.

A few hours after returning to the surgical nursing unit, a patient who has undergone a subtotal thyroidectomy develops laryngeal stridor and a cramp in the right hand. Which action will the nurse anticipate taking next? A) Infuse IV calcium gluconate. B) Suction the patient's airway. C) Prepare for endotracheal intubation. D) Assist with emergency tracheostomy.

A) Infuse IV calcium gluconate. The patient's clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve the stridor. Suctioning will not correct the stridor.

4) Which information about a patient who has been receiving fibrinolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider? A) No change in the patient's chest pain B) A large bruise at the patient's IV insertion site C) A decrease in ST segment elevation on the electrocardiogram (ECG) D) An increase in cardiac enzyme levels since admission

A) No change in the patient's chest pain Continued chest pain suggests that the fibrinolytic therapy is not effective and that other interventions such as percutaneous coronary intervention (PCI) may be needed. Bruising is a possible side effect of fibrinolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST segment elevation indicates that fibrinolysis is occurring and perfusion is returning to the injured myocardium. An increase in cardiac enzyme levels is expected with reperfusion and is related to the washout of enzymes into the circulation as the blocked vessel is opened.

Which information about a patient who has been receiving fibrinolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider A) No change in the patient's chest pain B) A large bruise at the patient's IV insertion site C) A decrease in ST segment elevation on the electrocardiogram (ECG) D) An increase in cardiac enzyme levels since admission

A) No change in the patient's chest pain A Continued chest pain suggests that the fibrinolytic therapy is not effective and that other interventions such as percutaneous coronary intervention (PCI) may be needed. Bruising is a possible side effect of fibrinolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST segment elevation indicates that fibrinolysis is occurring and perfusion is returning to the injured myocardium. An increase in cardiac enzyme levels is expected with reperfusion and is related to the washout of enzymes into the circulation as the blocked vessel is opened.

A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the nurse recognize as a positive response to the prescribed treatment? A) The client has lost 11 pounds in the past 10 days. B) The client's urine specific gravity is 1.048. C) No blood is observed in the client's urine. D) The client's blood pressure is 152/88 mm Hg.

A) The client has lost 11 pounds in the past 10 days.

A patient who is being admitted to the emergency department with severe chest pain gives the following list of medications taken at home to the nurse. Which of the medications has the most immediate implications for the patient's care? A) sildenafil (Viagra) B) furosemide (Lasix) C) diazepam (Valium) D) captopril (Capoten)

A) sildenafil (Viagra) The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using sildenafil because of the risk of sudden death caused by vasodilation. The other home medications also should be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment.

A patient with ST segment elevation in several electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy? A) "Do you take aspirin on a daily basis?" B) "What time did your chest pain begin?" C) "Is there any family history of heart disease?" D)"Can you describe the quality of your chest pain?"

B) "What time did your chest pain begin?" Fibrinolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information also will be needed, but it will not be a factor in the decision about fibrinolytic therapy.

A patient with renal calculi is hospitalized with gross hematuria and severe colicky left flank pain. Which nursing action will be of highest priority at this time? A) Encourage oral fluid intake. B) Administer prescribed analgesics. C) Monitor temperature every 4 hours. D) Give antiemetics as needed for nausea.

B) Administer prescribed analgesics. Although all of the nursing actions may be used for patients with renal lithiasis, the patient's presentation indicates that management of pain is the highest priority action. If the patient has urinary obstruction, increasing oral fluids may increase the symptoms. There is no evidence of infection or nausea.

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? A) Administer oxygen at 2 L/min. B) Allow continued bathroom privileges. C) Obtain a bedside commode. D) Suggest the client use a bedpan.

B) Allow continued bathroom privileges. This client's physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.

A nurse provides health screening for a community health center with a large population of African-American clients. Which priority assessment should the nurse include when working with this population? A) Measure height and weight. B) Assess blood pressure. C) Observe for any signs of abuse. D) Ask about medications

B) Assess blood pressure.

A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.) A) Administer pain medication before ambulating. B) Assist the client into a position of comfort in bed. C) Encourage high-protein diet selections. D) Provide complementary therapies such as music. E) Remind the client to splint the incision when coughing.

B) Assist the client into a position of comfort in bed. D) Provide complementary therapies such as music. E) Remind the client to splint the incision when coughing. BDE Non-pharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures.

When admitting a patient with a myocardial infarction (MI) to the intensive care unit, which action should the nurse carry out first? A) Obtain the blood pressure. B) Attach the cardiac monitor. C) Assess the peripheral pulses. D) Auscultate the breath sounds.

B) Attach the cardiac monitor. Because dysrhythmias are the most common complication of MI, the first action should be to place the patient on a cardiac monitor. The other actions also are important and should be accomplished as quickly as possible.

A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? A) Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours B) Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg C) Client who is 1 day post percutaneous coronary intervention, going home this morning D) Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

B) Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for.

A nurse is caring for four clients. Which client should the nurse assess first? A) Client with an acute myocardial infarction, pulse 102 beats/min B) Client who is 1 hour post angioplasty, has tongue swelling and anxiety C) Client who is post coronary artery bypass, chest tube drained 100 mL/hr D) Client who is post coronary artery bypass, potassium 4.2 mEq/L

B) Client who is 1 hour post angioplasty, has tongue swelling and anxiety The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable.

A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals? A) Dirty carpets in need of vacuuming B) Expired food in the refrigerator C) Old medications in the kitchen D) Several cats present in the home

B) Expired food in the refrigerator Expired food in the refrigerator demonstrates a safety concern for the client and a possible lack of money to buy food. The nurse can consider a referral to Meals on Wheels or another home-based food program. Dirty carpets may indicate the client has no household help and is waiting for clearance to vacuum. Old medications can be managed by the home health care nurse and the client working collaboratively. Having pets is not a cause for concern.

A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commission's Core Measures outcomes? A) Obtain an electrocardiogram (ECG) now and in the morning. B) Give the client an aspirin. C) Notify the Rapid Response Team. D) Prepare to administer thrombolytics.

B) Give the client an aspirin. The Joint Commission's Core Measures set for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG is vital, but getting another one in the morning is not part of the Core Measures set. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed.

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) A) Age B) Hypertension C) Obesity D) Smoking E) Stress

B) Hypertension C) Obesity D) Smoking E) Stress BCDE Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.

The home care nurse visits a 73-year-old Hispanic woman with chronic heart failure. Which clinical manifestations, if assessed by the nurse, would indicate acute decompensated heart failure (pulmonary edema)? A) Fatigue, orthopnea, and dependent edema B) Severe dyspnea and blood-streaked, frothy sputum C) Temperature is 100.4o F and pulse is 102 beats/minute D) Respirations 26 breaths/minute despite oxygen by nasal cannula

B) Severe dyspnea and blood-streaked, frothy sputum Clinical manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate > 30 breaths per minute, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased.

Which information collected by the nurse who is admitting a patient with chest pain suggests that the pain is caused by an acute myocardial infarction (AMI)? A) The pain increases with deep breathing. B) The pain has persisted longer than 30 minutes. C) The pain worsens when the patient raises the arms. D) The pain is relieved after the patient takes nitroglycerin

B) The pain has persisted longer than 30 minutes. Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of pericarditis or musculoskeletal pain. Stable angina is usually relieved when the patient takes nitroglycerin.

The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 2.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What should the nurse do next? A) Withhold the daily dose until the following day. B) Withhold the dose and report the potassium level. C) Give the digoxin with a salty snack, such as crackers. D) Give the digoxin with extra fluids to dilute the sodium level.

B) Withhold the dose and report the potassium level. Normal Potassium: 3.5-5.0

When caring for a patient who has survived a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient A) that sudden cardiac death events rarely reoccur. B) about the purpose of outpatient Holter monitoring. C) how to self-administer low-molecular-weight heparin. D) to limit activities after discharge to prevent future events.

B) about the purpose of outpatient Holter monitoring. Holter monitoring is used to determine whether the patient is experiencing dysrhythmias such as ventricular tachycardia during normal daily activities. SCD is likely to recur. Heparin will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting

A patient with hyperthyroidism is treated with radioactive iodine (RAI) at a clinic. Before the patient is discharged, the nurse instructs the patient A) that symptoms of hyperthyroidism should be relieved in about a week. B) that symptoms of hypothyroidism may occur as the RAI therapy takes effect. C) to discontinue the antithyroid medications taken before the radioactive therapy. D) about radioactive precautions to take with urine, stool, and other body secretions.

B) that symptoms of hypothyroidism may occur as the RAI therapy takes effect. There is a high incidence of postradiation hypothyroidism after RAI, and the patient should be monitored for symptoms of hypothyroidism. RAI has a delayed response, with the maximum effect not seen for 2 to 3 months, and the patient will continue to take antithyroid medications during this time. The therapeutic dose of radioactive iodine is low enough that no radiation safety precautions are needed.

After the nurse has finished teaching a patient about use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? A) "I can expect indigestion as a side effect of nitroglycerin." B) "I can only take the nitroglycerin if I start to have chest pain." C) "I will call an ambulance if I still have pain 5 minutes after taking the nitroglycerin." D) "I will help slow down the progress of the plaque formation by taking nitroglycerin."

C) "I will call an ambulance if I still have pain 5 minutes after taking the nitroglycerin." The emergency medical services (EMS) system should be activated when chest pain or other symptoms are not completely relieved 5 minutes after taking one nitroglycerin. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.

The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? A) "It constricts vessels, improving blood flow." B) "It dilates vessels, which lessens the work of the heart." C) "It increases the force of the heart's contractions." D) "It slows the heart rate down for better filling."

C) "It increases the force of the heart's contractions." A positive inotrope is a medication that increases the strength of the heart's contractions. The other options are not correct.

A nurse cares for a client who has pyelonephritis. The client states, "I am embarrassed to talk about my symptoms." How should the nurse respond? A) "I am a professional. Your symptoms will be kept in confidence." B) "I understand. Elimination is a private topic and shouldn't be discussed." C) "Take your time. It is okay to use words that are familiar to you." D) "You seem anxious. Would you like a nurse of the same gender to care for you?"

C) "Take your time. It is okay to use words that are familiar to you."

Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response, which of these assessment data would indicate that the exercise level should be decreased? A) BP changes from 118/60 to 126/68 mm Hg. B) Oxygen saturation drops from 100% to 98%. C) Heart rate increases from 66 to 90 beats/minute. D) Respiratory rate goes from 14 to 22 breaths/minute.

C) Heart rate increases from 66 to 90 beats/minute. A change in heart rate of more than 20 beats or more indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen saturation, are normal responses to exercise.

The nurse has just received change-of-shift report about the following four patients. Which patient should the nurse assess first? A) 38-year-old who has pericarditis and is complaining of sharp, stabbing chest pain B) 45-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge C) 51-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI) D) 60-year-old with variant angina who is to receive a scheduled dose of nifedipine (Procardia)

C) 51-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI) This patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient's blood pressure, pulse, and the access site immediately. The other patients also should be assessed as quickly as possible, but assessment of this patient has the highest priority.

A 54-year-old male patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first? A) Perform a bladder scan to assess for urinary retention. B) Restrict the patient's oral fluid intake to 500 mL per day. C) Assist the patient to a sitting position with arms on the over-bed table. D) Instruct the patient to use pursed-lip breathing until the dyspnea subsides.

C) Assist the patient to a sitting position with arms on the over-bed table. The nurse should place the patient with ADHF in a high Fowler's position with the feet horizontal in the bed or dangling at the bedside. This position helps decrease venous return because of the pooling of blood in the extremities. This position also increases the thoracic capacity, allowing for improved ventilation. Pursed-lip breathing helps with obstructive air trapping but not with acute pulmonary edema. Restricting fluids takes considerable time to have an effect.

To assist the patient with coronary artery disease (CAD) in making appropriate dietary changes, which of these nursing interventions will be most effective? A) Instruct the patient that a diet containing no saturated fat and minimal sodium will be necessary. B) Emphasize the increased risk for cardiac problems unless the patient makes the dietary changes. C) Assist the patient to modify favorite high-fat recipes by using monosaturated oils when possible. D) Provide the patient with a list of low-sodium, low-cholesterol foods that should be included in the diet.

C) Assist the patient to modify favorite high-fat recipes by using monosaturated oils when possible. Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monosaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Removing saturated fat from the diet completely is not a realistic expectation; up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.

4) A patient who has had severe chest pain for several hours is admitted with a diagnosis of possible acute myocardial infarction (AMI). Which of these ordered laboratory tests should the nurse monitor to help determine whether the patient has had an AMI? A) Homocysteine B) C-reactive protein C) Cardiac-specific troponin I and troponin T D) High-density lipoprotein (HDL) cholesterol

C) Cardiac-specific troponin I and troponin T Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI). The other laboratory data are useful in determining the patient's risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress.

A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 110. Based on this information, which nursing diagnosis is a priority for the patient? A) Acute pain related to myocardial ischemia B) Anxiety related to perceived threat of death C) Decreased cardiac output related to cardiogenic shock D) Activity intolerance related to decreased cardiac output

C) Decreased cardiac output related to cardiogenic shock All the nursing diagnoses may be appropriate for this patient, but the hypotension indicates that the priority diagnosis is decreased cardiac output, which will decrease perfusion to all vital organs (e.g., brain, kidney, heart).

9) What results in the edema associated with nephrotic syndrome? A) Hypercoagulability B) Hyperalbuminemia C) Decreased plasma oncotic pressure D) Decreased GFR

C) Decreased plasma oncotic pressure C: The massive proteinuria that results from increased glomerular membrane permeability in Nephrotic Syndrome leaves the blood without adequate proteins (hypoalbuminemia) to create an oncotic colloidal pressure to hold fluid in the vessels. Without op, fluid moves into the interstitium, causing severe edema. Hypercoagulablity occurs, but it's not a factor in edema formation.

A patient with Graves' disease has exophthalmos. Which nursing action will be included in the plan of care? A) Apply eye patches to protect the cornea from irritation. B) Place cold packs on the eyes to relieve pain and swelling. C) Elevate the head of the patient's bed to reduce periorbital fluid. D) Teach the patient to blink every few seconds to lubricate the cornea.

C) Elevate the head of the patient's bed to reduce periorbital fluid. The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos the patient is unable to close the eyes completely. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring. The swelling of the eye is not caused by excessive blood flow to the eye, so cold packs will not be helpful.

Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response, which of these assessment data would indicate that the exercise level should be decreased? A) BP changes from 118/60 to 126/68 mm Hg. B) Oxygen saturation drops from 100% to 98%. C) Heart rate increases from 66 to 90 beats/minute. D) Respiratory rate goes from 14 to 22 breaths/minute

C) Heart rate increases from 66 to 90 beats/minute. A change in heart rate of more than 20 beats or more indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen saturation, are normal responses to exercise.

A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? A) Administer an aspirin. B) Call for an electrocardiogram (ECG). C) Maintain airway patency. D) Notify the provider.

C) Maintain airway patency. Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the provider's prescription and the client's current medications.

Which assessment finding by the nurse who is caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the physician? A) Complaints of incisional chest pain B) Crackles audible at both lung bases C) Pallor and weakness of the right hand D) Redness on either side of the chest incision

C) Pallor and weakness of the right hand The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected and/or require nursing interventions.

Which finding by the nurse for a patient admitted with glomerulonephritis indicates that treatment has been effective? A) The patient denies pain with voiding. B) The urine dipstick is negative for nitrites. C) Peripheral and periorbital edema is resolved. D) The antistreptolysin-O (ASO) titer is decreased.

C) Peripheral and periorbital edema is resolved. Since edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Antibodies to streptococcus will persist after a streptococcal infection. Nitrites will be negative and the patient will not experience dysuria since the patient does not have a urinary tract infection.

Which finding by the nurse for a patient admitted with glomerulonephritis indicates that treatment has been effective? A) The patient denies pain with voiding. B) The urine dipstick is negative for nitrites. C) Peripheral and periorbital edema is resolved. D) The antistreptolysin-O (ASO) titer is decreased.

C) Peripheral and periorbital edema is resolved. Since edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Antibodies to streptococcus will persist after a streptococcal infection. Nitrites will be negative and the patient will not experience dysuria since the patient does not have a urinary tract infection.

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? A) Blood pressure that is 20 mm Hg below baseline B) Oxygen saturation of 94% on room air C) Poor peripheral pulses and cool skin D) Urine output of 1.2 mL/kg/hr for 4 hours

C) Poor peripheral pulses and cool skin Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.

A patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect to find related to this illness? A) Poor skin turgor B) High urine ketones C) Recent weight gain D) Low blood pressure

C) Recent weight gain The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high.

A patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect to find related to this illness? A) Poor skin turgor B) High urine ketones C) Recent weight gain D) Low blood pressure

C) Recent weight gain The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high.

A nurse reviews laboratory results for a client with glomerulonephritis. The client's glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.) A) Excessive GFR B) Normal GFR C) Reduced GFR D) Potential for fluid overload E) Potential for dehydration

C) Reduced GFR D) Potential for fluid overload

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine (Pyridium)? A) Take the medication for at least 7 days. B) Use sunscreen while taking the Pyridium. C) The urine may turn a reddish-orange color. D) Use the Pyridium before sexual intercourse.

C) The urine may turn a reddish-orange color. Patients should be taught that Pyridium will color the urine deep orange. Urinary analgesics should only be needed for a few days until the prescribed antibiotics decrease the bacterial count. Taking Pyridium before intercourse will not be helpful in reducing the risk for UTI. Pyridium does not cause photosensitivity.

During the administration of the fibrinolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences A) bleeding from the gums. B) surface bleeding from the IV site. C) a decrease in level of consciousness. D) a nonsustained episode of ventricular tachycardia.

C) a decrease in level of consciousness. The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of fibrinolytic therapy. Bleeding of the gums and prolonged bleeding from IV sites are expected side effects of the therapy. The nurse should address these by avoiding any further injuries, but they are not an indication to stop infusion of the fibrinolytic medication. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective.

2) A patient's renal calculus is analyzed as being very high in uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid eating A) milk and dairy products. B) legumes and dried fruits. C) organ meats and sardines. D) spinach, chocolate, and tea.

C) organ meats and sardines. Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.

A patient's renal calculus is analyzed as being very high in uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid eating A) milk and dairy products. B) legumes and dried fruits. C) organ meats and sardines. D) spinach, chocolate, and tea

C) organ meats and sardines. Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.

When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing action should the nurse delegate to an LPN/LVN? A) Perform the initial assessment of the catheter insertion site. B) Teach the patient about the usual postprocedure plan of care. C) Check the rate on the infusion pump used to administer heparin. D) Administer the scheduled aspirin and lipid-lowering medication.

D) Administer the scheduled aspirin and lipid-lowering medication. Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and administration of intravenous anticoagulant medications should be done by the RN

Which information will the nurse include when teaching a patient who has been newly diagnosed with Graves' disease? A) Exercise is contraindicated to avoid increasing metabolic rate. B) Restriction of iodine intake is needed to reduce thyroid activity. C) Surgery will eventually be required to remove the thyroid gland. D) Antithyroid medications may take several weeks to have an effect

D) Antithyroid medications may take several weeks to have an effect Medications used to block the synthesis of thyroid hormones may take several weeks before an effect is seen. Large doses of iodine are used to inhibit the synthesis of thyroid hormones. Exercise using large muscle groups is encouraged to decrease the irritability and hyperactivity associated with high levels of thyroid hormones. Radioactive iodine is the most common treatment for Graves' disease, although surgery may be used.

When administering IV nitroglycerin (Tridil) to a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? A) Check blood pressure. B) Monitor apical pulse rate. C) Monitor for dysrhythmias. D) Ask about chest discomfort.

D) Ask about chest discomfort. The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and BP and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.

When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having balloon angioplasty, the nurse obtains the following assessment data. Which data indicate the need for immediate intervention by the nurse? A) Pedal pulses 1+ B) Heart rate 100 beats/min C) Blood pressure 104/56 mm Hg D) Chest pain level 8 on a 10-point scale

D) Chest pain level 8 on a 10-point scale The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.

A 72-year-old who has benign prostatic hyperplasia is admitted to the hospital with chills, fever, and vomiting. Which finding by the nurse will be most helpful in determining whether the patient has an upper urinary tract infection (UTI)? A) Suprapubic pain B) Bladder distention C) Foul-smelling urine D) Costovertebral tenderness

D) Costovertebral tenderness Costovertebral tenderness is characteristic of pyelonephritis. The other symptoms are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI.

The nurse obtains the following data when caring for a patient who experienced an acute myocardial infarction (AMI) 2 days previously. Which information is most important to report to the health care provider? A) The patient denies ever having a heart attack. B) The cardiac-specific troponin level is elevated. C) The patient has occasional premature atrial contractions (PACs). D) Crackles are auscultated bilaterally in the mid-lower lobes.

D) Crackles are auscultated bilaterally in the mid-lower lobes. The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. Elevation in cardiac troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI.

The nurse is providing care for a patient who has been admitted to the hospital for the treatment of nephrotic syndrome. Which of the following is a priority nursing assessment in the care of this patient? A) Assessment of pain and level of consciousness B) Assessment of serum calcium and phosphorus levels C) Blood pressure and assessment for orthostatic hypotension D) Daily weights and measurement of the patient's abdominal girth

D) Daily weights and measurement of the patient's abdominal girth Peripheral edema is characteristic of nephrotic syndrome and a key nursing responsibility in the care of patients with the disease is close monitoring of abdominal girth, weights, and extremity size. Pain, level of consciousness, and blood pressure are less important in the care of patients with nephrotic syndrome. Abnormal calcium and phosphorus levels are not commonly associated with the etiology of nephrotic syndrome.

When the nurse is caring for a patient who has had left-sided extracorporeal shock wave lithotripsy, which assessment finding is most important to report to the health care provider? A) Blood in urine B) Left flank pain C) Left flank bruising D) Drop in urine output

D) Drop in urine output Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy.

A patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin? A) Platelet aggregation is enhanced by IV heparin infusion. B) Heparin will dissolve the clot that is blocking blood flow to the heart. C) Coronary artery plaque size and adherence are decreased with heparin. D) Heparin will prevent the development of new clots in the coronary arteries.

D) Heparin will prevent the development of new clots in the coronary arteries. Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation.

Which of these nursing interventions included in the plan of care for a patient who had an acute myocardial infarction (AMI) 3 days ago is most appropriate for the RN to delegate to an experienced LPN/LVN? A) Evaluating the patient's response to ambulation in the hallway B) Completing the documentation for a home health nurse referral C) Educating the patient about the pathophysiology of heart disease D) Reinforcing teaching about the purpose of prescribed medications

D) Reinforcing teaching about the purpose of prescribed medications LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient response to exercise after an AMI requires more education and should be done by the RN. Teaching and discharge planning/documentation are higher level skills that require RN education and scope of practice.

Which electrocardiographic (ECG) change is most important for the nurse to communicate to the health care provider when caring for a patient with chest pain? A) Frequent premature atrial contractions (PACs) B) Inverted P wave C) Sinus tachycardia D) ST segment elevation

D) ST segment elevation The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI) and immediate therapy with percutaneous coronary intervention (PCI) or fibrinolytic medications is indicated to minimize the amount of myocardial damage. The other ECG changes also may suggest a need for therapy, but not as rapidly

A 62-year-old asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is most appropriate to include in the care plan? A) Assist the patient to the bathroom q3hr. B) Place a commode at the patient's bedside. C) Demonstrate how to perform the Credé maneuver. D) Teach the patient how to perform Kegel exercises

D) Teach the patient how to perform Kegel exercises Exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence.

A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is best? A) Ask the family members to wait in the waiting area. B) Inform the client that this behavior is unacceptable. C) Stay out of the room to decrease the client's stress levels. D) Tell the client that anxiety is common and that you can help.

D) Tell the client that anxiety is common and that you can help. Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse should reassure the client that fear is common and offer to help. The other actions will not reduce the client's anxiety.

Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? A)The patient rates the pain at a level 3 to 5 (0 to 10 scale). B) The patient states that the pain "wakes me up at night." C) The patient says that the frequency of the pain has increased over the last few weeks. D) The patient states that the pain is resolved after taking one sublingual nitroglycerin tablet.

D) The patient states that the pain is resolved after taking one sublingual nitroglycerin tablet. Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.

Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? A) The patient rates the pain at a level 3 to 5 (0 to 10 scale). B) The patient states that the pain "wakes me up at night." C) The patient says that the frequency of the pain has increased over the last few weeks. D) The patient states that the pain is resolved after taking one sublingual nitroglycerin tablet.

D) The patient states that the pain is resolved after taking one sublingual nitroglycerin tablet. Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.

3) When developing a health teaching plan for a 60-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the A) family history of coronary artery disease. B) increased risk associated with the patient's gender. C) high incidence of cardiovascular disease in older people. D) elevation of the patient's serum low density lipoprotein (LDL) level.

D) elevation of the patient's serum low density lipoprotein (LDL) level. Because family history, gender, and age are non-modifiable risk factors, the nurse should focus on the patient's LDL level. Decreases in LDL will help reduce the patient's risk for developing CAD.

To prevent the recurrence of renal calculi, the nurse teaches the patient to A) use a filter to strain all urine. B) avoid dietary sources of calcium. C) drink diuretic fluids such as coffee. D) have 2000 to 3000 mL of fluid a day

D) have 2000 to 3000 mL of fluid a day. A fluid intake of 2000 to 3000 mL daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.

Nadolol (Corgard) is prescribed for a patient with angina. To determine whether the drug is effective, the nurse will monitor for A) decreased blood pressure and apical pulse rate. B) fewer complaints of having cold hands and feet. C) improvement in the quality of the peripheral pulses. D) the ability to do daily activities without chest discomfort.

D) the ability to do daily activities without chest discomfort. Because the medication is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure (BP) and apical pulse rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective b-blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in peripheral pulse quality or skin temperature.