Level 2 Gas Exchange, Perfusion, and Clotting

When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial blood pressure (BP) of 154/82 mm Hg and an ankle pressure of 112/74 mm Hg. The nurse calculates the patient's ankle-brachial index (ABI) as (round up to the nearest hundredth).

0.73 112/154

A priority for the nurse in the administration of oral medications and prevention of aspiration is: 1 Checking for a gag reflex 2 Allowing the client to self-administer 3 Assessing the ability to cough 4 Using straws and extra water for administration

1 To protect the client from aspiration, the nurse should determine the presence of a gag reflex before administering oral medications. The nurse should first check for a gag reflex. Then, if possible, the client should be allowed to self-administer oral medications. Checking for a gag reflex takes priority over assessing the ability to cough in preventing aspiration. Straws should be avoided because they decrease the control the client has over volume intake, which increases the risk of aspiration. Some clients cannot tolerate thin liquids such as water, and need for them to be thickened.

The client is assessed by the nurse as having a high risk for aspiration. The nursing diagnosis identified for the client is feeding self-care deficit related to unilateral weakness. An appropriate technique for the nurse to use when assisting the client with feeding is to: 1 Place food in the unaffected side of the mouth 2 Place the client in semi-Fowlers position 3 Have the client use a straw 4 Use thinner liquids

1 If the client has unilateral weakness, the nurse should place food in the stronger side of the mouth. The client should be positioned in an upright, seated position to prevent aspiration.Clients with unilateral weakness often have difficulty using a straw. Thickened liquids are often tolerated better and will help prevent aspiration, because clients with impaired swallowing often choke more with thin liquids.

The nurse measures a patient's blood pressure as 172/82 mm Hg. What is the patient's mean arterial pressure (MAP)?

112 mm Hg (172+2(82))/3

Which group of drugs will the nurse plan to include when teaching a patient who has a new diagnosis of peripheral artery disease (PAD)? a. Statins b. Antibiotics c. Thrombolytics d. Anticoagulants

A Statin use by patients with PAD improves multiple outcomes; aggressive lipid management is needed for all patients with PAD. Antibiotics are not needed as PAD is not associated with infection. Thrombolytics and/or anticoagulants may be used in treatment of acute arterial occlusion, but are not part of general management of PAD.

A patient who was admitted the previous day with pneumonia reports a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take first? a. Auscultate for breath sounds. b. Administer as-needed morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

A The patient's statement indicates that pleurisy or a pleural effusion may have developed, and the nurse will need to listen for a pleural friction rub and decreased breath sounds. Pneumonia does not usually cause severe pain, so assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.

The nurse is caring for a neonate with a suspected tracheoesophageal fistula (TEF). Nursing care should include which of the following? a. Elevating the head but give nothing by mouth b. Elevating the head for feedings c. Feeding glucose water only d. Avoiding suction unless infant is cyanotic

A When a newborn is suspected of having TEF, the most desirable position is supine with the head elevated on an incline plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. Feedings should not be given to infants suspected of having TEF. The oral pharynx should be kept clear of secretion by oral suctioning. This is to avoid cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.

Which classification of drugs is used to relieve an acute asthma episode? a. Short-acting beta2-adrenergic agonist b. Inhaled corticosteroids c. Leukotriene blockers d. Long-acting bronchodilators

A A short-acting beta2-adrenergic agonist is the first medication administered. Later, systemic corticosteroids decrease airway inflammation in an acute asthma attack. They are given for short courses of 5 to 7 days. Inhaled corticosteroids are used for long-term, routine control of asthma. Leukotriene blockers diminish the mediator action of leukotrienes and are used for long-term, routine control of asthma in children older than 12 years. A long-acting bronchodilator would not relieve acute symptoms.

What is the priority nursing intervention for a child hospitalized with hemarthrosis resulting from hemophilia? a. Immobilization and elevation of the affected joint b. Administration of acetaminophen for pain relief c. Assessment of the child's response to hospitalization d. Assessment of the impact of hospitalization on the family system

A Although acetaminophen may help with pain associated with the treatment of hemarthrosis, it is not the priority nursing intervention. Although acetaminophen may help with pain associated with the treatment of hemarthrosis, it is not the priority nursing intervention. Assessment of a child's response to hospitalization is relevant to all hospitalized children; however, in this situation, psychosocial concerns are secondary to physiologic concerns. A priority nursing concern for this child is the management of hemarthrosis. Assessing the impact of hospitalization on the family system is relevant to all hospitalized children, but it is not the priority in this situation.

A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment would the nurse complete first? a. Listen to the patient's breath sounds. b. Ask about inhaled corticosteroid use. c. Determine when the dyspnea started. d. Measure forced expiratory volume (FEV) flow rate

A Assessment of the patient's breath sounds will help determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient's status at present. Most patients having an acute attack will be unable to cooperate with an FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds.

Which patient statement is consistent with their experiencing venous insufficiency? a. "I can't get my shoes on at the end of the day." b. "I can't ever seem to get my feet warm enough." c. "I have burning leg pain after I walk two blocks." d. "I wake up during the night because my legs hurt."

A Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day. The other patient statements are characteristic of peripheral artery disease.

A child has a chronic, nonproductive cough and diffuse wheezing during the expiratory phase of respiration. What action by the nurse is most appropriate? a. Prepare to administer a bronchodilator. b. Give ordered antibiotics on time. c. Provide oxygen via face tent. d. Assess the airway for a foreign body.

A Children with asthma usually have these chronic symptoms. The nurse will prepare to administer a bronchodilator. Antibiotics are not used in asthma unless the child also has a bacterial infection, but there is no indication that this is the case. There is also no indication the child needs oxygen at this point. These manifestations do not suggest a foreign body aspiration.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Monitor for elevated white blood cell count

A Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiography and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. White blood count elevation might indicate infection but is not expected with cor pulmonale.

The mother of a child with hemophilia asks the nurse how long her child will need to be treated for hemophilia. What is the best response to this question? a. "Hemophilia is a lifelong blood disorder." b. "There is a 25% chance that your child will have spontaneous remission." c. "Treatment continues until after the toddler years." d. "Since your first child did not have hemophilia, treatment for this child is temporary."

A Hemophilia is a lifelong hereditary blood disorder with no cure. Treatment is life long.

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation

A Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.

A nurse is caring for four infants. Which one should the nurse assess first? a. Nasal flaring b. Respiratory rate of 55 breaths/min c. Irregular respiratory pattern d. Abdominal breathing

A Infants have difficulty breathing through their mouths; therefore nasal flaring is usually accompanied by extra respiratory efforts. A respiratory rate of 55 breaths/min is a normal assessment for an infant. Irregular respirations are normal in the infant. Abdominal breathing is common because the diaphragm is the neonate's major breathing muscle.

Propranolol (Inderal) is newly prescribed for a patient diagnosed with hypertension. Which information in the patient's history would prompt the nurse to consult with the health care provider before giving this drug? a. Asthma b. Daily alcohol use c. Peptic ulcer disease d. Myocardial infarction (MI)

A Non-cardioselective B-blockers block B1- and B2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. B-Blockers will have no effect on the patient's peptic ulcer disease or alcohol use. B-Blocker therapy is recommended after MI.

Which action by the nurse would support ventilation for a patient with chronic obstructive pulmonary disease (COPD).? a. Encourage the patient to sit upright and lean forward. b. Have the patient rest with the head elevated 15 degrees. c. Place the patient in the Trendelenburg position with pillows behind the head. d. Ask the patient to rest in bed in a high-Fowler's position with the knees flexed.

A Patients with COPD improve the mechanics of breathing by sitting up in the "tripod" position. Resting in bed with the head elevated in a semi-Fowler's position would be an alternative position if the patient was confined to bed but sitting in a chair allows better ventilation. The Trendelenburg position or sitting upright in bed with the knees flexed would decrease the patient's ability to ventilate well.

The nurse getting an end-of-shift report on a child with status asthmaticus should question which intervention? a. Administer oxygen by nasal cannula to keep oxygen saturation at 100%. b. Assess intravenous (IV) maintenance fluids and site every hour. c. Notify provider for signs of increasing respiratory distress. d. Organize care to allow for uninterrupted rest periods.

A Supplemental oxygen should not be administered to maintain oxygen saturation at 100%. Keeping the saturation around 95% is adequate. Administration of too much oxygen to a child may lead to respiratory depression by decreasing the stimulus to breathe, leading to carbon dioxide retention. When the child cannot take oral fluids because of respiratory distress, IV fluids are administered. The child with a continuous IV infusion must be assessed hourly to prevent complications. A provider should be notified of any changes indicating increasing respiratory distress. A child in respiratory distress is easily fatigued. Nursing care should be organized so the child can get needed rest without being disturbed.

The emergency department nurse is evaluating the outcomes for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? a. O2 saturation is >90%. b. No wheezes are audible. c. Respiratory rate is 16 breaths/min. d. Accessory muscle use has decreased.

A The goal for treatment of an asthma attack is to keep the O2 saturation above 90%. Absence of wheezes, slower respiratory rate, and decreased accessory muscle use may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack.

After being hospitalized for 2 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action would the nurse take first? a. Administer prescribed PRN O2 at 4 L/min. b. Check the patient's legs for swelling or tenderness. c. Notify the health care provider about the symptoms. d. Stay with the patient and offer reassurance to the family.

A The patient's clinical manifestations and history are consistent with a pulmonary embolism, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient but meeting the physiologic need for O2 is a higher priority. The health care provider should be notified after the O2 is started and pulse oximetry obtained concerning suspected fat embolism or venous thromboembolism.

What explanation should the nurse give to the parent of a child with asthma about using a peak flow meter? a. It is used to monitor the child's breathing capacity. b. It measures the child's lung volume. c. It will help the medication reach the child's airways. d. It measures the amount of air the child breathes in.

A The peak flow meter is a device used to monitor breathing capacity in the child with asthma. A child with asthma would have a pulmonary function test to measure lung volume. A spacer used with a metered-dose inhaler prolongs medication transit so medication reaches the airways. The peak flow meter measures the flow of air in a forced exhalation in liters per minute.

A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on O2 therapy. Which instruction would the nurse include in the discharge teaching? a. O2 use can improve the patient's quality of life. b. Travel is not possible with the use of O2 devices. c. O2 flow should be increased if the patient has more dyspnea. d. Storage of O2 requires large metal tanks that last 4 to 6 hours.

A The use of home O2 improves quality of life and prognosis. Because increased dyspnea may be a symptom of an acute process such as pneumonia, the patient should notify the health care provider rather than increasing the O2 flowrate if dyspnea becomes worse. O2 can be supplied using liquid, storage tanks, or concentrators, depending on individual patient circumstances. Travel is possible using portable O2 concentrators.

A 30-year-old patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which topic would the nurse plan to teach the patient? a. a1-Antitrypsin testing b. Leukotriene modifiers c. Use of the nicotine patch d. Continuous pulse oximetry

A When COPD occurs in young patients, especially without a smoking history, a genetic deficiency in 1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the patient requires continuous pulse oximetry. Leukotriene modifiers would be used in patients with asthma, not with COPD.

A nurse is teaching a group of parents about TEF. Which statement made by the nurse is accurate about TEF? a. This defect results from an embryonal failure of the foregut to differentiate into the trachea and esophagus. b. It is a fistula between the esophagus and stomach that results in the oral intake being refluxed and aspirated. c. An extra connection between the esophagus and trachea develops because of genetic abnormalities. d. The defect occurs in the second trimester of pregnancy.

A When the foregut does not differentiate into the trachea and esophagus during the fourth to fifth week of gestation, a TEF occurs. A TEF is an abnormal connection between the esophagus and trachea. There is no connection between the trachea and esophagus in normal fetal development. This defect occurs early in pregnancy during the fourth to fifth week of gestation.

A patient with a venous thromboembolism (VTE) has new prescriptions for enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate? a. "Taking two medications dissolves the blood clot much faster." b. "Enoxaparin works right away, but warfarin takes several days to prevent clots." c. "Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from forming." d. "Because

B Low-molecular-weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level, usually about 5 days. LMWH and warfarin have no thrombolytic properties and they do not dissolve clots. The use of two anticoagulants is not related to the risk for pulmonary embolism.

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which potential complication would thenurse identify as a priority for this patient? a. Hypovolemic shock b. Venous thromboembolism c. Fluid and electrolyte imbalance d. Impaired surgical wound healing

B The patient is older and relatively immobile, which are two risk factors for development of deep vein thrombosis. theother potential complications are possible postoperative problems, but they are not at a high risk based on thedata about this patient

The home health nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching? a. The patient lies in supine position when using the nebulizer. b. The patient removes the facial mask when the misting stops. c. The patient reports washing the nebulizer mouthpiece weekly. d. The patient inhales while holding the mask 4 inches away from the face.

B A mist is seen when the medication is aerosolized, and when all the medication has been used, the misting stops. The mask should be placed securely on the patient's face or the mouthpiece held between the teeth with the lips closed around the device. The patient should be positioned sitting upright. The home nebulize equipment should be washed and dried daily.

The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient would the nurse assess first? a. A patient with loud expiratory wheezes b. A patient with a respiratory rate of 38 breaths/min c. A patient who has a cough productive of thick, green mucus d. A patient with jugular venous distention and peripheral edema

B A respiratory rate of 38/min indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the patient with tachypnea.

The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a prescription for enalapril (Vasotec). Which statement by the new nurse to the patient requires the charge nurse's intervention? a. "Make an appointment with the dietitian for teaching." b. "Increase your dietary intake of high-potassium foods." c. "Check your blood pressure at home at least once a day." d. "Move slowly when moving from lying to sitting to stand

B ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril.

The nurse teaches a patient who has chronic bronchitis about a new prescription for combined fluticasone and salmeterol (Advair Diskus) in a dry powder inhaler. Which patient action indicates to the nurse that teaching about medication administration has been successful? a. The patient shakes the device before use. b. The patient rapidly inhales the medication. c. The patient attaches a spacer to the device. d. The patient performs huff coughing after inhalation.

B Advair Diskus is a dry powder inhaler; the patient should inhale the medication rapidly, or the dry particles will stick to the tongue and oral mucosa. Shaking dry powder inhalers is not recommended. Spacers are not used with dry powder inhalers. Huff coughing is a technique to move mucus into larger airways to expectorate. The patient should not huff cough or exhale forcefully after taking Advair to keep the medication in the lungs.

The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication would the nurse administer first? a. Methylprednisolone (Solu-Medrol) 60 mg IV b. Albuterol (Ventolin HFA) 2.5 mg per nebulizer c. Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI) d. Ipratropium (Atrovent) 2 puffs per metered-dose inhaler (MDI)

B Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications work more slowly.

The nurse has just finished teaching a hypertensive patient about a newly prescribed drug, ramipril (Altace). Which patient statement indicates that more teaching is needed? a. "The medication may not work well if I take aspirin." b. "I can expect some swelling around my lips and face." c. "The doctor may order a blood potassium level occasionally." d. "I will call the doctor if I notice that I have a frequent cough."

B Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor would be discontinued. The patient would be taught that if any swelling of the face or oral mucosa occurs, the health care provider would be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy.

The nurse is developing a teaching plan for a patient with coronary artery disease (CAD). Which factor would the nurse focus on during the teaching session? a. Family history of coronary artery disease b. Elevated low-density lipoprotein (LDL) level c. Greater risk associated with the patient's gender d. Increased risk of cardiovascular disease with aging

B Because family history, gender, and age are nonmodifiable 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.

A patient with hypertension who was prescribed atenolol (Tenormin) 2 weeks ago returns to the health clinic for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action would the nurse take first? a. Tell the patient why a change in drug dosage is needed. b. Ask the patient if the medication is being taken as prescribed. c. Review with the patient any lifestyle changes made to help control BP. d. Teach the patient that multiple drugs are often needed to treat

B Because nonadherence with antihypertensive therapy is common, the nurse's initial action would be to determine whether the patient is taking the atenolol as prescribed. The patient may not have been able to obtain the medication. The other actions also may be implemented, but these would be done after assessing patient adherence with the prescribed therapy.

The nurse is admitting a patient newly diagnosed with peripheral artery disease who takes clopidogrel. Which admission order would the nurse question? a. Cilostazol drug therapy b. Omeprazole drug therapy c. Use of treadmill for exercise d. Exercise to the point of discomfort

B Because the antiplatelet effect of clopidogrel is reduced when it is used with omeprazole, the nurse should clarify this order with the health care provider. The other interventions are appropriate for a patient with peripheral artery disease.

The nurse is evaluating the discharge teaching outcomes for a patient with chronic peripheral artery disease (PAD). Which patient statement indicates a need for further instruction? a. "I will buy loose clothes that do not bind across my legs or waist." b. "I will use a heating pad on my feet at night to increase the circulation." c. "I will walk to the point of pain, rest, and walk again for at least 30 minutes 3 times a week." d. "I will change my position every hour and avoid lo

B Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful.

The nurse is caring for a 70-yr-old patient who takes hydrochlorothiazide and enalapril (Norvasc). The patient's blood pressure (BP) continues to be high. Which patient information may indicate a need for a change? a. Patient takes a daily multivitamin tablet. b. Patient uses ibuprofen to treat osteoarthritis. c. Patient checks BP daily just after getting up. d. Patient drinks wine three to four times a week.

B Because use of nonsteroidal antiinflammatory drugs (NSAIDs) can prevent adequate BP control, the patient may need to avoid the use of ibuprofen. A multivitamin tablet will help supply vitamin D, which may help lower BP. BP decreases while sleeping, so self-monitoring early in the morning will result in obtaining pressures that are at their lowest. The patient's alcohol intake is not excessive.

A parent of a child with asthma asks if his child can still participate in sports. What response by the nurse is best? a. "Children with asthma are usually restricted from physical activities." b. "Children can usually play any type of sport if their asthma is well controlled." c. "Avoid swimming because exhaling underwater is dangerous for people with asthma." d. "Even with good asthma control, I would advise limiting the child to one athletic activity per school year.

B Children can usually play any type of sport if their asthma is well controlled. Children with asthma should not be restricted from physical activity. Sports participation depends on each child's response to the activity. Swimming is recommended as the ideal sport for children with asthma because the air is humidified and exhaling underwater prolongs exhalation and increases end-expiratory pressure.

The nurse is caring for a patient with mitral valve regurgitation. Which information obtained by the nurse would be reported to the health care provider immediately? a. The patient has 4+ peripheral edema. b. The patient has diffuse bilateral crackles. c. The patient has a loud systolic murmur across the precordium. d. The patient has a palpable thrill felt over the left anterior chest

B Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently.

The nurse is caring for an infant with bronchopulmonary dysplasia (BPD) who has RSV. Which treatment measure does the nurse prepare to provide? a. Pancreatic enzymes b. Cool humidified oxygen c. Erythromycin intravenously d. Intermittent positive pressure ventilation

B Humidified oxygen is delivered if the oxygen saturation level drops to less than 90%. Pancreatic enzymes are used for patients with cystic fibrosis. Antibiotics are ineffective against viral illnesses. Assisted ventilation is not necessary in the treatment of RSV infections.

A patient is receiving IV furosemide to treat stage 2 hypertension. Which assessment finding is most important to report to the health care provider? a. Blood glucose level of 175 mg/dL b. Serum potassium level of 3.0 mEq/L c. Orthostatic systolic BP decrease of 12 mm Hg d. Current blood pressure (BP) reading of 168/94 mm Hg

B Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider would be notified of the potassium level immediately and administration of potassium supplements initiated. The elevated blood glucose and BP also need collaborative intervention but will not require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg will require intervention only if the patient is symptomatic.

A patient who was admitted with a pulmonary embolism has a change in oxygen saturation (SpO2) from 94% to 88%. Which action would the nurse take? a. Suction the patient's oropharynx. b. Increase the prescribed O2 flowrate. c. Teach the patient to cough and deep breathe. d. Help the patient to sit in an upright position

B Increasing O2 flowrate will usually improve O2 saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which prescribed action would the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) suppository

B Initiating antibiotic therapy rapidly is essential, but it is important to obtain the cultures before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.

Which action would the nurse take when giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE)? a. Massage the site after giving the injection. b. Inject the drug into the abdominal subcutaneous tissue. c. Ejects the air bubble from the syringe before giving the drug. d. Check partial thromboplastin time (PTT) before giving the drug.

B Low-molecular-weight heparin (LMWH) is administered subcutaneously in the abdominal area. The air bubble is not ejected before giving fondaparinux to avoid loss of drug. The other actions by the nurse are appropriate for LMWHs typically do not require ongoing PTT monitoring and dose adjustment.

Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider? a. Leg bruises b. Tarry stools c. Skin abrasions d. Bleeding gums

B Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury but are not indicators of possible serious blood loss.

What intervention can be taught to the parents of a 3-year-old child with pneumonia who is not hospitalized? a. Offer the child only cool liquids. b. Offer the child favorite warm liquid drinks. c. Use a warm mist humidifier. d. Report a respiratory rate less than 28 breaths/min.

B Offering the child favorite fluids will facilitate oral intake. Warm liquids help loosen secretions. A humidifier may or may not be helpful. Typically parents are not taught to count their children's respirations and report abnormalities to the physician. Even if this were the case, a respiratory rate of less than 28 breaths/min is normal for a 3-year-old child. The expected respiratory rate for a 3-year-old child is 20 to 30 breaths/min.

Which action would the nurse plan to prevent aspiration in a high-risk patient? a. Turn and reposition an immobile patient at least every 2 hours. b. Raise the head of the bed for a patient who is receiving tube feedings. c. Insert a nasogastric tube for feeding a patient with high-calorie needs. d. Monitor respiratory symptoms in a patient who is immunosuppressed.

B Patients who have an orogastric or nasogastric tube are at risk for aspiration pneumonia. Elevating the head of the bed can help prevent this complication. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and O2 saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.

The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which action would the nurse implement for a patient who has an impaired breathing pattern due to anxiety? a. Titrate O2 to keep saturation at least 90%. b. Teach the patient how to use the pursed-lip technique. c. Discuss a high-protein, high-calorie diet with the patient. d. Suggest the use of over-the-counter sedative medications.

B Pursed-lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There is no indication that the patient requires O2 therapy or an improved diet. Sedative medications should be avoided because they decrease respiratory drive.

Which instructions would the nurse include in a teaching plan for an older adult patient newly diagnosed with peripheral artery disease (PAD)? a. "Exercise only if you do not experience any pain." b. "It is very important that you stop smoking cigarettes." c. "Try to keep your legs elevated whenever you are sitting." d. "Put elastic compression stockings on early in the morning."

B Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.

A patient who has a history of hypertension treated with a diuretic and clonidine (Catapres) arrives in the emergency department. The patient reports a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question would the nurse ask to follow up on these findings? a. "Have you recently taken any antihistamines?" b. "Have you consistently taken your medications?" c. "Did you take any acetaminophen (Tylenol) today?" d. "Have there been recent stressful ev

B Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.

The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) after hospitalization for venous thromboembolism (VTE). Which patient statement indicates a need for additional teaching? a. "I should get a Medic Alert device stating that I take warfarin." b. "Ishould reduce the amount of green, leafy vegetables that I eat." c. "I will need routine blood tests to monitor the effects of the warfarin." d. "I will check with my health care provider before I

B Teach patients taking warfarin to follow a consistent diet regarding foods that are high in vitamin K, such as green, leafy vegetables. There is no need to reduce the intake of these vegetables. The other patient statements are accurate.

A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor is on a low-sodium diet. The patient tells the home health nurse about a 5-lb weight gain in the past 3 days. Which action is the nurse's priority? a. Teach the patient about restricting dietary sodium. b. Assess the patient for manifestations of acute heart failure. c. Ask the patient about the use of the prescribed medications. d. Have the patient recall the dietary intake for t

B The 5-lb weight gain over 3 days indicates that the patient's chronic heart failure may be worsening. It is important that the patient be assessed immediately for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.

Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 48-yr-old patient with newly diagnosed hypertension? a. 98/56 mm Hg b. 128/76 mm Hg c. 128/92 mm Hg d. 142/78 mm Hg

B The 8th Joint National Committee's recommended goal for antihypertensive therapy for a 30- to 59-yr-old patient with hypertension is a BP below 130/80 mm Hg. The BP of 98/56 mm Hg may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient's treatment.

Which assessment finding is most useful in evaluating the effectiveness of treatment to improve gas exchange? a. Even, unlabored respirations b. Pulse oximetry reading of 92% c. Absence of wheezes or crackles d. Respiratory rate of 18 breaths/min

B The best data for evaluation of gas exchange are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue.

The nurse is caring for a patient who has type A hemophilia and is being admitted to the hospital with severe pain and swelling in the right knee. Which action would the nurse take? a. Apply heat to the knee. b. Immobilize the knee joint. c. Assist the patient with light weight bearing. d. Perform passive range of motion to the knee.

B The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.

Which action would the nurse in the hypertension clinic take to obtain an accurate baseline blood pressure (BP) for a new patient? a. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. b. Have the patient sit in a chair with the feet flat on the floor. c. Assist the patient to the supine position for BP measurement. d. Obtain two BP readings in the dominant arm and average the results

B The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, and the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.

After receiving change-of-shift report, which patient would the nurse assess first? a. Patient who is taking carvedilol (Coreg) and has a heart rate of 58 b. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L c. Patient who is taking captopril and has a frequent nonproductive cough d. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache

B The patient's low potassium level increases the risk for digoxin toxicity and potentially life-threatening dysrhythmias. The nurse would assess the patient for other signs of digoxin toxicity and then notify the health care provider about the potassium level. The other patients also have side effects of their drugs, but their symptoms do not indicate potentially life-threatening complications.

The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/min, and the current peak flow is 420 L/min. Which action would the nurse take first? a. Tell the patient to go to the hospital emergency department. b. Teach the patient to use the prescribed albuterol (Ventolin HFA). c. Ask about recent exposure to any new allergens or asthma triggers. d. Question the patient about use of the prescribed inhaled corticoste

B The patient's peak flow is 70% of normal, indicating a need for immediate use of short-acting B2-adrenergic SABA medications. Assessing for correct use of medications or exposure to allergens is appropriate but would not address the current decrease in peak flow. Because the patient is currently in the yellow zone, hospitalization is not needed at this point.

A patient seen in the asthma clinic has recorded daily peak flowrates that are 70% of the baseline. Which action will the nurse plan to take next? a. Teach the patient about the use of oral corticosteroids. b. Administer a bronchodilator and recheck the spirometry. c. Recommend increasing the dose of the leukotriene inhibitor. d. Instruct the patient to keep the scheduled follow-up appointmen

B The patient's peak flow reading indicates that the condition is worsening (yellow zone). The patient would take the bronchodilator and recheck the peak flow. Depending on whether the patient returns to the green zone, indicating well-controlled symptoms, the patient may be prescribed oral corticosteroids or a change in dosing of other medications. Keeping the next appointment is appropriate, but the patient first needs to be taught how to control symptoms now and use the bronchodilator.

What maternal assessment is related to an infant's diagnosis of TEF? a. Maternal age more than 40 years b. First term pregnancy for the mother c. Maternal history of polyhydramnios d. Complicated pregnancy

C A maternal history of polyhydramnios is associated with TEF. Advanced maternal age, first term pregnancy, or complicated pregnancy are not related.

A 62-yr-old patient who has no history of hypertension has a blood pressure (BP) of 198/110mm Hg during a routine wellness check. After reconfirming the BP, which information would the nurse provide to the patient? a. A BP recheck should be scheduled in a few weeks. b. Dietary sodium and fat content should be decreased. c. Diagnosis, treatment, and monitoring will be needed. d. There is danger of a stroke, requiring hospitalization.

C A sudden increase in BP in a patient older than age 50 years with no hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely and the BP may be managed as an outpatient. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP. Reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.

What clinical manifestation should a nurse be alert for when suspecting a diagnosis of esophageal atresia? a. A radiograph in the prenatal period indicates abnormal development. b. It is visually identified at the time of delivery. c. A nasogastric tube fails to pass at birth. d. The infant has a low birth weight.

C Atresia is suspected when a nasogastric tube fails to pass 10 to 11 cm beyond the gum line. Abdominal radiographs will confirm the diagnosis. Prenatal radiographs do not provide a definitive diagnosis. The defect is not externally visible. Bronchoscopy and endoscopy can be used to identify this defect. Infants with esophageal atresia may have been born prematurely and with a low birth weight, but neither is suggestive of the presence of an esophageal atresia.

The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy? a. The patient has chronic inflammatory bowel disease. b. The patient has a history of pneumonia 6 months ago. c. The patient takes propranolol (Inderal) for hypertension. d. The patient uses acetaminophen (Tylenol) for headaches.

C B-Blockers such as propranolol inhibit bronchodilation. The other information will be documented in the health history but does not indicate a need for a change in therapy.

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? a. Serum troponin b. Arterial blood gases c. B-type natriuretic peptide d. 12-lead electrocardiogram

C B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do with heart failure. Elevated BNP indicates a very probable diagnosis of heart failure. A 12-lead electrocardiogram, arterial blood gases, and troponin may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

Which action would the nurse take to prepare a patient for spirometry? a. Give the rescue medication immediately before testing. b. Administer oral corticosteroids 2 hours before the procedure. c. Withhold bronchodilators for 6 to 12 hours before the examination. d. Ensure that the patient has been NPO for several hours before the test.

C Bronchodilators are held before spirometry so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids should be held before spirometry. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.

A patient has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe. Which assessment finding would the nurse expect? a. Dilated superficial veins b. Swollen, dry, scaly ankles c. Prolonged capillary refill in all the toes d. Serosanguineous drainage from the ulcer

C Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed manifestations are consistent with chronic venous disease.

A hospitalized patient with chronic heart failure has a new order for captopril 12.5 mg PO. After giving the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? a. "I plan to take the medication with food." b. "I should eat more potassium-rich foods." c. "I will call for help when I need to get up to use the bathroom." d. "I can expect to feel more short of breath for the next few days."

C Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The angiotensin-converting enzyme (ACE) inhibitors are potassium sparing, and the nurse should not teach the patient to purposely increase sources of dietary potassium. Increased shortness of breath is expected with the initiation of B-adrenergic blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating.

Which finding would the nurse expect when assessing a patient with cor pulmonale? a. Chest pain b. Finger clubbing c. Peripheral edema d. Elevated temperature

C Cor pulmonale causes clinical manifestations of right ventricular failure, such as peripheral edema. The other clinical manifestations may occur in the patient with other complications of chronic obstructive pulmonary disease but are not indicators of cor pulmonale.

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action would the nurse plan to promote airway clearance? a. Restrict oral fluids during the day. b. Encourage pursed-lip breathing technique. c. Help the patient to splint the chest when coughing. d. Encourage the patient to wear the nasal O2 cannula.

C Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal O2 will improve gas exchange but will not improve airway clearance. Pursed-lip breathing can improve gas exchange in patients with chronic obstructive pulmonary disease but will not improve airway clearance.

An adult whose employment requires long periods of standing undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions would the nurse provide to the patient before discharge? a. Sitting at the work counter, rather than standing, is recommended. b. Exercise, such as walking or jogging, can cause recurrence of varicosities. c. Elastic compression stockings should be applied before getting out of bed. d. Taking an aspirin daily will help prevent

C Elastic compression stockings are applied with the legs elevated to reduce pressure in the lower legs. Walking is recommended to prevent recurrent varicosities. Sitting and standing are both risk factors for varicose veins and venous insufficiency. An aspirin a day is not adequate to prevent venous thrombosis and would not be recommended for a patient who had just had sclerotherapy.

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in the plan of care? a. Walk until pulse rate exceeds 130 beats/min. b. Stop exercising when you feel short of breath. c. Walk 15 to 20 minutes a day at least 3 times/wk. d. Limit exercise to activities of daily living (ADLs).

C Encourage the patient to walk 15 to 20 minutes a day at least three times a week with gradual increases. Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not improve the patient's exercise tolerance. A 70-yr-old patient should have a pulse rate of 120 beats/min or less with exercise (80% of the maximal heart rate of 150 beats/min).

What is a common trigger for asthma attacks in children? a. Febrile episodes b. Dehydration c. Exercise d. Seizures

C Exercise is one of the most common triggers for asthma attacks, particularly in schoolage children. Febrile episode, dehydration, and seizures are not triggers.

Which information is important for the nurse to include when teaching a patient newly diagnosed with hypertension? a. Most people can control hypertension through dietary changes. b. Annual BP checks are needed to monitor treatment effectiveness. c. Hypertension is usually asymptomatic until organ damage occurs. d. Increasing physical activity controls hypertension for most people.

C Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes (e.g., physical activity, dietary changes) are used to help manage BP, but drugs are needed for most patients. Home BP monitoring would be taught to the patient and findings checked by the health care provider frequently when starting treatment for hypertension and then every 3 months when stable.

A patient who has heart failure recently started taking digoxin in addition to furosemide and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider? a. Presence of 1+ to 2+ edema in the feet and ankles b. Palpable liver edge 2 cm below the ribs on the right side c. Serum potassium level 3.0 mEq/L after 1 week of therapy d. Weight increase from 120 pounds to 122 pounds over 3 days

C Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions) and potentiate the actions of digoxin. Hypokalemia also increases the risk for digoxin toxicity, which can also cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.

The nurse notes that a patient who was admitted with heart failure has jugular venous distention (JVD) when lying flat. Which follow-up action would the nurse take? a. Encourage the patient to drink more liquids. b. Assess the apical and radial pulse for a pulse deficit. c. Observe the neck with the patient elevated 45 degrees. d. Have the patient bear down to perform the Valsalva maneuver

C When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not a clinically significant) finding. JVD but is not confirmed based on the data given. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. More fluids will further increase any fluid overload.

An older patient has been diagnosed with possible white coat hypertension. Which planned action by the nurse addresses that suspected cause of the hypertension? a. Schedule the patient for regular BP checks in the clinic. b. Instruct the patient about the need to decrease stress levels. c. Teach the patient how to self-monitor and record BPs at home. d. Tell the patient and caregiver that major dietary changes are needed.

C In the phenomenon of "white coat" hypertension, patients have elevated BP readings in a clinical setting and normal readings when BP is measured elsewhere. Having the patient self-monitor BPs at home will provide a reliable indication about whether the patient has hypertension. Regular BP checks in the clinic are likely to be high in a patient with white coat hypertension. There is no evidence that this patient has elevated stress levels or a poor diet, and those factors do not cause white coat hypertension.

After the nurse teaches the patient with stage 1 hypertension about diet modifications, which diet choice indicates that the teaching has been effective? a. The patient avoids eating nuts or nut butters. b. The patient restricts intake of chicken and fish. c. The patient drinks low-fat milk with each meal. d. The patient has two cups of coffee in the morning

C Increased levels of dietary potassium and calcium are associated with lower BP. People with hypertension should receive adequate intake of these from food sources such as low-fat milk. Plant based and Mediterranean diets with increased fruit, nut, vegetable, legumes, and lean proteins from fish and vegetables decreases BP and mortality rates from cardiovascular disease. Caffeine intake or restriction and decreased protein intake are not recommendations.

The health care provider prescribes heparin infusion and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). Which action would the nurse include in the plan of care? a. Obtain a Doppler for monitoring bilateral pedal pulses. b. Decrease the infusion when the PTT value is 65 seconds. c. Avoid giving IM medications to prevent localized bleeding. d. Have vitamin K available in case reversal of the heparin is neede

C Intramuscular injections are avoided in patients receiving anticoagulation to prevent hematoma formation and bleeding from the site. A PTT of 65 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE.

Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a. Report of right calf pain b. Redness of right lower leg c. New onset shortness of breath d. Temperature of 100.4F (38C)

C New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as O2 administration and notification of the health care provider. The other findings are typical of VTE

Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a. Report of right calf pain b. Redness of right lower leg c. New onset shortness of breath d. Temperature of 100.4F (38C)

C New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as O2 administration and notification of the health care provider. The other findings are typical of VTE.

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement by the patient indicates a good understanding of the instructions? a. "I will call my health care provider if Istill feel tired after a week." b. "I will cancel my follow-up chest x-ray appointment if I feel better." c. "I will continue to do deep breathing and coughing exercises at home." d. "I will schedule two appointments for the pneumonia and influenza vaccines."

C Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The pneumococcal and influenza vaccines can be given at the same time in different arms. A follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.

Which statement by a 23-yr-old patient who has mitral valve prolapse (MVP) without valvular regurgitation indicates that discharge teaching has been effective? a. "I will take antibiotics before any dental appointments." b. "I will limit physical activity to avoid stressing the heart." c. "I should avoid over-the-counter drugs that contain stimulants." d. "I should take an aspirin a day to prevent clots from forming on the valve."

C Patients with MVP should avoid using stimulant drugs because they may exacerbate symptoms. Daily aspirin and restricted physical activity are not needed by patients with mild MVP. Antibiotic prophylaxis is needed for patients with MVP with regurgitation but will not be necessary for this patient.

The nurse teaches a patient who has asthma about peak flowmeter use. Which action by the patient indicates that teaching was successful? a. The patient inhales rapidly through the peak flowmeter mouthpiece. b. The patient takes montelukast (Singulair) for peak flows in the red zone. c. The patient uses albuterol (Ventolin HFA) for peak flows in the yellow zone. d. The patient calls the health care provider when the peak flow is in the green zone

C Readings in the yellow zone indicate a decrease in peak flow. The patient should use short-acting B2-adrenergic (SABA) medications. Readings in the green zone indicate good asthma control. The patient should exhale quickly and forcefully through the peak flowmeter mouthpiece to obtain the readings. Readings in the red zone do not indicate good peak flow, and the patient should take a fast-acting bronchodilator and call the health care provider for further instructions. Singulair is not indicated for acute attacks but is used for maintenance therapy

IV sodium nitroprusside is prescribed for a patient with acute pulmonary edema. Which reassessment finding indicates that the nurse should decrease the rate of nitroprusside infusion? a. Ventricular ectopy b. Dry, hacking cough c. Systolic BP below 90 mm Hg d. Heart rate below 50 beats/min

C Sodium nitroprusside is a potent vasodilator and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy.

When preparing a clinic patient who has chronic obstructive pulmonary disease (COPD) for pulmonary spirometry, which question would the nurse ask? a. "Are you claustrophobic?" b. "Are you allergic to shellfish?" c. "Have you taken any bronchodilators today?" d. "Do you have any metal implants or prostheses?"

C Spirometry will help establish the COPD diagnosis. Bronchodilators should be avoided at least 6 hours before the test. Spirometry does not involve being placed in an enclosed area such as for magnetic resonance imaging (MRI). Contrast dye is not used for spirometry. The patient may still have spirometry done if metal implants or prostheses are present because they are contraindications for an MRI.

Which information would the nurse teach the patient who has been prescribed captopril? a. Include high-potassium foods such as bananas in the diet. b. Increase fluid intake if dryness of the mouth is a problem. c. Change position slowly to help prevent dizziness and falls. d. Check the blood pressure in both arms before taking the drug.

C The angiotensin-converting enzyme (ACE) inhibitors often cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the drug. The patient is taught to use gum or hard candy to relieve dry mouth. The BP should be taken in the nondominant arm by newly diagnosed patients in the morning, before taking the drug, and in the evening. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.

What should the nurse teach a child about using an albuterol metered-dose inhaler for exercise-induced asthma? a. Take two puffs every 6 hours around the clock. b. Use the inhaler only when the child is short of breath. c. Use the inhaler 30 minutes before exercise. d. Take one to two puffs every morning upon awakening.

C The appropriate time to use an inhaled beta2 -agonist is before an event that could trigger an attack. Taking the medication every 6 hours will not prevent the exercise-induced asthma. Waiting until symptoms are severe is too late to begin using a metered- dose inhaler. Taking puffs every morning may be the child's usual schedule for medication. If exercise causes symptoms, additional medication is indicated.

What is descriptive of most cases of hemophilia? a. Autosomal dominant disorder causing deficiency in a factor involved in the blood-clotting reaction b. X-linked recessive inherited disorder causing deficiency of platelets and prolonged bleeding c. X-linked recessive inherited disorder in which a blood-clotting factor is deficient d. Y-linked recessive inherited disorder in which the red blood cells become moon shaped

C The inheritance pattern in 80% of all cases of hemophilia is X-linked recessive and results in deficient amounts of blood- clotting factors. The disorder involves coagulation factors, not platelets. The disorder does not involve red cells or the Y chromosome.

While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. What does this finding indicate? a. Jugular vein atherosclerosis b. Incompetent jugular vein valves c. Increased ventricular filling pressure d. Decreased intravascular fluid volume

C The jugular veins empty into the superior vena cava and then into the right atrium and ventricle, so JVD with the patient sitting at a 45-degree angle reflects increased atrial and ventricular pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.

A patient with hypertension received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention? a. The patient's pulse has dropped from 68 to 57 beats/min. b. The patient reports that the fingers and toes feel quite cold. c. The patient has developed wheezes throughout the lung fields. d. The patient's blood pressure (BP) reading is now 158/92 mm Hg.

C The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the non-cardioselective B-blockers) is occurring. The nurse would immediately obtain an O2 saturation measurement, apply supplemental O2, and notify the health care provider. The mild decrease in heart rate and cold fingers and toes are associated with -receptor blockade but do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated. However, this is not as urgently needed as addressing the bronchospasm.

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data indicates that the treatment is effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 6000/L. d. Increased tactile fremitus is palpable over the right chest

C The normal WBC count indicates that the antibiotics have been effective. Bronchial breath sounds, green mucus, or tactile fremitus suggest that different or additional treatment is needed.

A patient with chronic obstructive pulmonary disease (COPD) has been eating very little and has lost weight. Which intervention would be most important for the nurse to include in the plan of care? a. Encourage increased intake of whole grains. b. Increase the patient's menu order of fruits and fruit juices. c. Offer high-calorie protein snacks between meals and at bedtime. d. Assist the patient in choosing foods with high vegetable content.

C Underweight patients need extra protein and calories; eating small amounts more often (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Whole grains, fruits, and vegetables are part of a well-balanced diet, but the patient with COPD who is underweight needs an emphasis on protein to maintain muscle tissue needed for breathing.

Which instruction would the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)? a. "Avoid upper body exercises to prevent dyspnea." b. "Stop exercising if you start to feel short of breath." c. "Use the bronchodilator before you start to exercise." d. "Breathe in and out through the mouth while exercising."

C Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth (using a pursed-lip technique). Upper-body exercise can improve the mechanics of breathing in patients with COPD.

Which assessment finding for a patient with a history of asthma indicates that the nurse would take immediate action? a. Pulse oximetry reading of 91% b. Respiratory rate of 26 breaths/min c. Use of accessory muscles in breathing d. Peak expiratory flow rate of 240 L/min

C Use of accessory muscle indicates that the patient with asthma is experiencing respiratory distress, and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is required.

Which foods would the nurse recommend limiting for a patient on a 2000-mg sodium diet? a. Chicken and eggs b. Canned and frozen fruits c. Yogurt and milk products d. Fresh or frozen vegetables

C Yogurt and milk products (e.g., cheese) naturally contain a significant amount of sodium, and the intake of these would be limited for patients on a diet that limits sodium to 2000 mg daily. The other foods listed have minimal levels of sodium and can be eaten without restriction.

The nurse is obtaining a health history from a 24-yr-old patient with hypertrophic cardiomyopathy (CMP). Which information obtained by the nurse is most important in planning care? a. The patient had a recent upper respiratory infection. b. The patient has a family history of coronary artery disease. c. The patient reports using cocaine "a few times" as a teenager. d. The patient's 29-yr-old brother died from a sudden cardiac arrest.

D About half of all cases of hypertrophic CMP have a genetic basis, and it is the most common cause of sudden cardiac death in otherwise healthy young people. The information about the patient's brother will be helpful in planning care (e.g., an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against the use of stimulant drugs, but the limited past history indicates that the patient is not currently at high risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy but not for hypertrophic CMP.

Which statement made by a patient with coronary artery disease indicates that further diet teaching is needed? a. "I will switch from whole milk to 1% milk." b. "Ilike salmon and I will plan to eat it more often." c. "I can have a glass of wine with dinner if I want one." d. "I will miss being able to eat peanut butter sandwiches.

D Although only 30% of the daily calories should come from fats, most of the fat in the diet should come from monounsaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the diet. The other patient comments indicate a good understanding of the recommended diet.

Which action would the nurse take when giving the first dose of oral labetalol to a patient hospitalized with hypertension? a. Encourage the use of hard candy to prevent dry mouth. b. Teach the patient that headaches often occur with this drug. c. Instruct the patient to call for help if heart palpitations occur. d. Ask the patient to request assistance before getting out of bed.

D Labetalol decreases sympathetic nervous system activity by blocking both a- and B-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dry mouth, dehydration, and headaches are possible side effects of other antihypertensives.

A patient at the clinic says, "I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though." Which focused assessment would the nurse make? a. Look for the presence of tortuous veins bilaterally on the legs. b. Ask about any skin color changes that occur in response to cold. c. Assess for unilateral swelling, redness, and tenderness of either leg. d. Palpate for the presence of dorsalis pedis and posterior tibial pu

D The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness indicate venous thromboembolism.

Following an acute myocardial infarction, a previously healthy 63-yr-old develops heart failure. Which medication topic would the nurse anticipate including in discharge teaching? a. Calcium channel blocker b. Selective SA node inhibitor c. Digoxin and potassium therapy regimen d. Angiotensin-converting enzyme (ACE) inhibitor

D ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other drugs such as ACE-inhibitors, diuretics, and B-adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. Ivabradine would likely be used for a patient with HF who has symptoms despite optimal doses of other medications.

A patient with pneumonia has a fever of 101.4F (38.6C), a nonproductive cough, and an O2 saturation of 88%. The patient is weak and needs assistance to get out of bed. Which patient problem would the nurse assign as the priority? a. Fatigue b. Altered temperature c. Musculoskeletal problem d. Impaired respiratory function

D All these problems are appropriate for the patient, but the patient's O2 saturation indicates that all body tissues are at risk for hypoxia unless the respiratory function is improved.

A male patient with hemophilia asks the nurse if his future children will have hemophilia. Which response by the nurse is accurate? a. "All of your children will be at risk for hemophilia." b. "Hemophilia is a multifactorial inherited condition." c. "Only your male children are at risk for hemophilia." d. "Your female children will be carriers for hemophilia."

D Because hemophilia is caused by a mutation of the X chromosome, all female children of a man with hemophilia are carriers of the disorder and can transmit the mutated gene to their offspring. Sons of a man with hemophilia will not have the disorder. Hemophilia is caused by a single genetic mutation and is not a multifactorial inherited condition.

Which intervention is appropriate for the infant hospitalized with bronchiolitis? a. Position on the side with neck slightly flexed. b. Administer antibiotics as ordered. c. Restrict oral and parenteral fluids if tachypneic. d. Give cool, humidified oxygen.

D Cool, humidified oxygen is given to relieve dyspnea, hypoxemia, and insensible fluid loss from tachypnea. The infant should be positioned with the head and chest elevated at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. The etiology of bronchiolitis is viral. Antibiotics are only given if there is a secondary bacterial infection. Tachypnea increases insensible fluid loss. If the infant is tachypneic, fluids are given parenterally to prevent dehydration.

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6F with a frequent cough and severe pleuritic chest pain. Which prescribed medication would the nurse give first? a. Codeine b. Guaifenesin c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)

D Early initiation of antibiotic therapy has been shown to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy

A patient newly diagnosed with asthma is being discharged. Which topic would the nurse include in the discharge teaching? a. Complications associated with O2 therapy b. Use of long-acting B-adrenergic medications c. Side effects of sustained-release theophylline d. Self-administration of inhaled corticosteroids

D Inhaled corticosteroids are more effective in improving asthma than any other drug and are indicated for all patients with persistent asthma. The other therapies would not typically be first-line treatments for newly diagnosed asthma.

A patient is being treated for heart failure. Which laboratory test result will the nurse review to determine the effects of the treatment? a. Troponin b. Homocysteine (Hcy) c. Low-density lipoprotein (LDL) d. B-type natriuretic peptide (BNP)

D Levels of BNP are a marker for heart failure. The other laboratory results would assess for myocardial infarction (troponin) or the risk for coronary artery disease (Hcy and LDL).

The nurse completes an admission assessment on a patient with asthma. Which information indicates a need for discussion with the health care provider about a change in therapy? a. The patient uses an albuterol inhaler before aerobic exercise. b. The patient's only medications are albuterol and salmeterol inhalers. c. The patient's heart rate increases slightly after using the albuterol inhaler. d. The patient used albuterol more often when symptoms were worse in the spring.

D Long-acting 2-agonists would be used only in patients who also are using an inhaled corticosteroid for long-term control; salmeterol would not be used as the first-line therapy for long-term control. Using a bronchodilator before exercise is appropriate. The other information given by the patient requires further assessment by the nurse but is not unusual for a patient with asthma.

What information should the nurse teach workers at a daycare center about RSV? a. RSV is transmitted through particles in the air. b. RSV can live on skin or paper for up to a few seconds after contact. c. RSV can survive on nonporous surfaces for about 60 minutes. d. Frequent handwashing can decrease the spread of the virus.

D Meticulous handwashing can decrease the spread of organisms. RSV infection is not airborne. It is acquired mainly through contact with contaminated surfaces. RSV can live on skin or paper for up to 1 hour. RSV can live on cribs and other nonporous surfaces for up to 6 hours.

Which statement by a patient newly diagnosed with heart failure indicates to the nurse that teaching was effective? a. "I will take furosemide (Lasix) every day just before bedtime." b. "I will use the nitroglycerin patch whenever I have chest pain." c. "I will use an additional pillow if I am short of breath at night." d. "I will call the clinic if my weight goes up 3 pounds in a week."

D Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 lb in 2 days or 3 to 5 lb in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an "as needed" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops rather than just compensating by further elevating the head of the bed.

Which patient statement indicates that the nurse's teaching about sublingual nitroglycerin (Nitrostat) has been effective? a. "I can expect nausea as a side effect of nitroglycerin." b. "Ishould only take nitroglycerin when I have chest pain." c. "Nitroglycerin helps prevent a clot from blocking blood flow to my heart." d. "I will call an ambulance if I have pain 5 minutes after taking nitroglycerin."

D The emergency response system (ERS) should be activated when chest pain or other symptoms are the same or worse 5 minutes after taking a sublingual nitroglycerin tablets. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.

A patient with a possible pulmonary embolism reports chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action would the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.

D The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be performed after the head is elevated and O2 is started. The health care provider may order a spiral CT to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.

An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider? a. 2+ bilateral pedal edema b. Heart rate of 52 beats/min c. Report of increased fatigue d. Blood pressure 88/42 mm Hg

D The patient's blood pressure indicates that the dose of metoprolol may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of -adrenergic blockade, though it may need to be monitored. -Adrenergic blockade initially will worsen symptoms of heart failure in many patients and patients would be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs.

An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. After the nurse notifies the health care provider, what would the nurse do next? a. Apply a compression stocking to the leg. b. Elevate the leg above the level of the heart. c. Assist the patient in gently exercising the leg. d. Keep the patient in bed in the supine position.

D The patient's history and clinical manifestations are consistent with acute arterial occlusion. Resting the leg will decrease the O2 demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.

Which information will the nurse include in the teaching plan for a patient newly diagnosed with asthma? a. Use the inhaled corticosteroid when shortness of breath occurs. b. Inhale slowly and deeply when using the dry powder inhaler (DPI). c. Hold your breath for 2 seconds after using the bronchodilator inhaler. d. Tremors are an expected side effect of rapidly acting bronchodilators.

D Tremors are a common side effect of short-acting 2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold the breath for 10 seconds after using inhalers.

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider? a. The patient's temperature is 100.3F (37.9C). b. The patient's calf is swollen and warm to touch. c. The patient reports abdominal pain when ambulating. d. The patient has fluid intake 600 mL greater than the output.

The calf pain, swelling, and warmth suggest that the patient has a venous thromboembolism (VTE). This will require the health care provider to prescribe diagnostic tests, anticoagulants, or both and is most critical because a VTE could result in a pulmonary embolism. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3F on the second postoperative day is suggestive of atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the prescribed analgesic before patient activities.