MedSurg Exam 1 (pt 2)

A client recovering from an exacerbation of left-sided heart failure is experiencing activity intolerance. Which change in vital signs during activity would be the best indicator that the client is tolerating mild exercise? 1. Oxygen saturation decreased from 96% to 91%. 2. Pulse rate increased from 80 to 104 beats per minute. 3. Blood pressure decreased from 140/86 to 112/72 mm Hg. 4. Respiratory rate increased from 16 to 19 breaths per minute.

4. Respiratory rate increased from 16 to 19 breaths per minute.

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was unsuccessful? 1. Rising blood pressure 2. Clearly audible heart sounds 3. Client expressions of relief 4. Rising central venous pressure 4. Rising central venous pressure

4. Rising central venous pressure

The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse plan, based on the health care provider's prescriptions?Select all that apply. 1. Elevation of the right leg 2. Ambulation in the hall every 4 hours 3. Application of moist heat to the right leg 4. Administration of acetaminophen (Tylenol) 5. Monitoring for signs of pulmonary embolism

1. Elevation of the right leg 3. Application of moist heat to the right leg 4. Administration of acetaminophen (Tylenol) 5. Monitoring for signs of pulmonary embolism

The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse should immediately ask the client which question? 1. "Where is the pain located?" 2. "Are you having any nausea?" 3. "Are you allergic to any medications?" 4. "Do you have your nitroglycerin with you?"

1. "Where is the pain located?"

A nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has mild pitting with slight indentation and no perceptible swelling of the leg. How should the nurse define and document this finding? 1. 1+ edema 2. 2+ edema 3. 3+ edema 4. 4+ edema

1. 1+ edema

A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem? 1. Ambulates 10 feet farther each day 2. Verbalizes the benefits of increasing activity 3. Chooses a healthy diet that meets caloric needs 4. Sleeps without awakening throughout the night

1. Ambulates 10 feet farther each day

A nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply. 1. Emotional stress 2. Atrial fibrillation 3. Nutritional anemia 4. Peptic ulcer disease 5. Recent upper respiratory infection

1. Emotional stress 2. Atrial fibrillation 3. Nutritional anemia 5. Recent upper respiratory infection

The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a ventricular rate of 150 beats/min. The nurse should next assess the client for which finding? 1. Hypotension 2. Flat neck veins 3. Complaints of nausea 4. Complaints of headache

1. Hypotension

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? 1. Listening to lung sounds 2. Monitoring for organomegaly 3. Assessing for jugular vein distention 4. Assessing for peripheral and sacral edema

1. Listening to lung sounds

During assessment of a client newly diagnosed with hypertension, the nurse recognizes that which is a common occurrence? 1. Be asymptomatic 2. Be short of breath 3. Have visual disturbances 4. Have frequent nosebleeds

1. Be asymptomatic

A nurse is providing postoperative care for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse should be most concerned about monitoring for which potential complications? 1. Bleeding and infection 2. Thrombosis and infection 3. Bleeding and wound dehiscence 4. Wound dehiscence and evisceration

1. Bleeding and infection

A client has been diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse is identifying measures to help the client cope with lifestyle changes needed to control the disease process. The nurse plans to refer the client to which member of the health care team? 1. Dietitian 2. Medical social worker 3. Pain management clinic 4. Smoking-cessation program

4. Smoking-cessation program

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider will most likely prescribe which option? 1. Maintain bed rest. 2. Maintain the affected leg in a dependent position. 3. Administer an opioid analgesic every 4 hours around the clock. 4. Apply cool packs to the affected leg for 20 minutes every 4 hours.

1. Maintain bed rest.

The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary to control disease progression. Which statement by the client indicates a need for further teaching? 1. "I will avoid using table salt with meals." 2. "It is best to exercise once a week for 1 hour." 3. "I will take nitroglycerin whenever chest discomfort begins." 4. "I will use muscle relaxation to cope with stressful situations."

2. "It is best to exercise once a week for 1 hour."

The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? 1. Use nail polish to protect the nail beds from injury. 2. Stop smoking because it causes cutaneous vasospasm. 3. Wear gloves for all activities involving use of both hands. 4. Always wear warm clothing even in warm climates to prevent vasoconstriction.

2. Stop smoking because it causes cutaneous vasospasm.

The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? 1. Bananas 2. Broccoli 3. Antacids 4. Cantaloupe

3. Antacids

An ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which statement indicates the client needs additional education? 1. "It is important that I limit protein intake." 2. "I need to maintain a regular exercise program." 3. "I understand that I need to avoid adding salt to foods." 4. "It is important that I begin reducing and then maintaining weight."

1. "It is important that I limit protein intake."

A nurse notes that a client's serum calcium level is 6.0 mg/dL. Which assessment findings should be anticipated in this client? Select all that apply. 1. Tetany 2. Constipation 3. Renal calculi 4. Hypotension 5. Prolonged QT interval 6. Positive Chvostek's sign

1. Tetany 4. Hypotension 5. Prolonged QT interval 6. Positive Chvostek's sign

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? 1. The neurovascular status is normal because of increased blood flow through the leg. 2. The neurovascular status is moderately impaired, and the surgeon should be called. 3. The neurovascular status is slightly deteriorating and should be monitored for another hour. 4. The neurovascular status is adequate from an arterial approach, but venous complications are arising.

1. The neurovascular status is normal because of increased blood flow through the leg.

The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? Select all that apply. 1. Soak the feet in hot water daily. 2. Be careful not to injure the legs or feet. 3. Use a heating pad on the legs to aid vasodilation. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet.

2. Be careful not to injure the legs or feet. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet.

A hospitalized client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned and takes action, knowing that this level could ultimately lead to which complication? 1. Stroke 2. Cardiac arrest 3. High blood pressure 4. Urinary stone formation

2. Cardiac arrest

The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? 1. Keep the legs aligned with the heart. 2. Elevate the legs higher than the heart. 3. Clean the skin with alcohol every hour. 4. Position the client onto the side every shift.

2. Elevate the legs higher than the heart.

The health care provider prescribes bedrest for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. 1. Place in Fowler's position for eating. 2. Encourage coughing with deep breathing. 3. Encourage increased oral intake of water daily. 4. Place thigh-length elastic stockings on the client. 5. Place sequential compression boots on the client. 6. Encourage the intake of dark green, leafy vegetables.

2. Encourage coughing with deep breathing. 3. Encourage increased oral intake of water daily. 4. Place thigh-length elastic stockings on the client.

A nurse is assessing a client with an abdominal aortic aneurysm. Which assessment finding by the nurse is most likely unrelated to the aneurysm? 1. Pulsatile abdominal mass 2. Hyperactive bowel sounds in the area 3. Systolic bruit over the area of the mass 4. Subjective sensation of "heart beating" in the abdomen

2. Hyperactive bowel sounds in the area

A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse should next assess the client for which finding? 1. Bilateral edema 2. Increased calf circumference 3. Diminished distal peripheral pulses 4. Coolness and pallor of the affected limb

2. Increased calf circumference

A client is admitted to the hospital with a diagnosis of mitral stenosis. The narrowing of this valve will impede circulation of blood through which structures? 1. Left ventricle to aorta 2. Left atrium to left ventricle 3. Right atrium to right ventricle 4. Right ventricle to pulmonary artery 2. Left atrium to left ventricle

2. Left atrium to left ventricle

A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? 1. Sleep with the head of bed flat. 2. Weigh himself or herself on a daily basis. 3. Take a double dose of the diuretic if peripheral edema is noted. 4. Withhold prescribed digoxin (Lanoxin) if slight respiratory distress occurs.

2. Weigh himself or herself on a daily basis.

A female client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. The nurse should make which response to the client? 1. "Apply warm packs to the leg." 2. "Keep the leg elevated as much as possible." 3. "Contact your health care provider right away to report this problem." 4. "This normally occurs after surgery and will subside when the edema goes down."

3. "Contact your health care provider right away to report this problem."

The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem? 1. Anxiety related to the need to make lifestyle changes 2. Boredom resulting from having already learned the material 3. An attempt to ignore or deny the need to make lifestyle changes 4. Lack of understanding of the material provided at the teaching session and embarrassment about asking questions

3. An attempt to ignore or deny the need to make lifestyle changes

A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse determines that the client understands the effect of this medication on the diet if the client states to avoid which fruit? 1. Apples 2. Pears 3. Bananas 4. Cranberries

3. Bananas

A client has been admitted with left-sided heart failure. When planning care for the client, interventions should be focused on reduction of which specific problem associated with this type of heart failure? 1. Ascites 2. Pedal edema 3. Bilateral lung crackles 4. Jugular vein distention

3. Bilateral lung crackles

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving after this episode if which breath sounds are noted? 1. Rhonchi 2. Wheezes 3. Crackles in the bases 4. Crackles throughout the lung fields

3. Crackles in the bases

The nurse should recognize that a client who has developed severe pulmonary edema would most likely exhibit which symptom? 1. Mild anxiety 2. Slight anxiety 3. Extreme anxiety 4. Moderate anxiety

3. Extreme anxiety

A client has developed uncontrolled atrial fibrillation with a ventricular rate of 150 beats/min. What manifestation should the nurse observe for when performing the client's focused assessment? 1. Flat neck veins 2. Nausea and vomiting 3. Hypotension and dizziness 4. Clubbed fingertips and headache

3. Hypotension and dizziness

A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms? 1. Left atrium 2. Right atrium 3. Left ventricle 4. Right ventricle

3. Left ventricle

The nurse is giving discharge instructions to a client who has just undergone vein ligation and stripping. The nurse evaluates that the client understands activity and positioning limitations if the client states that which action is appropriate to do? 1. Walk for as long as possible each day. 2. Cross the legs at the ankle only, not at the knee. 3. Lie down with the legs elevated and avoid sitting. 4. Sit in a chair 3 times a day for 3 hours at a time.

3. Lie down with the legs elevated and avoid sitting.

The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit. The nurse notes that a cardiac troponin T level assay was performed while the client was in the intensive care unit. The nurse determines that this test was performed to assist in diagnosing which condition? 1. Heart failure 2. Atrial fibrillation 3. Myocardial infarction 4. Ventricular tachycardia

3. Myocardial infarction

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics? 1. Sinus bradycardia 2. Sick sinus syndrome 3. Normal sinus rhythm 4. First-degree heart block

3. Normal sinus rhythm

A nurse is preparing to ambulate a client on the third day after cardiac surgery. What should the nurse plan to do to enable the client to best tolerate the ambulation? 1. Remove telemetry equipment. 2. Provide the client with a walker. 3. Premedicate the client with an analgesic. 4. Encourage the client to cough and breathe deeply.

3. Premedicate the client with an analgesic.

A nurse is auscultating a 56 year old adult client's apical heart rate before giving digoxin (Lanoxin) and notes that the heart rate is 48 beats/minute. Which action should the nurse take? 1. Withhold the digoxin, and reevaluate the heart rate in 4 hours. 2. Administer half the prescribed dose to avoid a further decrease in heart rate. 3. Withhold the digoxin; assess for signs of decreased cardiac output and digoxin toxicity. 4. Administer the digoxin. The heart rate would be considered normal because of the client's age.

3. Withhold the digoxin; assess for signs of decreased cardiac output and digoxin toxicity.

The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? 1. "I need to be sure not to go barefoot around the house." 2. "If I cut my toenails, I need to be sure that I cut them straight across." 3. "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." 4. "I need to be sure that I elevate my leg above my heart level for at least an hour every day." 4. "I need to be sure that I elevate my leg above my heart level for at least an hour every day."

4. "I need to be sure that I elevate my leg above my heart level for at least an hour every day."

A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? 1. Sensation of palpitations 2. Causative factors, such as caffeine 3. Precipitating factors, such as infection 4. Blood pressure and oxygen saturation

4. Blood pressure and oxygen saturation

A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1. Regular insulin 2. Glipizide (Glucotrol) 3. Repaglinide (Prandin) 4. Metformin (Glucophage)

4. Metformin (Glucophage)

The nurse is teaching a client with cardiomyopathy about home care safety measures. The nurse should address with the client which most important measure to ensure client safety? 1. Assessing pain 2. Administering vasodilators 3. Avoiding over-the-counter medications 4. Moving slowly from a sitting to a standing position

4. Moving slowly from a sitting to a standing position

A client with pulmonary edema has been receiving diuretic therapy. The client has a prescription for additional furosemide (Lasix) in the amount of 40 mg intravenous push. Knowing that the client will also be started on digoxin (Lanoxin), which laboratory result should the nurse review as the priority? 1. Sodium level 2. Digoxin level 3. Creatinine level 4. Potassium level

4. Potassium level

The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage should the nurse instruct the client to select from the menu? 1. Tea 2. Cola 3. Coffee 4. Raspberry juice

4. Raspberry juice