Pn2

A nurse suspects a client is experiencing chronic obstructive pulmonary disease when which of the following is assessed?

-Cough Sputum production dyspnea (peripheral edema)?

=The parents of a child diagnose with cystic fibrosis ask the nurse how their child developed the disease. Which of the" following should explain to the parents?

Cystic fibrosis is passed on by defective gene from both parents.

=A nurse working with client with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crisis. a client communicates the need for additional teaching by which of the following statements?

I will avoid exercise.

The nurse is assessing a client with asthma wheezing noting initially diminish sounds until no audible sounds her this has occurred to which of the following

Increase airway construction is blocking the airway

The provider to order the normal saline with 20 mEq of KCl to infuse at 125 mL/hour. The first liter bag was hung at 1200. What time does the nurse anticipate needing to hang the second bag of IV fluids? (Record answer in military time)

2000

=A client undergoes a purified protein derivative (PPD) test. When should the test be read?

48 to 72 hours after the test.

Which of the following statements should the nurse teach a client who is receiving warfarin sodium?

international normalize ratio (INR) is used to assess its effectiveness.

With which client does the nurse anticipate complications from obstructive sleep apnea following abdominal surgery?

-28-year-old who is 80lbs (36.4 kg) overweight and has a short neck

The health care provider has just prescribed the client with a deep vein thrombosis (DVT) warfarin sodium. The nurse knows that this client is still receiving intravenous heparin, Which is the nurse's best action?

-Administer the medications as prescribed.

A client is admitted with abdominal aortic aneurysm. For which of the following complications should the nurse be concerned?

-Aneurysm rupture or cardiac arrhythmia

The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which finding requires further evaluation?

-Ankle-brachial index of 0.65

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure?

-B-type natriuretic peptide (BNP)

A client is undergoing diagnostic testing for infective endocarditis. Which of the following laboratory tests would be, most useful in diagnosis?

-Blood cultures

The nurse is assessing a client diagnosed with an abdominal aortic aneurysm. Which of the following sounds is they nurse likely auscultates during the assessment?

-Bruit

Which of the following would the nurse most likely assess in a client diagnosed with right-sided heart failure?

-Distended neck veins (JVD)

A nurse is assessing a patient who has right heart ventriculat failure. Which of the following findings should the nurse expect?

-Hepatomegaly

A nurse is assessing a male client who has a new diagnosis of peripheral artery disease (PAD). Which of the following findings should the nurse expect to find on the affected extremity? (Select all that

-Pain Pulselessness Paresthesia Paralysis Pallor Poikilothermic

A nurse completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for the client?

-Peripherally inserted central catheter

A client receiving a heparin infusion is demonstrating of acute bleeding. Which of the following should the nurse prepare to administer to this client?

-Protamine sulfate

A client comes into the ER with acute shortness of breath and a cough that produces pink, frothy sputum. Admission assessment reveals crackles and wheezes, a BP 85/46, a HR of 122 BPM, and a respiratory rate of 38 breaths/minute. The client's medical history included DM, HTN, and a heart failure. Which of the following disorders should the nurse suspect?

-Pulmonary edema

When a patient with hypertension who has a new prescription for atenolol returns to the health clinic after 2 weeks for a follow-up visit, the BP is unchanged from the previous visit. Which action should the nurse take first?

-Question the patient about whether the medication is actually being taken.

A nurse is caring for a client who arrived at an emergency department with status asthmaticus. Based on the progress Note: BP 140/90, P 104, and Temp 98.4 F, RR 34, audible wheezing, ABG results pH 7.22, PaCO2 69, and HCO3-26. The nurse suspects that the client has what abnormality?

-Respiratory acidosis

The nurse is assigned to a client who just arrived to the emergency room after a motor vehicle accident and has rib fractures. Knowing the client could potentially have a pneumothorax, what are the signs and symptoms the nurse would correlate with this condition?

-Respiratory distress

A patient who has a history of pulmonary valve stenosis tells the healthcare provider, "I don't have a lot of energy anymore, and both of my feet get swollen in the late afternoon." Which of these problems does the healthcare provider conclude is the likely cause of these clinical findings?

-Right side heart failure

A client is having laboratory tests conducted to confirm a diagnosis of arteriosclerosis. Which of the following laboratory values would support this client's medical diagnosis? (Select all that apply)

-Serum cholesterol 300 mg/dL -LDL 145 mg/dL -HDL 25 mg/dL -Triglycerides 400 mg/dL

A nurse is reviewing the labs for a newly admitted heart failure patient and notes a K+ level of 5.6. Upon reviewing the patient's medications, the nurse realizes which of the following medications most likely contributed to this electrolyte imbalance?

-Spironolactone

Of the following client assignments made by the charge nurse, which would you question?

-The LPN with 20 years of experience caring for a diabetic client complaining of a headache and with blood pressure of 210/150

A client is receiving an IV infusion of heparin sodium at 1,200 units/hour. The drug concentration is heparin sodium 25,000 units/500 ML. What is the rate (in mL/hr) the nurse must infuse the medication

24

Order for dobutamine to infuse at 5 mcg/kg/min. The client weighs 198 lb. The pharmacy supplied a bag of dobutamine 250mg/250mL. What is the rate (in mL/hr) the nurse must infuse the medication at? (Record the answer to the nearest whole number. Do not use a trail in zero

27

A client has a history of heart failure and has been prescribed furosemide Digoxin and potassium chloride The client has nausea blurred vision headache and weakness the nurse notes that the client is confused refusing to eat and complaining of nausea the nurse should assess the client for signs

Digoxin toxicity

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?

Edema

A client has diagnosed with TB what action by the nurse takes highest priority

Educating the client adherence to treatment regimen

Isoniazid and rifampin have been prescribed for a client with TB a nurse reviews the medical record of the client which of the noted In the clients history will require the nurse to question the order for these medication

Hep c or b

A patient is admitted to the hospital with a diagnosed of chronic insufficiency which of these statements by the patient is most consistent with the diagnosis

I can't get my shoes on at the end of the day

The nurse is notifying the healthcare provider via telephone of a change in the condition of a client diagnosed with an exacerbation of asthma. Arrange the nursing statements in order as they would be communicated using the SBAR method. 1. Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically controls his asthma with oral medication and inhaler's at home. He has ordered albuterol treatment twice daily. Oxygen is prescribed at 2L nasal cannula. 2. I am notifying you because Bob Smith has become increasingly short of breath with audible wheezing this afternoon. 3. I recommend that we increased his oxygen dose and prescribe an extra albuterol treatment. 4. Hello. My name is nurse Jones from unit D. 5. Respirations are now 32 breaths/minute. The pulse oximeter is 89% on 2 L nasal cannula. Lungs reveal wheezing in all lung fields. Slight nasal flaring as noted.

4,2,1,5,3

A nurse is caring for a child who has status asthmaticus. Which is an appropriate action for to take?

Admin albuterol saba

client is diagnosed with acute peripheral arterial oc he nurse should prepare to provide which of the

Administer heparin as prescribed

A nurse caring for a client who had a chest tube placed 6 hours ago and refuse to take deep breaths because of the pain. Which action should the nurse take?

Administer pain medication an encourage the client to take deep breaths.

=The nurse is considering the risk factor for clients developing of primary hypertension. Which of the following are nonmodifiable risk factors for the client? (SATA)

Age, Gender, Ethnicity

=The nurses reviewing a medical record for a client with hypertension. which of the following medications may be used in the management of hypertension?

Amlodipine Atenolol enalapril hydralazine Spironolactone Lasix

A claim with bacterial pneumonia becomes increasingly restless and confused temperature is 100.4 and post blood pressure and respirations are increased since the last assessment six hours ago which action should the nurse take first

Assess oxygen saturation

A client with bacterial pneumonia becomes increasingly restless and confused. temperature is 100 F, and pulse, blood pressure, and respirations are increased since the last assessment 6 hours ago. which action should the nurse take first?

Assess oxygen saturation.

=The post anesthesia care nurse is caring for a client who just had a mitral valve replacement surgery. the clients arterial blood gas are as follows PH 7.22, HCO3 21 mEq/L PCO2 65 mm Hg, and PO2 58 mm Hg. which is the priority action by the nurse?

Assessing the client's airway.

=A client is diagnosed with acute peripheral arterial occlusion. The nurse should prepare to provide which of the following interventions for this client?

Assist with ambulation.

The nurse is caring for a group of clients on a pulmonary unit. The nurse can delegate which task to unlicensed I assistive personnel?

Assisting a client with adjusting his or her nasal cannula

A patient who has just been admitted with pneumococcal Pneumonia has a temperature of 100.6 with a frequent cough and is complaining of severe chest pain which of the prescribe medication should the nurse get first

Azithromycin

=When teaching a client about Propranolol hydrochloride. What information should the nurse include in the education for the client?

Blocks beta-adrenergic stimulation and thus causes decrease heart rate, myocardial contractility, and conduction.

=Which assessment finding for a client receiving Lasix furosemide 40mg twice daily to treat stage 2 hypertension which is most important to report to the health care provider?

Blood potassium level of 3.3 mEq/L.

=A nurse is caring for a client who has heart failure and taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness, Which of the following action should be a priority for the nurse to take?

Check the client vital sign and heart rhythm.

=A client who underwent a lobectomy and has a water seal chest drainage system appears to have an increased work of breathing and at a fastest rate then 1 hour ago. The client's pulse rate is also increased. The nurse should do which of the following?

Check the tubing to ensure that the client is not laying on it or kinking it.

Which finding requires immediate intervention when planning care for an adolescent with cystic fibrosis

Chest pain dyspnea

=A nurse evaluate the following arterial blood gas and vital signs results for a client with chronic obstructive pulmonary disease (COPD) Arterial Blood Gas Results PH - 7.32 PaCO2 - 62 mm Hg Pa02 -46 mm Hg HCO3 - 28 mEq/L Vital signs respiratory rate 12 beats/minutes blood pressure 145/65 mm Hg heart rate 110 beats/minute oxygen saturation 76% on room air Which action should the nurse take first?

Initiate oxygenation therapy to increase oxygen saturation to 92%.

=A client with chronic bronchitis who has a new prescription for a fluticasone and salmeterol combination inhaler ask the nurse the purpose of using two drugs.

One drug decrease inflammation and the other is a bronchodilator.

Which ABG values are expected with anxiety induced hyperventilation

Ph 7.29; PaCO2 55 mm Hg

The nurse is assessing a client for risks in the development of varicose veins. Which of the following findings would increase this client's risk?

Prolonged standing

=A client is experiencing an asthmatic attack. The client is noted to have respirations of 40 beats per minute, pause 132 beats per minute, oxygen saturation 86% on room air, and long sounds with audible wheezing. which findings indicate achievement of the desired outcomes of treatment with levalbuterol?

Pulse 96 beats/minute oxygen saturation of 92% on room air.

Which findings are significant data together from a client who has been diagnosed with pneumonia

Quality of breath sounds Occurrence of chest pain color of nail beds

A client is admitted with ABG of 7.30 paco2 60 hco3 22 the nurše concludes the patient has which acid base. imbalance?

Respiratory acidosis

=A client with an acute exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. How can the nurse best position the client to improve gas exchange?

Sitting up at the bedside or in a chair and leaning slightly forward.

-A nurse is assessing a client who is taking lisinopril to treat hypertension. which finding s the highest priority to report?

Swelling of the tongue

The nurse is preparing a teaching plan for a client who is being discharged after being admitted for atherosclerosis. The client has been taking simvastatin 40 mg for the last two years. the lab results for the client's lipid panel results are total/ cholesterol 195 mg/dl: triglycerides 106 mg/dl and high-density lipoprotein (HDL) 69 mg/dl. Which action should the nurse take?

Tell the clients that their cholesterol levels are within normal limits.

A nurse assessing a client in preparation for receiving a blood transfusion. Pre-transfusion vitals are temperature 92.2°F, heart rate 82 beats/min, respirations 18 breaths/minute, blood pressure MISSING mm Hg, oxygen saturation 96% on room air. Fifteen minutes after starting the transfusion the nurse measures the following vital signs which of the following is the highest priority for action?

Temperature 100.6°F. --Indication of infection

Which action by the patient who has asthma indicates a good understanding of the nurse is teaching about peak flow meter

The patient who's albuterol meter dose inhaler for peak flows in the yellow zone

Which of the following conditions is most commonly responsible for right heart failure?

left sided heart failure