practice exam
Which information from a patient helps the nurse confirm a prior diagnosis of chronic stable angina?
The pain goes away after a nitroglycerin tab
The nurse has received the laboratory results for a patient who developed chest pain 5 hours ago and may be having a myocardial infarction. The laboratory test result most helpful in indicating myocardial damage will be
Troponin
A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. which of the following lab test should the nurse anticipate the provider to prescribe?
Troponin I - Troponin I and T are proteins that only exist in cardiac muscle and enter the blood stream within a few hours of myocardial injury - the most specific indicator of myocardial damage
A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. which of the following lab tests are used to diagnose a myocardial infarction?
Troponin I Troponin T CPK Myoglobin
a nurse is caring for a client who has multiple sclerosis. What 3 findings from day 3 that require immediate follow up?
WBC count respirations temperature
A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take?
obtain an EKG rationale: the nurse should obtain an EKG to detect heart rhythm abnormalities within 10 min of the client's reported discomfort
a nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis.
oral mucosa - nurse should monitor for tongue and lips for manifestations of central cyanosis
a nurse is preparing for the admission of a client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client?
place the care in a private room with a special ventilation system
a nurse is caring for a client in the emergency department The nurse should first _________ followed by _________
place the client in high-fowlers position, obtaining IV access
a nurse is providing teaching about the heart healthy diet to a client newly who has diagnosis of hypertension. which of the following statements by the client indicates a need for further teaching?
"I do not need to limit my lean protein intake."
A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates understanding of teaching?
"I must stop smoking." "I need to monitor my weight." "I am limiting my intake of fast foods."
a nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?
"I plan to slow down if I am tired the day after exercising."
a nurse is preparing to administer clindamycin 300 mg by intermittent IV bolus over 30 min to a client who has staphylococci infection. Available is clindamycin premixed in 50 mL 0.90% sodium chloride. The nurse should set the IV pump to deliver how many mL/hr?
100 mL/ hr 50/0.5
a nurse is calculating the total fluid intake for a client during a 4 hr period. the client consumes 1 cup of coffee 4 oz of orange juice 3 oz of water 1 cup of flavored gelatin 1 cup of tea 5 oz of broth 3 oz of water the nurse should record how many m: of intake on the client's record?
1170 mL
what are consistent with Myocardial infarction?
12 lead EKG report client's initial report of manifestations provider consult
what are consistent with anginas?
12 lead EKG report result of nitroglycerin therapy client's initial report of manifestations treadmill stress test provider consult
a nurse in a community health center is assessing the results of a tuberculin skin test she performed for a client. Which of the following results indicate exposure to and a possible infection with tuberculosis (TB)?
15 mm induration positive reaction: induration (hardened ara) that is 10mm or greater
A nurse is preparing to administer potassium chloride 20 mEq suspension PO daily. The amount available is potassium chloride suspension 10 mEq/mL. How many mL should the nurse administer?
2 mL
a nurse is calculating the intake of a client during the past 9 hour. The client's intake includes lactated ringer's IV at 150 mL/hr cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride two units of packed RBCs of 275 mL and 250 mL two IV bolus infusions of 250 mL of 0.9% sodium chloride famatidine 20 mg IV intermittent bolus in 50 mL of 0.9% sodium chloride How many mL of intake should the nurse record?
2,525 mL
A nurse is preparing to administer digoxin 1.5 mg PO to a client. The amount available is digoxin 0.5 mg/tablet. How many tablets should the nurse administer?
3 tablets
a nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction. Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI?
Dyspnea chest pain nausea and vomiting tachycardia diaphoresis
A nurse in a provider's office is assessing the a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions?
Heart failure rationale: fatigue and tachycardia are early manifestations of heart failure
Asystole
absence of contractions of the heart
A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min RR 40/min blood pressure 140/80 mm Hg Her arterial blood gases are pH 7.5, PaCO2 29 mmHg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86% Which of the following is the priority nursing intervention?
administer oxygen via face mask - the pH reflects alkalosis - low PaCO2 indicates lungs are involved - client has respiratory alkalosis - o2 sat is low so priority is to administer oxygen via mask attempting to achieve an oxygen sat of at least 95%
a nurse is admitting a client who has tuberculosis and a productive cough. which of the following types of isolation precautions should the nurse initiate for the client?
airborne
a home health nurse visits a client who has COPD and receives oxygen at 2L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?
assess the client's respiratory status
A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea (shortness of breath) and a dry, hacking cough. Which nursing action would be a priority over the others?
auscultate lung sounds
A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. Which of the following information should the nurse include about anginal pain.
avoid activities that trigger the pain - exertion and anxiety can trigger pain of angina
a nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition.
breathlessness others are crackles or wheezes due to pulmonary congestion
this allied health specialist treats health problems associated with the muscular, nervous, and skeletal systems, especially the spine.
chiropractor
a nurse is caring for a client who has COPD. 5 findings that require a follow up are
disorientation yellow sputum nebulizer use ankle edema lives alone
a nurse is caring for a client who has COPD. The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
encouraging the client to drink 2 to 3 L of water daily
a nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect
frothy sputum
a nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?
hacking cough
a nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?
hepatomegaly - liver enlargement
a nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder?
hypercholesterolemia hypertension obesity smoking
a nurse is caring for a client day 1 postoperative who developed atelectasis. Which of the following manifestations is an expected finding for this condition?
hypoxemia - decreased oxygenation of the red blood cells and cyanosis due to poor oxygen exchange
a nurse is assisting with the care of a client who is postoperative following an open appendectomy. The client is at risk for developing __________ as evidence by the client's ________
hypoxia, respiratory data collection findings
a nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client.
increased anteroposterior diameter of the chest
A doctor who diagnoses and treats diseases that are caused by microorganisms is a/an
infectious disease specialist
A nurse at a provider's office receives a phone call from a client who reports nausea and unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse.
instruct the client to call 911 rationale: the nurse should intrust the client to call 911 for transportation to the emergency department because the client is having unstable angina or MI
a nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?
instruct the client to use pursed-lip breathing
a nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect?
intercostal retractions
A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis?
night sweats low grade fever blood sputum weight loss
the nurse will set which patient care goals for a patient with chronic obstructive pulmonary disease (COPD)? Select all that apply.
prevention of disease progression improved quality of life ability to perform activities of daily living relief of symptoms
a nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mmHg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
respiratory acidosis
a nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances?
respiratory acidosis
the nurse is caring for a patient who had been admitted to the general medical unit two days earlier with an acute asthma attack. Which sign reassures the nurse the patient is stable?
respiratory rate 18 bpm without the use of accessory muscles
a nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension?
sedentary lifestyle
A 20 year-old patient is having his first asthma attack; his respiratory rate is 45 breaths per minute. What is the best position for the nurse to place the patient?
sitting up high fowlers
a nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?
sputum culture for acid-fast bacillus
treatment by operation or manual (hand) methods
surgery
a nurse is admitting a client who has a history of hear failure. What 5 findings require an immediate follow up?
vital signs respiratory assessment renal function BNP ECG results
A patient with heart failure is scheduled to receive 80mg of Lasix IV at 2:00pm. On hand is the vial pictured. How many ml's will the nurse draw up for administration?
8 mL
