Unit 2 Semester 2

A female patient who had a stroke 24 hours ago has expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.

ask questions that the patient can answer with "yes" or "no."

A patient will attempt oral feedings for the first time after having a stroke. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patient's appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.

assist the patient into a chair.

Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient? (Select all that apply.) a. Assess for bradycardia. b. Ask about epigastric pain. c. Observe for increased appetite. d. Check for elevated blood glucose levels. e. Monitor for a decrease in respiratory rate.

b. Ask about epigastric pain. c. Observe for increased appetite. d. Check for elevated blood glucose levels.

The nurse is working with a patient who recently lost her spouse after a lengthy illness. The patient shares that she would like to sell her home and move to another state now that her spouse has passed away. Which of the following interventions would be considered a priority for this patient? (Select all that apply.) a. Notify the provider to evaluate for antidepressant therapy. b. Suggest that the patient consider a support group for widows. c. Suggest that the patient learn stress reduction breathing exercises. d. Suggest that the patient take prescribed anti-anxiety medications. e. Assist the patient in identifying support systems. f. Notify the provider to evaluate the need for anti-anxiety medications.

b. Suggest that the patient consider a support group for widows. c. Suggest that the patient learn stress reduction breathing exercises. e. Assist the patient in identifying support systems.

The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

For a patient who had a right hemisphere stroke, the nurse anticipates planning interventions to manage a. impaired physical mobility related to right-sided hemiplegia. b. risk for injury related to denial of deficits and impulsiveness. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.

risk for injury related to denial of deficits and impulsiveness.

A patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.

teach the family that emotional outbursts are common after strokes.

A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin drip administration. d. tissue plasminogen activator (tPA) infusion.

tissue plasminogen activator (tPA) infusion.

When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a. to monitor and record the blood pressure daily. b. to call the health care provider if stools are tarry. c. that clopidogrel will dissolve clots in the cerebral arteries. d. that clopidogrel will reduce cerebral artery plaque formation.

to call the health care provider if stools are tarry.

When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, "I will a. use a heating pad on my feet at night to increase the circulation." b. buy some loose clothes that do not bind across my legs or waist." c. walk to the point of pain, rest, and walk again for at least 30 minutes 3 times a week." d. change my position every hour and avoid long periods of sitting with my legs crossed."

use a heating pad on my feet at night to increase the circulation."

The nurse comes into the room of a child who was just diagnosed with a chronic disability. The child's parents begin to yell at the nurse about a variety of concerns. The nurse's best response is: a. "What is really wrong?" b. "Being angry is only natural." c. "Yelling at me will not change things." d. "I will come back when you settle down."

"Being angry is only natural."

The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows the student understands this problem when the student makes which statement? a. "Central perfusion is monitored only by the physician." b. "Central perfusion involves the entire body." c. "Central perfusion is decreased with hypertension." d. "Central perfusion is toxic to the cardiac system."

"Central perfusion involves the entire body."

A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should 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 events in your life?"

"Have you consistently taken your medications?"

A patient diagnosed with hypertension asks the nurse how this disease could have happened to them. What is the nurse's best response? a. "Hypertension happens to everyone sooner or later. Don't be concerned about it." b. "Hypertension can happen from eating a poor diet, so change what you are eating." c. "Hypertension can happen from arterial changes that block the blood flow." d. "Hypertension happens when people do not exercise, so you should walk every day."

"Hypertension can happen from arterial changes that block the blood flow."

The nurse has just finished teaching a hypertensive patient about the 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."

"I can expect some swelling around my lips and face."

A 52-yr-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, a. "I need to start eating more red meat and liver." b. "I will stop having a glass of wine with dinner." c. "I could choose nasal spray rather than injections of vitamin B12." d. "I will need to take a proton pump inhibitor such as omeprazole (Prilosec)."

"I could choose nasal spray rather than injections of vitamin B12."

Which statement shows that the newly diagnosed asthma patient understands how to use a peak expiratory flow meter (PEFM)? 1 "I have to blow out as fast and hard into the machine as I can." 2 "I can stand or sit to use the flow meter. I just can't lie down." 3 "I have to take three readings and record the average on the flow sheet." 4 "I'll use the meter whenever I can throughout the day; it doesn't really matter when."

"I have to blow out as fast and hard into the machine as I can."

The nurse leader suffers from headaches, hypertension, and gastrointestinal problems. Which statement by the leader reflects an appropriate way to manage the stress? 1 "I will avoid protein." 2 "I will plan a vacation." 3 "I will get enough sleep." 4 "I will participate in support groups."

"I will get enough sleep."

Which statement by a patient indicates additional teaching is required about the medication warfarin? a. "I will continue my diabetic diet and restrict sugar." b. "I will increase the intake of green, leafy vegetables for a more healthful diet." c. "I will restrict the intake of foods high in vitamin C." d. "I will increase the amount of protein in my diet to protect my kidneys."

"I will increase the intake of green, leafy vegetables for a more healthful diet."

The nurse teaches a patient about pulmonary spirometry testing. Which statement, if made by the patient, indicates teaching was effective? a. "I should use my inhaler right before the test." b. "I won't eat or drink anything 8 hours before the test." c. "I will inhale deeply and blow out hard during the test." d. "My blood pressure and pulse will be checked every 15 minutes."

"I will inhale deeply and blow out hard during the test."

The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use? a. "I have not had any acute asthma attacks during the past year." b. "I became short of breath an hour before coming to the hospital." c. "I've been taking Tylenol 650 mg every 6 hours for chest wall pain." d. "I've been using my albuterol inhaler more frequently over the last 4 days."

"I've been using my albuterol inhaler more frequently over the last 4 days."

A patient tells the nurse, "I'm told that I should reduce the stress in my life, but I have no idea where to start." Which would be the best initial nursing response? a. "Why not start by learning to meditate? That technique will cover everything." b. "In cases like yours, physical exercise works to elevate mood and reduce anxiety." c. "Reading about stress and how to manage it might be a good place to start." d. "Let's talk about what is going on in your life and then look at possible options."

"Let's talk about what is going on in your life and then look at possible options."

A client who has undergone a mastectomy because of breast cancer is now undergoing chemotherapy, which has caused hair loss. The client states, "I feel like I've lost my sense of power." Which response would the nurse give? 1 "Hair does not empower a person." 2 "Losing power seems important to you." 3 "Knowledge is power; I'll give you some pamphlets to read." 4 "Hair loss is common; it will grow back, so you should not worry."

"Losing power seems important to you."

While working in the outpatient clinic, the nurse notes that a patient has a history of intermittent claudication. Which statement by the patient would support this information? a. "When I stand too long, my feet start to swell." b. "My legs cramp when I walk more than a block." c. "I get short of breath when I climb a lot of stairs." d. "My fingers hurt when I go outside in cold weather."

"My legs cramp when I walk more than a block."

A nurse is explaining to a student nurse about perfusion. The nurse knows the student understands the concept of perfusion when the student makes which statement? a. "Perfusion is a normal function of the body, and I don't have to be concerned about it." b. "Perfusion is monitored by the physician." c. "Perfusion is monitored by vital signs and capillary refill." d. "Perfusion varies as a person ages, so I would expect changes in the body."

"Perfusion is monitored by vital signs and capillary refill."

A diabetic patient who is hospitalized tells the nurse, "I don't understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up." Which response by the nurse is appropriate? a. "It is probably just coincidental that your blood sugar is high when you are ill." b. "Stressors such as illness cause the release of hormones that increase blood sugar." c. "Increased blood sugar occurs because the kidneys are not able to metabolize glucose as well during stressful times." d. "Your diet is different here in the hospital than at home, and that is the most likely cause of the increased glucose level."

"Stressors such as illness cause the release of hormones that increase blood sugar."

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The obstructing plaque is surgically removed from inside an artery in the neck." b. "The diseased portion of the artery in the brain is replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery, and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."

"The obstructing plaque is surgically removed from inside an artery in the neck."

The patient asks the nurse to explain the function of the sinoatrial node in the heart. What is the nurse's best response? a. "The sinoatrial node stimulates the heart to beat in a normal rhythm." b. "The sinoatrial node protects the heart from atherosclerotic changes." c. "The sinoatrial node provides the heart with oxygenated blood." d. "The sinoatrial node protects the heart from infection."

"The sinoatrial node stimulates the heart to beat in a normal rhythm."

The nurse has been asked to administer a coping measurement instrument to a patient. What education would the nurse present to the patient related to this tool? a. "This tool will let us compare your stress to other patients in the hospital." b. "This tool is short because it only measures the negative stressors you are experiencing." c. "You will need to ask your parents about stressors you had as a child to complete this tool." d. "This tool will help assess recent positive and negative events you are experiencing."

"This tool will help assess recent positive and negative events you are experiencing."

When a client with a health care-acquired respiratory tract infection asks the nurse what this means, which response will the nurse give? 1 "You developed an infection that requires antibiotics." 2 "This is a highly contagious infection requiring isolation." 3 "An infection you had before beginning treatment has flared up." 4 "Your infection occurred because of exposure to a health care facility. "

"Your infection occurred because of exposure to a health care facility. "

Which life-threatening wounds are treated with hyperbaric oxygen therapy? Select all that apply. One, some, or all responses may be correct. 1 Burns 2 Skin cancer 3 Osteomyelitis 4 Diabetic ulcers 5 Myocardial infarction

1 Burns 3 Osteomyelitis 4 Diabetic ulcers

A client is prescribed albuterol to relieve severe asthma. Which adverse effects will the nurse instruct the client to anticipate? Select all that apply. One, some, or all responses may be correct. 1 Tremors 2 Lethargy 3 Palpitations 4 Bronchoconstriction 5 Decreased pulse rate

1 Tremors 3 Palpitations

Which is a risk factor of necrotizing enterocolitis in the preterm infant? 1 Polycythemia 2 Hypoglycemia 3 Ventilatory support 4 Antibiotic administration

Polycythemia

In which order would the nurse take these prescribed actions when caring for a client with chronic obstructive pulmonary disease (COPD) who is admitted with fever, increased dyspnea, and oxygen saturation of 86%?

1. Start oxygen per non-rebreather mask. 2. Obtain blood and sputum cultures. 3. Infuse ceftriaxone 1 g intravenously. 4. Administer acetaminophen for fever.

he nurse obtains a blood pressure of 176/82 mm Hg for a patient. What is the patient's mean arterial pressure (MAP)? MAP = (SBP + 2 DBP)/3

113 mm Hg

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

128/76 mm Hg

Which clinical manifestations are associated with a diagnosis of tuberculosis? Select all that apply. One, some, or all responses may be correct. 1 Diarrhea 2 Anorexia 3 Weight gain 4 Hemoptysis 5 Night sweats

2 Anorexia 4 Hemoptysis 5 Night sweats

Which iron-rich foods would the nurse recommend for a toddler diagnosed with iron deficiency anemia? Select all that apply. One, some, or all responses may be correct. 1 Carrots 2 Chicken 3 Broccoli 4 Lean steak 5 Whole milk

2 Chicken 3 Broccoli 4 Lean steak

Which sources of stress would the nurse plan to include in the assessment for a 9-year-old client who is scheduled for a routine health maintenance visit? Select all that apply. One, some, or all responses may be correct. 1 Stature 2 Fair play 3 Propriety 4 Interruptions 5 Rebelliousness

2 Fair play 3 Propriety 4 Interruptions 5 Rebelliousness

Which interventions should the nurse take to ensure the well-being of a community-dwelling older adult with hypertension? Select all that apply. One, some, or all responses may be correct. 1 Suggest that the client have annual Papanicolaou (Pap) smears and mammograms. 2 Promote dietary modifications by using varied techniques. 3 Assess the client's current lifestyle and promote lifestyle changes. 4 Monitor the client's blood pressure and weight, and establish blood pressure screening programs. 5 Teach the client about correct body mechanics and the availability of mechanical appliances.

2 Promote dietary modifications by using varied techniques. 3 Assess the client's current lifestyle and promote lifestyle changes. 4 Monitor the client's blood pressure and weight, and establish blood pressure screening programs.

Which conscious, healthy, coping behaviors would the nurse recommend a client use to reduce anxiety? Select all that apply. One, some, or all responses may be correct. 1 Eating 2 Sublimation 3 Exercise 4 Suppression 5 Rationalization 6 Talking to friends

3 Exercise 4 Suppression 6 Talking to friends

A 50-year-old client is diagnosed with chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100 beats/min, a blood pressure of 138/82 mm Hg, a respiratory rate of 32 breaths/min, a tympanic temperature 98.2°F (36.8°C), and an oxygen saturation of 80%. Which vital signs obtained by the nurse indicates a positive outcome? Select all that apply. One, some, or all responses may be correct. 1 Radial pulse: 70 beats/min 2 Temperature: 98.6°F (37°C) 3 Respiratory rate: 14 breaths/min 4 Blood pressure: 110/70 mm Hg 5 Oxygen saturation: 92%

3 Respiratory rate: 14 breaths/min 4 Blood pressure: 110/70 mm Hg 5 Oxygen saturation: 92%

Which would be the respiratory rate in a 2-year-old child? 1 20 breaths/min 2 30 breaths/min 3 40 breaths/min 4 50 breaths/min

30 breaths/min ( The normal range for the respiratory rate in a 2-year-old child (toddler) is between 25 and 32 breaths/min. Twenty breaths per minute is the normal respiratory rate in adolescents and adults. The normal respiratory rate in newborns is 40 breaths/min. The normal respiratory rate in infants is 50 breaths/min.)

The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a. 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain b. 52-yr-old with a blood pressure of 198/90 mm Hg who has intermittent claudication c. 50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL d. 43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria

48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain

After receiving the change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-yr-old patient with right-sided weakness has an infusion of tPA prescribed b. A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled d. A 40-yr-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due

A 60-yr-old patient with right-sided weakness has an infusion of tPA prescribed

When the nurse is reviewing a client's arterial blood gas results, which finding is consistent with respiratory alkalosis? 1 An elevated pH, elevated partial pressure of carbon dioxide (PCO 2) 2 A decreased pH, elevated PCO 2 3 An elevated pH, decreased PCO 2 4 A decreased pH, decreased PCO 2

An elevated pH, decreased PCO 2

A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? a. The infant is becoming more active. b. There is an increase in intake of breast milk or formula. c. The infant is unable to maintain an adequate iron intake. d. A depletion of fetal hemoglobin occurs.

A depletion of fetal hemoglobin occurs

After the nurse has received change-of-shift report, which patient should the nurse assess first? a. A patient with pneumonia who has crackles in the right lung base b. A patient with chronic bronchitis who has a low forced vital capacity c. A patient with possible lung cancer who has just returned after bronchoscopy d. A patient with hemoptysis and a 16-mm induration after tuberculin skin testing

A patient with possible lung cancer who has just returned after bronchoscopy

Which nursing observation would indicate that the nurse hold the medication warfarin (Couma-din)? a. An INR (international normalize ratio) of 1.8 b. An INR of 4.8 c. A partial thromboplastin time (APTT) level of 25 seconds d. An APTT level of 35 seconds

An INR of 4.8

A depressed client whose spouse recently died begins to cry when another group member talks about her divorce and feelings of abandonment. Which intervention would the nurse use? 1 Ask group members to turn the discussion to the depressed client's feelings. 2 Have the 2 clients stay after group so that they can share feelings of abandonment. 3 Observe the depressed client's behavior carefully during the next several hours. 4 Accompany the depressed client to her room and encourage her to express her feelings.

Accompany the depressed client to her room and encourage her to express her feelings.

The nurse observes that a patient with respiratory disease experiences a decrease in SpO2 from 93% to 88% while the patient is ambulating. What is the priority action of the nurse? a. Notify the health care provider. b. Administer PRN supplemental O2. c. Document the response to exercise. d. Encourage the patient to pace activity.

Administer PRN supplemental O2.

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Encourage the patient to take deep slow breaths. c. Start the prescribed PRN oxygen at 2 to 4 L/min. d. Administer the prescribed normal saline bolus and insulin.

Administer the prescribed normal saline bolus and insulin.

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor).

Administer the prescribed short-acting insulin.

Which complication is the nurse's main priority during the early postoperative period after a subtotal thyroidectomy? 1 Hemorrhage 2 Thyrotoxic crisis 3 Airway obstruction 4 Hypocalcemic tetany

Airway obstruction

A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT? a. Allergy to shellfish b. Apical pulse of 104 c. Respiratory rate of 30 d. O2 saturation of 90%

Allergy to shellfish

The nurse is assessing a patient's differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient's gas exchange? a. An elevation of the total white cell count indicates generalized inflammation. b. Eosinophil count will assist to identify the presence of a respiratory infection. c. White cell count will differentiate types of respiratory bacteria. d. Level of neutrophils provides guidelines to monitor a chronic infection.

An elevation of the total white cell count indicates generalized inflammation.

Approach behaviors are coping mechanisms that result in a family's movement toward adjustment and resolution of the crisis of having a child with a chronic illness or disability. What is considered an approach behavior in parents? a. Are unable to adjust to a progression of the disease or condition b. Anticipate future problems and seek guidance and answers c. Look for new cures without a perspective toward the possible benefit d. Fail to recognize the seriousness of child's condition despite physical evidence

Anticipate future problems and seek guidance and answers

A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.

Apply intermittent pneumatic compression stockings.

A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching? a. Have the patient repeat the instructions immediately after teaching. b. Accomplish the patient teaching just before the scheduled discharge. c. Arrange for the patient's caregiver to be present during the teaching. d. Start giving the patient discharge teaching during the admission process.

Arrange for the patient's caregiver to be present during the teaching.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia? 1 Red blood cell count 2 Sputum culture 3 Arterial blood gas 4 Total hemoglobin

Arterial blood gas

A patient is the primary caregiver for a disabled family member at home, and has now been unexpectedly hospitalized for surgery. What action can the nurse take to enhance the coping ability of the patient? a. Ask if there is another family member who can help at home while the patient is in the hospital. b. Plan to transfer the patient to a rehabilitation unit after surgery to allow uninterrupted time to recover. c. Coordinate an ambulance transfer of the family member to an alternate family member's home. d. Ask social services to assess what the patient's needs will be after discharge to home.

Ask if there is another family member who can help at home while the patient is in the hospital.

A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should 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. Inform the patient that multiple drugs are often needed to treat hypertension. d. Question the patient regarding any lifestyle changes made to help control BP.

Ask the patient if the medication is being taken as prescribed.

Which action should the nurse take when giving the initial dose of oral labetalol to a patient 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.

Ask the patient to request assistance before getting out of bed.

When a client is newly diagnosed with chronic obstructive pulmonary disease (COPD), which action by the nurse has the highest priority? 1 Teach the client how to use the prescribed inhalers. 2 Discuss the normal progression of the disease process. 3 Ask whether the client is interested in quitting smoking. 4 Explain the purpose of a pulmonary rehabilitation program.

Ask whether the client is interested in quitting smoking.

The nurse is preparing to administer an intravenous piggyback antibiotic that has been newly prescribed. Shortly after initiation, the client becomes restless and flushed and begins to wheeze. After stopping the infusion, which priority action will the nurse take? 1 Notify the primary health care provider immediately about the client's condition. 2 Take the client's blood pressure. 3 Obtain the client's pulse oximetry. 4 Assess the client's respiratory status.

Assess the client's respiratory status.

Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.

Assist the patient onto the bedside commode every 2 hours.

A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.

Assist the patient to eat with the right hand.

Which crisis intervention is the most effective for a female client who cannot function because of an impending divorce? 1 Limiting her support system to promote independence 2 Assisting her in exploring new coping abilities 3 Helping her gain insight into precipitating factors 4 Developing an action plan to repair the marital relationship

Assisting her in exploring new coping abilities

Which defect results in increased pulmonary blood flow? a. Pulmonic stenosis b. Tricuspid atresia c. Atrial septal defect d. Transposition of the great arteries

Atrial septal defect

The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus. Which action should the nurse take next? a. Palpate the anterior chest and observe for barrel chest. b. Encourage the patient to turn, cough, and deep breathe. c. Review the chest x-ray report for evidence of pneumonia. d. Auscultate anterior and posterior breath sounds bilaterally

Auscultate anterior and posterior breath sounds bilaterally

Which assessment finding indicates that the nurse should take immediate action for an older patient? a. Weak cough effort b. Barrel-shaped chest c. Dry mucous membranes d. Bilateral basilar crackles

Bilateral basilar crackles

Which finding would the preoperative nurse expect when assessing a child before repair of a ventricular septal defect? 1 Severe cyanosis 2 High hemoglobin and hematocrit levels 3 Bilateral lung sounds with rales and rhonchi 4 High blood pressure in the arms and low blood pressure in the legs

Bilateral lung sounds with rales and rhonchi

An adolescent child with sickle cell anemia is admitted to the pediatric unit during a vaso-occlusive crisis. Which pathophysiology is correct? 1 Severe depression of the circulating thrombocytes 2 Diminished red blood cell (RBC) production by the bone marrow 3 Pooling of blood in the spleen with splenomegaly as a consequence 4 Blockage of small blood vessels as a result of clumping of RBCs

Blockage of small blood vessels as a result of clumping of RBCs

Metoprolol is prescribed for a client with hypertension. The nurse monitors the client for which adverse effect? 1 Hirsutism 2 Bradycardia 3 Restlessness 4 Angina

Bradycardia

A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? a. Ask the patient to lie down to complete a full physical assessment. b. Briefly ask specific questions about this episode of respiratory distress. c. Complete the admission database to check for allergies before treatment. d. Delay the physical assessment to first complete pulmonary function tests.

Briefly ask specific questions about this episode of respiratory distress.

The nurse assesses the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time? 1 Client with shock 2 Client with anemia 3 Client with epilepsy 4 Client with peripheral vascular disease

Client with epilepsy

How would the nurse position a client with epistaxis? A. Supine B. Side-lying C. Upright leaning forward D. Sitting with the head tipped backward

C. Upright leaning forward

A patient's serum electrolytes are being monitored. The nurse notices that the potassium level is low. What should the nurse monitor for in this patient? a. Tissue ischemia b. Brain malformations c. Intestinal blockage d. Cardiac dysrhythmia

Cardiac dysrhythmia

To which part of the respiratory system would the client's radiology report refer when identifying the angle of Louis? 1 Hilum 2 Carina 3 Alveoli 4 Epiglottis

Carina

A patient has just been diagnosed with hypertension and has been started on captopril . Which information is most important to include when teaching the patient about this drug? 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 blood pressure (BP) in both arms before taking the drug.

Change position slowly to help prevent dizziness and falls.

A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Take the patient's blood pressure. b. Check the respiratory rate and effort. c. Assess the Glasgow Coma Scale score. d. Send the patient for a computed tomography (CT) scan.

Check the respiratory rate and effort.

The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? a. Chronic lung disease with increased carbon dioxide retention b. Acute anxiety, hyperventilation, and decreased carbon dioxide retention c. Decreased cardiac output with increased serum lactic acid production d. Gastric drainage with increased removal of gastric acid

Chronic lung disease with increased carbon dioxide retention

The nurse is assessing four clients. Which client is at the highest medical risk of coronary heart disease and hypertension? 1 Client A 2 Client B 3 Client C 4 Client D

Client D

Which nursing action should the nurse take first to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? a. Collect a detailed diet history. b. Provide a list of low-sodium foods. c. Help the patient make an appointment with a dietitian. d. Teach the patient about foods that are high in potassium.

Collect a detailed diet history.

The mother of a school-age child tells the school nurse that she and her spouse are going through a divorce. The child has not been doing well in school and sometimes has trouble sleeping. The nurse should recognize this as: a. Indicative of maladjustment. b. Common reaction to divorce. c. Suggestive of lack of adequate parenting. d. Unusual response that indicates need for referral.

Common reaction to divorce.

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (chest x-ray) c. Computed tomography (CT) scan d. 12-Lead electrocardiogram (ECG)

Computed tomography (CT) scan

Which laboratory result would the nurse expect when reviewing the results for a client hospitalized with a chronic obstructive pulmonary disease exacerbation? 1 Hematocrit 51% (0.51) 2 Partial pressure of carbon dioxide (PaCO 2) 28 mm Hg (3.72 kPa) 3 Blood glucose 200 mg/dL (11.1 mmol/L) 4 Serum potassium 3.4 mEq/L (3.4 mmol/L)

Hematocrit 51% (0.51)

Which patient finding would the nurse identify as being a risk factor for altered transport of oxygen? a. Hemoglobin level of 8.0 b. Bronchoconstriction and mucus c. Peripheral arterial disease d. Decreased thoracic expansion

Hemoglobin level of 8.0

A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value? a. Daily alcohol intake b. Dietary protein intake c. Multivitamin/mineral use d. Over-the-counter (OTC) laxative use

Daily alcohol intake

Which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema? 1 Prevents bronchial spasm 2 Decreases air trapping in lung 3 Improves alveolar surface area 4 Strengthens diaphragmatic contraction

Decreases air trapping in lung

A patient states that his legs have pain with walking that decreases with rest. The nurse observes absence of hair on the patient's lower leg and the patient has a thready, posterior tibial pulse. How would the nurse position the patient's legs? a. Elevated b. Crossed at the knee c. Slightly bent with a pillow under the knees d. Dependent position

Dependent position

A patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions

Difficulty comprehending instructions

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a. Interrupted family processes related to effects of illness of a family member b. Situational low self-esteem related to increasing dependence on spouse for care c. Disabled family coping related to inadequate understanding by patient's spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

Disabled family coping related to inadequate understanding by patient's spouse

The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous, high-pitched sounds of short duration during inspiration d. A series of long-duration, discontinuous, low-pitched sounds during inspiration

Discontinuous, high-pitched sounds of short duration during inspiration

The nurse is reviewing the patient's arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What might the nurse expect to observe on assessment of this patient? a. Disorientation and tremors b. Tachycardia and decreased blood pressure c. Increased anxiety and irritability d. Hyperventilation and lethargy

Disorientation and tremors

The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment? a. Elevated blood pressure b. Bounding pedal pulses c. Night blindness d. Reflux disease

Elevated blood pressure

The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding will the nurse expect? a. Cool extremities b. Pallor and weakness c. Elevated temperature d. Low oxygen saturation

Elevated temperature

The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired gas exchange? a. Blood glucose of 350 mg/dL b. Anticoagulant therapy for 10 days c. Hemoglobin of 8.5 g/dL d. Heart rate of 100 beats/min and blood pressure of 100/60

Hemoglobin of 8.5 g/dL

A client with gestational hypertension is receiving education from the nurse in self-care. Which instruction would the nurse give for this client? 1 Eat a low-protein diet 2 Ensure adequate sodium intake 3 Join a weight-reduction program 4 Follow the prescribed diuretic regimen

Ensure adequate sodium intake

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

Explain that the aspirin is ordered to decrease stroke risk.

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient complains of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a. Check to make sure the nasogastric tube is patent. b. Give the patient the PRN IV morphine sulfate 4 mg. c. Notify the health care provider about the ABG results. d. Teach the patient how to take slow, deep breaths when anxious.

Give the patient the PRN IV morphine sulfate 4 mg.

A common parental reaction to a child with special needs is parental overprotection. Parental behavior suggestive of this includes: a. Giving inconsistent discipline. b. Providing consistent, strict discipline. c. Forcing a child to help self, even when not capable. d. Encouraging social and educational activities is not appropriate to the child's level of capability.

Giving inconsistent discipline.

Families progress through various stages of reactions when a child is diagnosed with a chronic illness or disability. After the shock phase, a period of adjustment usually follows. This is often characterized by: a. Denial. b. Guilt and anger. c. Social reintegration. d. Acceptance of child's limitations.

Guilt and anger.

A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? a. Elevate the head of the bed to 45 degrees. b. Have the patient lie on the left side for 1 hour. c. Apply a sterile 2-inch gauze dressing to the site. d. Use a half-inch sterile gauze to pack the wound.

Have the patient lie on the left side for 1 hour.

Which action will 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 measurements. d. Obtain two BP readings in the dominant arm and average the results.

Have the patient sit in a chair with the feet flat on the floor.

After a management decision to admit terminal care patients to a medical unit, the nursing manager notes that the nursing staff on the unit appear tired and anxious. Staff absences from work are increasing. The nurse manager is concerned that staff may be experiencing stress and burnout at work. What action would be best for the manager to take that will help the staff? a. Ask the administration to require staff to meditate daily for at least 30 minutes. b. Have a staff psychologist available on the unit once a week for the required counseling. c. Have training sessions to help the staff understand their new responsibilities. d. Ask support staff from other disciplines to complete some nursing tasks to provide help.

Have training sessions to help the staff understand their new responsibilities.

The nurse would expect to administer an anticoagulant to a patient following which surgery? a. Hip replacement b. Hysterectomy c. Abdominal aorta aneurism (AAA) repair d. Appendectomy

Hip replacement

A patient who had been complaining of intolerable stress at work has demonstrated the ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with stress? a. The patient's wife reports that he spends more time sitting quietly at home. b. He reports that his appetite, mood, and energy levels are all good. c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg). d. He reports that he feels better and that things are not bothering him as much.

His systolic blood pressure has gone from the 140s to the 120s (mm Hg).

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

Hypertension is usually asymptomatic until target organ damage occurs.

Cardiac catheterization in a child with a ventricular septal defect (VSD) serves which purpose? 1 Identifies the specific location of the defect 2 Confirms the presence of a pansystolic murmur 3 Reveals the degree of cardiomegaly that is present 4 Establishes the presence of ventricular hypertrophy

Identifies the specific location of the defect

The nurse is developing a care plan for a patient with ineffective coping skills. Which intervention would be an example of a problem-focused coping strategy? a. Scheduling a regular exercise program b. Attending a seminar on treatment options c. Identifying a confidant to share feelings d. Attending a support group for families

Identifying a confidant to share feelings

The nurse is reviewing the care plan for a patient experiencing difficulty coping with stress. The nurse recognizes that an example of initiating a cognitive restructuring intervention to enhance coping abilities is known as which of the following? a. Identifying the cause of fear b. Accessing a community support group c. Identifying relaxation methods d. Reviewing an educational pamphlet

Identifying the cause of fear

Which arterial blood gas finding would be expected of a child with an acute asthma exacerbation? 1 High oxygen level 2 Increased alkalinity 3 Decreased bicarbonate 4 Increased carbon dioxide level

Increased carbon dioxide level

The school nurse is assessing coping skills of high school students who attend an alternative school for students at high risk to not graduate. What is the priority concern that the nurse has for this student population? a. Altered vital sign readings b. Inaccurate perceptions of stressors c. Increased risk for suicide d. Decreased access to alcoholic beverages

Increased risk for suicide

On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding? a. Inspiratory crackles at the bases b. Expiratory wheezes in both lungs c. Abnormal lung sounds in the apices of both lungs d. Pleural friction rub in the right and left lower lobes

Inspiratory crackles at the bases

A client with chronic hypertension and superimposed preeclampsia gives birth at 39 weeks' gestation to a 4 lb 12 oz (2155 g) infant. Which condition would the nurse anticipate when assessing this infant? 1 Prematurity 2 Cardiac anomalies 3 Respiratory infection 4 Intrauterine growth restriction

Intrauterine growth restriction

Which collaborative action would the nurse anticipate when caring for a client with pneumonia whose arterial blood gases are pH 7.24, PaCO 2 60 mm Hg (7.98 kPa), HCO 3 20 mEq/L (20 mmol/L), PaO 2 54 mm Hg (7.18 kPa), and O 2 saturation 88% (0.88)? 1 Oxygen at 6 L/minute by nasal cannula 2 Nebulized albuterol treatment 3 Intubation and mechanical ventilation 4 Sodium bicarbonate intravenously

Intubation and mechanical ventilation

A patient with chronic cough is scheduled to have a bronchoscopy with biopsy. Which intervention will the nurse implement directly after the procedure? a. Encourage the patient to drink clear liquids. b. Place the patient on bed rest for at least 4 hours. c. Keep the patient NPO until the gag reflex returns. d. Maintain the head of the bed elevated 90 degrees.

Keep the patient NPO until the gag reflex returns.

The nurse is teaching pursed-lip breathing to a client with chronic obstructive pulmonary disease (COPD). The client asks about the benefit of the exercises. Which explanation would the nurse give? 1 Prevents complications that are associated with COPD 2 Relieves shortness of breath by increasing the breath rate 3 Increases the amount of air that the client can inhale with each breath 4 Keeps the airway open longer to decrease the work that goes into breathing

Keeps the airway open longer to decrease the work that goes into breathing

A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding? a. Intercostal retractions b. Kussmaul respirations c. Low oxygen saturation (SpO2) d. Decreased venous O2 pressure

Kussmaul respirations

Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Listen to a patient's lung sounds for wheezes or crackles. b. Label specimens obtained during percutaneous lung biopsy. c. Instruct a patient about how to use home spirometry testing. d. Measure induration at the site of a patient's intradermal skin test.

Label specimens obtained during percutaneous lung biopsy.

The nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? 1 Lips 2 Sclera 3 Conjunctiva 4 Mucus membrane

Lips

The nurse would anticipate that which of the following patient conditions will be treated with the collaborative treatment of regular phlebotomies? a. Hemophilia b. Thrombocytopenia c. Eosinophilia d. Polycythemia

Polycythemia

The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient? a. Low dietary fiber intake b. No regular physical exercise c. Drinks a beer with dinner every night d. Weight is 5 pounds above ideal weight

No regular physical exercise

A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first? a. Notify the patient's health care provider. b. Obtain an order to draw a potassium level. c. Review the last magnesium level on the patient's chart. d. Teach the patient about magnesium-containing antacids.

Notify the patient's health care provider.

The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first? a. Obtain vital signs. b. Teach wound care. c. Assess pedal pulses. d. Check the wound site.

Obtain vital signs.

Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice

Omelet and whole wheat toast

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

Omeprazole drug therapy

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

Patient uses ibuprofen (Motrin) treat osteoarthritis.

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping b. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes

The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. What is the priority of care for this patient? a. Mental alertness b. Perfusion c. Pain d. Reaction to medications

Perfusion

Most parents of children with special needs tend to experience chronic sorrow. This is characterized by: a. Lack of acceptance of the child's limitation. b. Lack of available support to prevent sorrow. c. Periods of intensified sorrow when experiencing anger and guilt. d. Periods of intensified sorrow and loss that occur in waves over time.

Periods of intensified sorrow and loss that occur in waves over time.

The nurse would identify which patient condition as a problem of impaired gas exchange secondary to a perfusion problem? a. Peripheral arterial disease of the lower extremities b. Chronic obstructive pulmonary disease (COPD) c. Chronic asthma d. Severe anemia secondary to chemotherapy

Peripheral arterial disease of the lower extremities

A patient in metabolic alkalosis is admitted to the emergency department and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse expect to take next? a. Complete a head-to-toe assessment. b. Administer an inhaled bronchodilator. c. Place the patient on high-flow oxygen. d. Obtain repeat arterial blood gases (ABGs).

Place the patient on high-flow oxygen.

A patient who was recently diagnosed with diabetes is having trouble concentrating. This patient is usually very organized and laid back. Which action should the nurse take? a. Ask the health care provider for a psychiatric referral. b. Administer the PRN sedative medication every 4 hours. c. Suggest the use of a home caregiver to the patient's family. d. Plan to reinforce and repeat teaching about diabetes management.

Plan to reinforce and repeat teaching about diabetes management.

Which clinical management prevention concept would the nurse identify as representative of secondary prevention? a. Decreasing venous stasis and risk for pulmonary emboli b. Implementation of strict hand washing routines c. Maintaining current vaccination schedules d. Prevention of pneumonia in patients with chronic lung disease

Prevention of pneumonia in patients with chronic lung disease

The nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise? 1 Decreases chest pain 2 Conserves energy 3 Increases oxygen saturation 4 Promotes elimination of CO 2

Promotes elimination of CO 2

Which structural defects constitute tetralogy of Fallot? a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy

Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. What are the priority nursing assessments? 1 Level of consciousness and pupil size 2 Characteristics of pain and blood pressure 3 Quality of respirations and presence of pulses 4 Observation of abdominal contusions and other wounds

Quality of respirations and presence of pulses

Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)? a. Hyperresonance b. Tripod positioning c. Reduced excursion d. Accessory muscle use

Reduced excursion

A client in the coronary care unit develops "viselike" chest pain radiating to the neck. Assessment reveals a blood pressure of 124/64 mm Hg, an irregular apical pulse of 64 beats per minute, and diaphoresis. Cardiac monitoring is instituted, and morphine sulfate 4 mg intravenous (IV) push stat is prescribed. Which intervention is the priority nursing care for this client? 1 Relief of pain 2 Client teaching 3 Cardiac monitoring 4 Maintenance of bed rest

Relief of pain

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the health care provider? a. Respirations are 36 breaths/min. b. Anterior-posterior chest ratio is 1:1. c. Lung expansion is decreased bilaterally. d. Hyperresonance to percussion is present.

Respirations are 36 breaths/min.

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco 2 of 60 mm Hg. These blood gas results require nursing attention because they indicate which condition? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

Respiratory acidosis

A client takes morphine sulfate for severe metastatic bone pain. The nurse will assess the client for which adverse effect? 1 Diarrhea 2 Addiction 3 Respiratory depression 4 Diuresis

Respiratory depression

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway

Risk for aspiration related to inability to protect airway

The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical and occupational therapy, which problem is the highest priority? History Physical Assessment Physical/Occupational Therapy • Well controlled type 2 diabetes for 10 years •Married 45 years; spouse has heart failure and chronic obstructive pulmonary disease •Oriented to time, place, person •Speech clear •Minimal left leg weakness •Uses cane with walking •Spouse does household cleaning and cooking and assists patient with bathing and dressing a. Risk for hypoglycemia b. Impaired transfer ability c. Risk for caregiver role strain d. Ineffective health maintenance

Risk for caregiver role strain

During the admission process, the nurse obtains information about a patient through a physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate? a. Deficient fluid volume b. Impaired gas exchange c. Risk for injury: seizures d. Risk for impaired skin integrity

Risk for injury: seizures

A client is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). Which action would the nurse take to prevent client fatigue? 1 Provide small, frequent meals. 2 Encourage pursed-lip breathing. 3 Schedule nursing activities to allow for rest. 4 Encourage bed rest until energy level improves.

Schedule nursing activities to allow for rest.

The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? a. Serum creatinine of 2.8 mg/dL b. Serum potassium of 4.5 mEq/L c. Serum hemoglobin of 14.7 g/dL d. Blood glucose level of 96 mg/dL

Serum creatinine of 2.8 mg/dL

Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2 hypertension 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. Most recent blood pressure (BP) reading of 168/94 mm Hg

Serum potassium level of 3.0 mEq/L

The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside . Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Evaluate effectiveness of nitroprusside therapy on blood pressure (BP). b. Assess the patient's environment for adverse stimuli that might increase BP. c. Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg. d. Set up the automatic noninvasive BP machine to take readings every 15 minutes.

Set up the automatic noninvasive BP machine to take readings every 15 minutes.

Which client response is most important for the nurse in the postanesthesia care unit to monitor when caring for a client who had a thyroidectomy? 1 Urinary retention 2 Signs of restlessness 3 Decreased blood pressure 4 Signs of respiratory obstruction

Signs of respiratory obstruction

The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? a. High-Fowler's position with the left arm extended b. Supine with the head of the bed elevated 30 degrees c. On the right side with the left arm extended above the head d. Sitting upright with the arms supported on an over bed table

Sitting upright with the arms supported on an over bed table

A patient has not been sleeping well because he is worried about losing his job and not being able to support his family. The nurse takes the patient's vital signs and notes a pulse rate of 112 beats/min, respirations are 26 breaths/min, and his blood pressure is 166/88 instead his usual 110-120/76-84 range. Which nursing intervention or recommendation should be used first? a. Go to sleep 30 to 60 minutes earlier each night to increase rest. b. Relax by spending more time playing with his pet dog. c. Slow and deepen breathing via use of a positive, repeated word. d. Consider that a new job might be better than his present one.

Slow and deepen breathing via use of a positive, repeated word.

A patient admitted with possible stroke has been aphasic for 3 hours, and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Start a labetalol drip to keep BP less than 140/90 mm Hg. d. Administer tissue plasminogen activator (tPA) intravenously per protocol.

Start a labetalol drip to keep BP less than 140/90 mm Hg.

A patient admitted to the emergency department complaining of sudden onset shortness of breath is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis? a. Ensure that the patient has been NPO. b. Start an IV so contrast media may be given. c. Inform radiology that radioactive glucose preparation is needed. d. Instruct the patient to expect to inspire deeply and exhale forcefully.

Start an IV so contrast media may be given.

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

Statins

The nurse is planning to teach a patient how to use relaxation techniques to prevent elevation of blood pressure and heart rate. The nurse is teaching the patient to control which physiological function? a. Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode. b. Alter the internal state by modifying electronic signals related to physiologic processes. c. Replace stress-producing thoughts and activities with daily stress-reducing thoughts and activities. d. Reduce catecholamine production and promote the production of additional beta-endorphins.

Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode.

An older client with a history of congestive heart failure expresses concern about potential exposure to tuberculosis (TB) from his or her roommate at the extended care facility. The roommate coughs a great deal and sometimes spits up blood. Which is the primary reason that the nurse pursues more information about the roommate? 1 Death from TB is on the increase in older populations. 2 The roommate is causing increased anxiety and stress in the client. 3 TB adversely affects older adults with chronic illness. 4 Most likely, the roommate prevents the client from getting proper sleep.

TB adversely affects older adults with chronic illness.

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

Teach the patient how to self-monitor and record BPs at home.

A patient tells the nurse "My doctor thinks my problems with stress relate to the negative way I think about things, and he wants me to learn a new way of thinking." Which response would be in keeping with the doctor's recommendations? a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts b. Encouraging the patient to imagine being in calming circumstances c. Teaching the patient to use instruments that give feedback about bodily functions d. Provide the patient with a blank journal and guidance about journaling

Teaching the patient to recognize, reconsider, and reframe irrational thoughts

A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in decreased pulmonary blood flow? a. Atrial septal defect b. Tetralogy of Fallot c. Ventricular septal defect d. Patent ductus arteriosus

Tetralogy of Fallot

A patient who is 2 days post femoral popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/LVN) caring for the patient requires the registered nurse (RN) to intervene? a. The LPN/LVN has the patient to sit in a chair for 2 hours. b. The LPN/LVN gives the prescribed aspirin after breakfast. c. The LPN/LVN assists the patient to walk 40 feet in the hallway. d. The LPN/LVN places the patient in Fowler's position for meals.

The LPN/LVN has the patient to sit in a chair for 2 hours.

The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action? a. The bicarbonate level (HCO3-) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 92%. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.

The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately? a. The bibasilar breath sounds are decreased. b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The patient reports feeling "sick to my stomach."

The patellar and triceps reflexes are absent.

The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? a. Urine output over 8 hours is 250 mL less than the fluid intake. b. The patient cannot move the left arm and leg when asked to do so. c. Tremors are noted in the fingers when the patient extends the arms. d. The patient complains of a headache with pain at level 7 of 10 (0 to 10 scale).

The patient cannot move the left arm and leg when asked to do so.

After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been most 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.

The patient drinks low-fat milk with each meal.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure (BP) is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

The patient has atrial fibrillation and takes warfarin (Coumadin).

During change-of-shift report, the nurse obtains the following information about a hypertensive patient who 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 complains 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 158/91 mm Hg.

The patient has developed wheezes throughout the lung fields.

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.

The patient has difficulty speaking.

A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

The patient reports that symptoms began with a severe headache.

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

The patient's blood pressure (BP) is 90/50 mm Hg.

Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 lb above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

The patient's usual blood pressure (BP) is 170/94 mm Hg.

A client has delivered her infant by cesarean birth. The nurse monitors the newborn's respiration closely, because infants born via the cesarean method are prone to atelectasis. Why does this occur? 1 The ribcage is not compressed and released during birth. 2 The sudden temperature change at birth causes aspiration. 3 There is usually oxygen deprivation after a cesarean birth. 4 There is no gravity during the birth to promote drainage from the lungs.

The ribcage is not compressed and released during birth.

The nurse observes a student who is listening to a patient's lungs. Which action by the student indicates a need to review respiratory assessment skills? a. The student compares breath sounds from side to side at each level. b. The student listens during the inspiratory phase, then moves the stethoscope. c. The student starts at the apices of the lungs, moving down toward the lung bases. d. The student instructs the patient to breathe slowly and deeply through the mouth.

The student listens during the inspiratory phase, then moves the stethoscope.

Soft swishing sounds of breathing are heard when the nurse auscultates a client's chest. Which term would be used when documenting this assessment finding? 1 Fine crackles 2 Adventitious sounds 3 Vesicular breath sounds 4 Diminished breath sounds

Vesicular breath sounds

When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding? 1 Adventitious sounds 2 Fine crackling sounds 3 Vesicular breath sounds 4 Diminished breath sounds

Vesicular breath sounds

A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen? 1 To prevent dyspnea 2 To prevent cyanosis 3 To increase oxygen concentration to heart cells 4 To increase oxygen tension in the circulating blood

To increase oxygen concentration to heart cells

A patient on a medical surgical unit has a platelet count of 90,000 per mm3. The nurse knows to include which of the following precautions in discharge instructions? a. Use a standard safety razor for shaving. b. Use a soft bristle toothbrush. c. Have aggressive dental care immediately to prevent dental caries. d. Do not eat fresh fruit.

Use a soft bristle toothbrush.

Which action will be included in the plan of care when the nurse is caring for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency? a. Organize nursing activities so that the patient has undisturbed sleep for 8 hours at night. b. Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting. c. Assist the patient up in the chair for meals to avoid complications associated with immobility. d. Use an automated noninvasive blood pressure machine to obtain frequent measurements.

Use an automated noninvasive blood pressure machine to obtain frequent measurements.

Prophylaxis of subacute bacterial endocarditis is given before and after birth when a pregnant woman has: a. Valvular disease. b. Congestive heart disease. c. Arrhythmias. d. Postmyocardial infarction.

Valvular disease.

Which assessment finding is consistent with bronchospasm? 1 Wheezing 2 Rhonchi 3 Pleural friction rub 4 Low-pitched crackles

Wheezing

The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? a. Monocytes 4% b. Hemoglobin 13.6 g/dL c. Platelet count 168,000/μL d. White blood cell (WBC) count 15,500/μL

White blood cell (WBC) count 15,500/μL

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory test findings to include a. an RBC count of 4,500,000/L. b. a hematocrit (Hct) value of 38%. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

The nurse is assessing the coping patterns of a newly admitted patient. What will the nurse include in this assessment? (Select all that apply.) a. Current stressors as perceived by the patient b. Use of drugs or alcohol c. Recent weight changes d. Age and height e. Temperature

a. Current stressors as perceived by the patient b. Use of drugs or alcohol c. Recent weight changes

The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) a. Neurologic system b. Endocrine system c. Pulmonary system d. Immune system e. Cardiovascular system f. Hepatic system

a. Neurologic system c. Pulmonary system e. Cardiovascular system

The nurse is making a home visit to a patient who was discharged from the hospital on Lovenox and warfarin following replacement of the patient's pacemaker. Which observation indicates excessive bleeding? (Select all that apply.) a. New ecchymosis on the abdomen b. A nosebleed that does not stop with pressure c. Pain of the lower extremity with flexion d. Extreme fatigue e. Pallor f. Sudden onset of severe headache

a. New ecchymosis on the abdomen b. A nosebleed that does not stop with pressure d. Extreme fatigue e. Pallor f. Sudden onset of severe headache

Which describe avoidance behaviors a parent may exhibit when learning that his or her child has a chronic condition (select all that apply)? a. Refuses to agree to treatment b. Shares burden of disorder with others c. Verbalizes possible loss of a child d. Withdraws from the outside world e. Punishes self because of guilt and shame

a. Refuses to agree to treatment d. Withdraws from the outside world e. Punishes self because of guilt and shame

The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? a. Avoid intramuscular injections. b. Encourage increased oral fluids. c. Check temperature every 4 hours. d. Increase intake of iron-rich foods.

a. Avoid intramuscular injections.

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

a. Metabolic acidosis

The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) a. Respiratory rate is 24 breaths/min. b. The oxygen saturation level is 98%. c. The right side of the thorax expands slightly more than the left. d. The trachea is just to the left of the sternal notch. e. Nail beds are pink with a good capillary refill. f. There is the presence of quiet, effortless breath sounds at the lung base bilaterally.

b. The oxygen saturation level is 98%. e. Nail beds are pink with a good capillary refill. f. There is the presence of quiet, effortless breath sounds at the lung base bilaterally.

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. tPA. b. aspirin. c. warfarin (Coumadin). d. nimodipine

b. aspirin.

A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use the National Institute of Health Stroke Scale to assess patient.

c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient. a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA).

During the change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.

c. visual deficits.

When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place needed objects on the patient's left side. d. Teach the patient that the left visual deficit will resolve.

c. Place needed objects on the patient's left side.

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).

c. oral low-dose aspirin therapy.

Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this drug when the patient reveals a history of a. daily alcohol use. b. peptic ulcer disease. c. reactive airway disease. d. myocardial infarction (MI).

c. reactive airway disease.

An older patient presents to the outpatient clinic with a chief complaint of headache and insomnia. In gathering the history, the nurse notes which factors as contributing to this patient's chief complaint? a. The patient is responsible for caring for two school-age grandchildren. b. The patient's daughter works to support the family. c. The patient is being treated for hypertension and is overweight. d. The patient has recently lost her spouse and needed to move in with her daughter.

d. The patient has recently lost her spouse and needed to move in with her daughter.

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

d. Respiratory alkalosis

A 56-yr-old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that a. a BP recheck should be scheduled in a few weeks. b. dietary sodium and fat content should be decreased. c. diagnosis, treatment, and ongoing monitoring will be needed. d. there is an immediate danger of a stroke, requiring hospitalization.

diagnosis, treatment, and ongoing monitoring will be needed.

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron. b. folic acid. c. cobalamin (vitamin B12). d. ascorbic acid (vitamin C).

folic acid.

The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to a. increase the dietary intake of high-potassium foods. b. make an appointment with the dietitian for teaching. c. check the blood pressure (BP) at home at least once a day. d. move slowly when moving from lying to sitting to standing.

increase the dietary intake of high-potassium foods.