290 Practice Questions
Which finding would the nurse expect when assessing a client with peripheral arterial disease (PAD)? Select all that apply. - pallor of feet - warm extremities - ulcers on the toes - delayed capillary refill - thick, hardened skin - hair loss to lower extremities - muscle atrophy - intermittent claudication
- pallor to feet - ulcers on the toes - delayed capillary refill - hair loss to lower extremities - muscle atrophy (loss of muscle tissue/weakness) - intermittent claudication (pain with movement)
Which topic will the nurse include in teaching for a client with Raynaud disease? A) tobacco avoidance B) dietary salt reduction C) need for increased exercise D) low-fat, low-cholesterol diet
A) tobacco avoidance
Which finding for a client who has a potassium level of 2.8 mEq/L would be of MOST concern to the nurse? A) abdominal cramps B) irregular heart rate C) decreased reflexes D) muscle weakness
B) irregular heart rate
When the nurse is reviewing the laboratory results for a client with chronic bronchitis, which result is MOST important to communicate to the health care provider? A) PaO2 75 mm Hg B) PaCO2 48 mm Hg C) Hematocrit 52% (0.52) D) Leukocytes 16,000 mm ^3 (16 x 10 ^9/L)
D) Leukocytes 16,000 mm ^3 (16 x 10 ^9/L)
A client taking multiple medications for hypertension develops a persistent hacking cough. Which anti-hypertensive medication class would the nurse identify as the likely cause of the cough? A) thiazide diuretics B) calcium channel blockers C) direct renin inhibitors D) angiotensin-converting enzyme (ACE) inhibitors
D) angiotensin-converting enzyme (ACE) inhibitors
Captopril is prescribed for a client. Which effect would the nurse anticipate? A) increased urine output B) decreased anxiety C) improved sleep D) decreased blood pressure
D) decreased blood pressure
A 68-year-old client has multiple risk factors for peripheral arterial disease, including client age, siblings with diabetes, a sedentary lifestyle, and family history of heart disease. Which risk factor is highest priority for client teaching? A) older age B) low activity level C) blood glucose control D) family history of cardiac disease
B) low activity level
Which type of acid-base imbalance would the nurse expect in a child admitted with a severe asthma exacerbation? A) metabolic alkalosis caused by excessive production of acid metabolites B) respiratory alkalosis caused by accelerated respirations and loss of carbon dioxide C) respiratory acidosis caused by impaired respirations and increased formation of carbonic acid D) metabolic acidosis caused by the kidneys' inability to compensate for increased carbonic acid formation
C) respiratory acidosis caused by impaired respirations and increased formation of carbonic acid
How would the nurse determine if a client is experiencing the therapeutic effect of valsartan? A) check a lipid profile B) assess an apical pulse C) measure urinary output D) check the blood pressure
D) check the blood pressure
Which nursing assessment supports a diagnosis of atelectasis in a postoperative client? A) productive cough B) clubbing of the fingertips C) low-pitched expiratory rhonchi D) diminished breath sounds on auscultation
D) diminished breath sounds on auscultation
Why is sitting upright while leaning forward with the arms supported help with pulmonary edema?
it is an attempt to maximize thoracic expansion and limit the pressure of abdominal organs against the diaphragm
Which clinical manifestation is indicative of the fluid/electrolyte imbalance associated with a parathyroidectomy? A) constipation B) muscle spams C) hypoactive reflexes D) increased specific gravity
B) muscle spams
Which action will the nurse take when a client's chest x-ray shows atelectasis? A) administer O2 B) suction the upper airway C) position for postural drainage D) encourage incentive spirometer use
D) encourage incentive spirometer use
Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety? A) respiratory acidosis B) respiratory alkalosis C) respiratory compensation D) respiratory decompensation
B) respiratory alkalosis
After the nurse has completed teaching a client with hypertension about a heart-healthy diet, which meal choice by the client indicates that the teaching has been effective? A) bean soup with ham B) grilled steak and green salad C) chicken and cheese enchiladas D) fried fish and green beans
B) grilled steak and green salad
When a client has difficulty swallowing after a stroke, which action by the nurse would be MOST important in preventing pneumonia? A) giving influenza vaccine to the client B) having suction available during meals C) assisting the client to take deep breaths D) teaching about incentive spirometer use
B) having suction available during meals
Which findings are consistent with hypercalcemia after prolonged immobility? Select all that apply. - bone pain - convulsions - muscle spasms - tingling of extremities - depressed deep tendon reflexes
- bone pain - depressed deep tendon reflexes
Which clinical manifestations will the nurse expect when caring for a client with a diagnosis of pulmonary edema? Select all that apply. - crackles - coughing - orthopnea - yellow sputum - anxiety - dependent edema - restlessness - lethargy
- crackles - coughing - orthopnea - anxiety - restlessness - lethargy
What does the DASH diet include?
- fruits - vegetables - low-fat/fat-free foods - fish - poultry - reduced sigar
When a client with heart failure is seen in the clinic with new-onset ankle edema, the nurse would question the client about which lifestyle factor that may have contributed to the ankle swelling? Select all that apply. - intake of salty foods - increased fluid consumption - dietary fat intake - medication compliance - family stresses - recent travel - increased physical activity
- intake of salty foods - increased fluid consumption - medication compliance - recent travel - alcohol intake
When a client is admitted with dehydration, which clinical manifestations would the nurse expect to find? Select all that apply. - oliguria - dyspnea - hypotension - pulmonary crackles - tenting skin turgor
- oliguria - hypotension - tenting skin turgor
Which dietary choice reflects the recommendations of the Dietary Approaches to Stop Hypertension (DASH) diet? Select all that apply. - salami - pickles - salmon - french fries - canned soup
- salmon
Which information will the employee health nurse include when teaching about ways to prevent transmission of influenza in the workplace? Select all that apply. - sneeze/cough into the upper sleeve - avoid use of over-the-counter antihistamines - use alcohol-based hand sanitizers after blowing the nose - turn the head away from others when coughing or sneezing - antiviral medications are the most effective means of transmission prevention
- sneeze/cough into the upper sleeve - use alcohol-based hand sanitizers after blowing the nose - turn the head away from others when coughing or sneezing
Normal WBC count
4,500-11,000/mm3
When caring for a client with peripheral arterial disease, which assessment findings will the nurse expect? Select all that apply. A) absence of hair on the toes B) pink/moist ankle ulcers C) pitting edema of the lower legs D) reports of pain associated with exercising E) increased pigmentation of the medial malleolus area
A) absence of hair on the toes D) reports of pain associated with exercising
A client with hypertension has received a prescription for metoprolol. Which info will the nurse include when teaching this client about metoprolol? A) do not abruptly discontinue the medication B) Consume alcoholic beverages in moderation C) report a heart rate of less than 70 bpm D) increase the medication dosage if chest pain occurs
A) do not abruptly discontinue the medication
When teaching a group of clients about risk factors for heart disease, which topics will the nurse include? Select all that apply. A) obesity B) hypertension C) diabetes insipidus D) Asian-American ancestry E) Increased HDL
A) obesity B) hypertension
Metoprolol is prescribed for a client with hypertension. The nurse monitors the client for which adverse effect? A) hirsutism B) bradycardia C) restlessness D) angina
B) bradycardia
The nurse administers a parenteral preparation of potassium slowly to avoid which complication? A) metabolic acidosis B) cardiac arrest C) seizure activity D) respiratory depression
B) cardiac arrest
A client with chronic venous insufficiency has ankle edema. Which action would the nurse take? A) restrict fluids B) elevate the legs C) apply a Unna boot D) discuss sclerotherapy
B) elevate the legs
A client with COPD has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO2) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing? A) metabolic acidosis B) metabolic alkalosis C) respiratory acidosis D) respiratory alkalosis
C) respiratory acidosis
Which nursing action is a priority before administering prescribed furosemide? A) weigh the client B) assess skin turgor C) review the potassium level results D) check the 24-hour intake and output
C) review the potassium level results
Which client statements indicate that the teaching about furosemide is understood? Select all that apply. A) "it may take 2 or 3 days for this medication to take effect B) "i should wear dark glasses when outdoors during the day" C) "i should avoid lying flat in bed" D) "i need to change my position slowly E) "i should eat more food that is high in potassium"
D) "i need to change my position slowly E) "i should eat more food that is high in potassium"
When a client in the clinic is offered the influenza vaccine and states, "I had the vaccination already last year, so I won't need it now", which response will the nurse give? A) "the flu vaccine is recommended for everyone" B) "you need 1 flu shot in your lifetme to achieve immunity" C) "as long as you are younger than 50 years old, you will not really need vaccination" D) "the immunization changes, so you need to get vaccine annually to stay protected"
D) "the immunization changes, so you need to get vaccine annually to stay protected"
When a client with venous insufficiency has questions about the brownish discoloration of the skin on the legs, which response will the nurse make to explain the discoloration? A) "the arterial blood supply is inadequate" B) "there is delayed healing in the area after an injury C) "the production of melanin in the area has increased" D) "there is leakage of red blood cells through the vein wall"
D) "there is leakage of red blood cells through the vein wall"
A client tells the nurse, "My legs begin to hurt after walking for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition would the nurse consider as the MOST likely cause of the client's pain? A) spinal stenosis B) Buerger disease C) Rheumatoid arthritis D) intermittent claudication
D) intermittent claudication
What is Raynaud's phenomenon?
Episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes.
TRUE/FALSE: Increased levels of low-density lipoprotein increase the risk for heart disease, but high HDL decreases coronary artery disease risk.
TRUE
TRUE OR FALSE: 2 L of oxygen promotes respirations while preventing carbon dioxide narcosis
True
TRUE OR FALSE: sitting facilitates breathing by increasing lung expansion
True
What happens with removal of the parathyroids?
can cause hypocalcemia and associated neuromuscular irritability
When teaching a group of older adults about the differences between the common cold and influenza, the nurse would educate the clients that it is MOST important to communicate with the health care provider about which symptom? A) earache B) sneezing C) nasal stuffiness D) elevated temperature
fever or an elevated temperature is common in influenza but rare in viral rhinitis (common cold) so .....D) elevated temperature
What is pulmonary edema?
fluid moves into the pulmonary interstitial space and then into the alveoli; this results in crackles, severe dyspnea, and coughing
What is sodium polystyrene sulfonate used for?
given to treat hyperkalemia; the effectiveness of the medication is determined by a decreasing serium potassium level
A flattened T wave is associated with what?
hypkalemia
Fluid retention in heart failure may be caused by what?
increased salt intake with associated water retention
Arterial occlusion prevents adequate blood flow to the muscles of the legs, causing what?
ischemia (lack blood flow to body) and pain
Extravasation
leakage from a vessel into the tissue
Sodium-potassium pump facilitates conduction of what?
nerve impulses and muscle activity
Why does pallor occur?
occurs as the peripheral blood vessels constrict in an effort to shunt blood to the vital organs in the center of the body (deficient blood supply)
Positives of pursed-lip breathing
prolongs the expiratory phase and increases airway positive pressure, leading to more complete expiration and reduced air trapping; also bronchi/bronchioles stay open longer and are expanded
Abrupt discontinuation of metoprolol may cause what?
rebound hypertension and an acute myocardial infarction (heart attack)
Why is recent travel an important factor lifestyle factor that may have contributed to ankle swelling?
recent travel may cause fluid retention because of changes in environmental temperature, effects of airplane travel on fluid retention, or changes in dietary sodium intake
What is atelectasis?
signifies alveolar collapse and indicates a need for the client to take deep breaths that will expand the alveoli - use incentive spirometer or teach patient deep breathing/coughing exercises
Why does ACE inhibitors cause a hacking cough?
the ACE breaks down kinins. when ACE is inhibited, the increase of kinins in the lungs can cause bronchial irritation, leading to the common adverse effect sometimes referred to as an ACE cough.
Which information would the nurse include when teaching a client about dietary guidelines to reduce heart disease risk? A) eat small, frequent meals B) decrease the amount of proteins C) increase complex carbohydrates D) avoid monounsaturated fats
the fiber component of complex carbohydrates helps bind and eliminate dietary cholesterol and fosters growth of intestinal microorganisms to break down bile salts and release the cholesterol component for excretion so therefore..... C) increase complex carbohydrates
After obtaining client blood pressures of 172/104 mm Hg and 164/98 mm Hg during a blood pressure screening, which action would the nurse take next? A)provide health teaching about a low-sodium diet B) call the paramedics for transport to the hospital C) suggest ways to decrease the client's stress level D) refer the client to a primary health care provider
this client has stage 2 hypertension which would require... D) refer the client to a primary health care provider
Which clinical manifestations indicate to the nurse that the client has an inadequate fluid volume? Select all that apply. - decreased urine - hypotension - dyspnea - dry mucous membranes - lung crackles - poor skin turgor
- decreased urine - hypotension - dry mucous membranes - poor skin turgor
A client with known peripheral arterial disease calls the clinic and tells the nurse about experiencing several symptoms. Which symptom requires the MOST rapid action by the nurse? A) anxiety B) chest pain C) weak pulse quality D) cool and pale lower legs
B) chest pain
When teaching a client who has a new diagnosis of Raynaud disease, which information will the nurse include? Select all that apply. A) medications will be needed to control the symptoms B) stop cigarette smoking/other tobacco use C) wear gloves when getting food from the freezer D) plan to take a daily low-dose aspirin tablet E) avoid going quickly from a warm to a cold environment
B) stop cigarette smoking/other tobacco use C) wear gloves when getting food from the freezer E) avoid going quickly from a warm to a cold environment
The nurse is caring for a client with dysphagia. Which interventions would the nurse include in the plan of care? Select all that apply. A) Recline after meals B) Rinse mouth with water C) Keep suction equipment nearby D) Provide thickened liquids E) Sit in high Fowler position
C) Keep suction equipment nearby D) Provide thickened liquids E) Sit in high Fowler position
The nurse is assessing four clients in a health care setting who have respiratory disorders. Which client's findings indicate possible metabolic acidosis? A) tachypnea B) pursed-lip breathing C) Kussmaul respirations D) abdominal paradox
C) Kussmaul respirations
A client is admitted to the hospital with a long history of uncontrolled hypertension. Which laboratory result will be MOST important for the nurse to review? A) blood glucose level b) WBC count C) blood urea nitrogen D) lactic dehydrogenase
C) blood urea nitrogen
On admission to an intensive care unit, a client is diagnosed with compensated metabolic acidosis. The nurse expects which assessment finding? A) muscle twitching B) mental instability C) deep/rapid respirations D) tachycardia and cardiac dysrhythmias
C) deep/rapid respirations
When an obese client receives a diagnosis of high blood pressure, which topic would be the MOST important to include in client teaching? A) causes of hypertension B) symptoms of hypertension C) effect of weigh loss in hypertension D) effect of lowering alcohol intake in hypertension
C) effect of weigh loss in hypertension
Which action would the nurse anticipate taking when a client with anxiety begins hyperventilating and reports feeling dizzy? A) administering O2 B) offering an incentive spirometer C) having the client breathe in and out of a paper bag D) administering IV sodium bicarbonate
C) having the client breathe in and out of a paper bag
In which category of fluids would the nurse classify an IV solution of 0.45% sodium chloride? A) isotonic B) isomeric C) hypotonic D) hypertonic
C) hypotonic
A client with chronic obstructive pulmonary disease (COPD) is breathing rapidly and using accessory muscles of respiration. The nurse ausculates the lungs and hears crackles and wheezes. Which action would the nurse take? A) encourage the client to take slow, deep breaths and administer 5 L/min O2 per nasal cannula B) place the client in a side-lying position and perform chest physiotherapy using clapping and vibration C) raise the head of the bed to a high-Fowler position and administer 2 L/min O2 per nasal cannula D) assist the client in assuming a position of comfort and perform postural drainage
C) raise the head of the bed to a high-Fowler position and administer 2 L/min O2 per nasal cannula
Which medication requires the nurse to monitor the client for signs of hyperkalemia? A) furosemide B) metolazone C) spironolactone D) hydrochlorothiazide
C) spironolactone because it is a potassium-sparing diuretic
Which client would the nurse consider to have the highest risk of pneumonia? A) 16 y.o; has nutritional status + received pneumococcal vaccine in the last 3 months B) 28 y.o; uses tobacco + received vaccine 2 years ago C) 45 y.o; consumes alcohol regularly + received vaccine over a year ago D) 67 y.o; chronic lung disease + received vaccine more than 5 years ago
D) 67 y.o; chronic lung disease + received vaccine more than 5 years ago
TRUE OR FALSE: antiviral medication such as oseltamivir can be taken after 48 hours onset of symptoms to be effective
FALSE; antiviral medication such as oseltamivir must be taken within the first 48 hours after onset of symptoms to be effective