357 test

A nurse at the clinic is talking with a client who has cancer and takes extended release opioids twice daily. The client reports an increase in localized, achy pain over the last few days. How should you document A: Phantom limb pain B: Mixed pain C: Breakthrough pain D: Neuropathic pain

C: Breakthrough pain

The nurse is providing discharge teaching to a client with type 2 diabetes and peripheral neuropathy. Which statement by the client indicates a need for further teaching about injury prevention? A: "I can break in my shoes by wearing them all day." B: "I need to monitor my feet daily for blisters or skin breaks." C: "I will never go barefoot." D: "I need to quit smoking."

A: "I can break in my shoes by wearing them all day."

The nurse is teaching a client with newly diagnosed type 2 diabetes about the importance of weight control. Which comment by the client indicates a need for further teaching? A: "I will begin exercising for at least an hour a day." B: "I will monitor my diet and avoid empty calories." C: "If I lose weight, I may not need to use the insulin anymore." D: "Weight loss can be a sign of diabetic ketoacidosis."

A: "I will begin exercising for at least an hour a day."

A client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care? A: "My leg might turn very white after the surgery." B: "I must be concerned if my foot turns blue." C: "I must report a fever or any drainage." D: "Warmness, redness, and swelling are expected."

A: "My leg might turn very white after the surgery."

A client with unstable angina has received education about acute coronary syndrome. Which statement indicates that the client has understood the teaching? A: "This is a big warning; I must modify my lifestyle or I am at risk for having a heart attack." B: "Angina is just a temporary interruption of blood flow to my heart." C: "I need to tell my wife I've had a heart attack." D: "Because this was temporary, I will not need to take any medications for my heart."

A: "This is a big warning; I must modify my lifestyle or I am at risk for having a heart attack."

A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonary embolism? (select all) A: A client who has a BMI of 30 B: A female client who is postmenopausal C: A client who has a fractured femur D: A client who is a marathon runner E: A client who has chronic atrial fibrillation

A: A client who has a BMI of 30 C: A client who has a fractured femur E: A client who has chronic atrial fibrillation

Which is the best referral that the community health nurse can suggest to a client who has been newly diagnosed with diabetes? A: American Diabetes Association (ADA) B: Centers for Disease Control and Prevention C: Primary health care provider office D: Pharmaceutical representative

A: American Diabetes Association (ADA)

A nurse is caring for a client who asks why the provider prescribed a daily aspirin. Which of the following responses should the nurse make? A: Aspirin reduces the formation of blood clots that could cause a heart attack B: Aspirin relieves the pain due to Myocardial ischemia C: Aspirin dissolves clots that are forming in your coronary arteries D: Aspirin relieves headaches that are caused by other medications

A: Aspirin reduces the formation of blood clots that could cause a heart attack

A nurse is teaching a client who has a prescription for clopidogrel. Which of the following instruction should the nurse include? (select all) A: Avoid taking herbal supplements while taking this medication B: Monitor for the presence of black, tarry stools C: Take this medication when you have pain D: Schedule a weekly PT test E: Limit food sources containing vitamin K while taking this medication

A: Avoid taking herbal supplements while taking this medication B: Monitor for the presence of black, tarry stools

A client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." The client's vital signs are: T 98.4°F (36.9°C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air. Which action will the nurse take first? A: Check the blood glucose. B: Administer oxygen. C: Offer reassurance. D: Attach a cardiac monitor.

A: Check the blood glucose.

A nurse at the provider's office is reviewing the laboratory test results for a group of clients. The nurse should identify that which of the following results indicates the client is at risk for heart disease? (select all) A: Cholesterol 245 B: HDL 90 C: LDL 140 D: Triglycerides 125 E: Troponin I 0.02 ng/mL

A: Cholesterol 245 C: LDL 140

The nurse working on a medical surgical endocrine unit has just received change-of-shift report. Which client will the nurse see first? A: Client with type 1 diabetes whose insulin pump is beeping "occlusion" B: Newly diagnosed client with type 1 diabetes who is reporting thirst C: Client with type 2 diabetes who has a blood glucose of 150 mg/dL (8.3 mmol/L) D: Client with type 2 diabetes with a blood pressure of 150/90 mm Hg

A: Client with type 1 diabetes whose insulin pump is beeping "occlusion"

A nurse is reviewing manifestations of a thoracic aortic aneursym with a newly hired nurse. Which of the following findings should the nurse include in the discussion? (select all) A: Cough B: shortness of breath C: Upper chest pain D: Diaphoresis E: altered swallowing

A: Cough B: shortness of breath E: altered swallowing

A nurse is providing discharge teaching to a client who had diabetic ketoacidosis. Which of the following information should the nurse include about preventing DKA? (select all) A: Drink 2 L fluids daily B: Monitor blood glucose every 4 hour while awake C: Administer insulin as prescribed when ill D: Notify the provider when blood glucose is 200mg/dL E: Report ketones in the urine after 24 hours of illness

A: Drink 2 L fluids daily B: Monitor blood glucose every 4 hour while awake C: Administer insulin as prescribed when ill E: Report ketones in the urine after 24 hours of illness

A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 diabetes mellitus. Which of the following should the nurse include in the information? (select all that apply) A: Eat at regular intervals B: Decrease intake of saturated fats C: Increase daily fiber intake D: Limit saturated fat intake to 15% of daily caloric intake E: Include omega-3 fatty acids in the diet

A: Eat at regular intervals B: Decrease intake of saturated fats C: Increase daily fiber intake E: Include omega-3 fatty acids in the diet

A nurse is reviewing the health record of a client who has severe otitis media. Which of the following are expected findings? (select all) A: Enlarged adenoids B: Report of recent colds C: Client prescription for daily furosemide D: Light reflex visible on otoscopic exam in affected ear E: Ear pain relieved by meclinzine

A: Enlarged adenoids B: Report of recent colds

A nurse is reviewing the health history of a client who has diabetes mellitus type 2. Which of the following are risk factors for hyperglycemic-hyperosmolar state? Select all A: Evidence of recent MI B: BUN 35 C: Take CCB D: Age 77 E: Daily insulin injections

A: Evidence of recent MI B: BUN 35 C: Take CCB D: Age 77

The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective? Select all A: Has maintained a low-sodium, no-added-salt diet B: Has lost 3 pounds (1.4 kg) since last seen in the clinic C: Cooks food in palm oil to save money D: Exercises once weekly E: Has cut down on caffeine

A: Has maintained a low-sodium, no-added-salt diet B: Has lost 3 pounds (1.4 kg) since last seen in the clinic E: Has cut down on caffeine

A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? A: Hip arthroplasty 2 weeks ago B: Elevated sedimentation rate C: Incident of exercise-induced asthma 1 week ago D: Elevated platelet count

A: Hip arthroplasty 2 weeks ago

A nurse is completing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching? A: I should restrict movements and avoid bending from the waist for several weeks B: I should wait until the day after surgery to wash my hair C: I will remove the dressing behind my ear in 7 days D: My hearing should be back to normal right after my surgery

A: I should restrict movements and avoid bending from the waist for several weeks

A nurse is caring for a client who is experiencing mild acute pain after spraining an ankle. Which of the following analgesics should the nurse expect to administer? A: Ketorolac B: Ketamine C: Meperidine D: Methadone

A: Ketorolac - NSAID

Which are risk factors that are known to contribute to atherosclerosis-related diseases? (select all) A: LDL of 160 B: smoking C: Aspirin (acetylsalicylic acid [ASA]) consumption D: Type 2 diabetes E: Vegetarian diet

A: LDL of 160 B: smoking D: Type 2 diabetes

A nurse is providing discharge teaching for a client who has a prescription for furosemide 40 mg PO daily. The nurse should instruct the client to take this medication at which of the following times of day? A: Morning B: Immediately after lunch C: Immediately before dinner D: Bedtime

A: Morning

When planning care for a client in the emergency department, which interventions are needed in the acute phase of myocardial infarction (MI)? Select all that apply. A: Oxygen B: Morphine sulfate C: Nitroglycerin D: Naloxone E: Acetaminophen F: Verapamil (Calan, Isoptin)

A: Oxygen B: Morphine sulfate C: Nitroglycerin?

A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? (select all) A: Reduce exposure to bright lighting B: Move head slowly when changing positions C: DO not eat fruit high in potassium D: Plan evenly spaced daily fluid intake E: Avoid fluids containing caffeine

A: Reduce exposure to bright lighting B: Move head slowly when changing positions D: Plan evenly spaced daily fluid intake

A postoperative client is receiving epidural analgesia and reports itching. What does the nurse do next? A: Reduces the analgesic dose B: Give Diphenhydramine C: Gives an antiemetic D: Calls the surgeon

A: Reduces the analgesic dose

The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess? A: Reproducible leg pain with exercise B: Unilateral swelling of affected leg C: Decreased pain when legs are elevated D: Pulse oximetry reading of 90%

A: Reproducible leg pain with exercise

A nurse is admitting a client who has suspected myocardial infarction and a history of angina. Which of the following finds will help the nurse distinguish stable angina from an MI? A: Stable angina can be relieved with rest and nitroglycerin B: The pain of an MI resolves in less than 15 minutes C: They type of activity that causes an MI can be identified D: Stable angina can occur for longer than 30 min

A: Stable angina can be relieved with rest and nitroglycerin

A client has undergone an embolectomy for acute arterial occlusion after creation of a lower arm arteriovenous fistula for dialysis. Which finding does the nurse report to the primary health care provider (PCP) immediately? A: Swelling and tenseness in the affected area B: Incisional pain and tenderness at the surgical site C: Pink, mobile fingers D: An order for heparin infusion

A: Swelling and tenseness in the affected area

The nurse is assigned to all of these clients. Which client would be assessed first? A: The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago B: The client admitted with hypertensive crisis who has a nitroprusside (Nipride) drip and blood pressure of 149/80 mm Hg C: The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid D: The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot

A: The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago

After receiving change-of-shift report in the coronary care unit, which client does the nurse assess first? A: The client with acute coronary syndrome who has a 3-pound (1.4 kg) weight gain and dyspnea B: The client with percutaneous coronary angioplasty who has a dose of heparin scheduled C: The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min D: A client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction

A: The client with acute coronary syndrome who has a 3-pound (1.4 kg) weight gain and dyspnea

A nurse educator is reviewing the use of cardiopulmonary bypass during sx for coronary artery bypass grafting with a group of nurses. Which of the following statements should the nurse include in the discussion? (select all) A: The client's demand for oxygen is lowered B: Motion of the heart ceases C: Rewarming of the client takes place D: The client's metabolic rate is increased E: Blood flow to the heart is stopped

A: The client's demand for oxygen is lowered B: Motion of the heart ceases C: Rewarming of the client takes place

The nurse is preparing to teach a client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome should the nurse include in the discussion? Select all that apply. A: Truncal obesity B: Hypercholesterolemia C: Elevated homocysteine levels D: Glucose intolerance E: Client taking losartan (Cozaar)

A: Truncal obesity B: Hypercholesterolemia D: Glucose intolerance E: Client taking losartan (Cozaar)

The nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding? A: Urine output of 20 mL over 2 hours B: Blood pressure of 106/58 mm Hg C: Absent bowel sounds D: +3 pedal pulses

A: Urine output of 20 mL over 2 hours

A nurse is planning care for a client who has a PICC line in the right arm. Which of the following interventions should the nurse include? (select all) A: Use a 10 mL syringe to flush the PICC line B: Apply gentle force if resistance is met during injection C: Cleanse ports with alcohol for 15 seconds prioir to use D: Maintain a transparent dressing over the insertion site E: Flush with 10mL heparin before and after medication administration

A: Use a 10 mL syringe to flush the PICC line C: Cleanse ports with alcohol for 15 seconds prioir to use D: Maintain a transparent dressing over the insertion site

A nurse is planning postoperative care for a client following a surgical placement of an endovascular stent graft to repair an aneurysm. Which of the following interventions should the nurse include in the plan of care? (select all) A: assess pedal pulses. B: monitor for an increase in pain below the graft site C: Maintain the client in high-fowler's position D: Monitor the femoral site for bleeding E: Report hourly urine output for 60mL

A: assess pedal pulses. B: monitor for an increase in pain below the graft site D: Monitor the femoral site for bleeding

A nurse is teaching a client who had a new diagnosis of severe PAD. Which of the following instructions should the nurse include? A: Wear tight fitting socks with shoes when going outside B: Elevate both legs about the heart when resting C: Apply a heating pad to both legs for discomfort D: Place both legs in dependent position when sleeping

D: Place both legs in dependent position when sleeping

The nurse is teaching a client the precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective? A: "I can use an electric razor or a regular razor." B: "Eating foods like green beans won't interfere with my Coumadin therapy." C: "If I notice I am bleeding a lot, I should stop taking Coumadin right away." D: "When taking Coumadin, I may notice some blood in my urine."

B: "Eating foods like green beans won't interfere with my Coumadin therapy."

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? A: "I feel my heart beating in my abdominal area." B: "I just started to feel a tearing pain in my belly." C: "I have a headache. May I have some acetaminophen?" D: "I have had hoarseness for a few weeks."

B: "I just started to feel a tearing pain in my belly."

The nurse is teaching a client with diabetes about proper foot care. Which statement by the client indicates that teaching was effective? A: "I will go barefoot in my house so that my feet are exposed to air." B: "I must inspect my shoes for foreign objects before putting them on." C: "I will soak my feet in warm water to soften calluses before trying to remove them." D: "I must wear canvas shoes as much as possible to decrease pressure on my feet."

B: "I must inspect my shoes for foreign objects before putting them on."

The nurse is teaching a client about the manifestations and emergency management of hypoglycemia. Which response by the client indicates a correct understanding of what to do if the client feels hungry and shaky? A: "I will drink a glass of water." B: "I will eat three graham crackers." C: "I will give myself 1 mg of glucagon." D: "I will sit down and rest."

B: "I will eat three graham crackers."

The clinic nurse is providing teaching to a client with newly diagnosed diabetes. Which statement by the client indicates a correct understanding about the need to wear a MedicAlert bracelet? A: "If I become hyperglycemic, it is a medical emergency." B: "If I become hypoglycemic, I could become unconscious." C: "Medical personnel may need confirmation of my insurance." D: "I may need to be admitted to the hospital suddenly."

B: "If I become hypoglycemic, I could become unconscious."

A client with type 1 diabetes mellitus received regular insulin at 7:00 a.m. The client will need to be monitored for hypoglycemia at which time? A: 7:30 a.m. B: 11:00 a.m. C: 2:00 p.m. D: 7:30 p.m.

B: 11:00 a.m.

A client with chronic pain feels no relief with high-dose opioids and says, "I just can't manage living right now." What intervention does the nurse anticipate the health care provider will order for this client? A: Adding Tylenol B: Adding duloxetine (Cymbalta) as adjuvant therapy C: Increasing the opioid dose to control the pain D: Replacing the opioid with Norpramin for depression.

B: Adding duloxetine (Cymbalta) as adjuvant therapy

A nurse is caring for a client who is 4 hours postoperative following coronary artery bypass grafting sx. The client is able to inspire 200mL with the incentive spirometer, then declines to try to cough because of fatigue and pain. Which of the following actions should the nurse take? A: All the client to rest and return in 1 hour B: Administer IV bolus analgesic and return in 15 min C: Document the 200mL as an appropriate inspired volume D: Tell the client coughing after incentive spirometry is required

B: Administer IV bolus analgesic and return in 15 min

The nurse is caring for a client with dark-colored toe ulcers and blood pressure (BP) of 190/100 mm Hg. Which nursing action does the nurse delegate to the LPN/LVN? A: Assess leg ulcers for evidence of infection. B: Administer a clonidine patch for hypertension. C: Obtain a request from the health care provider for a dietary consult. D: Develop a plan for discharge, and assess home care needs.

B: Administer a clonidine patch for hypertension.

A nurse is preparing to administer a morning dose of insulin aspart to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take? A: Check blood glucose immediately after breakfast B: Administer insulin when breakfast arrives C: Hold breakfast for 1 hour after insulin administration D: Clarify the prescription because insulin should not be administered at this time

B: Administer insulin when breakfast arrives

The nurse is caring for a group of clients who have sustained myocardial infarction (MI). The nurse observes the client with which type of MI most carefully for the development of left ventricular heart failure? A: Inferior wall B: Anterior wall C: Lateral wall D: Posterior wall

B: Anterior wall

A nurse is caring for a client who had chronic venous insufficiency and a prescription for thigh-high compression stockings. Which of the following actions should the nurse take? A: Elevate the clients legs for 10 minutes, two to three times daily while wearing stocking B: Apply the stockings in the morning upon awakening and before getting out of bed C: Roll the stockings down to the knees to relieve discomfort on the legs D: Remove the stockings while out of bed for 1 hour a day, to allow the legs to rest

B: Apply the stockings in the morning upon awakening and before getting out of bed

A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a CVP of 7 mm Hg and a PAWP of 17 mmHg. Which of the following findings should the nurse expect (select all) A: Poor skin turgor B: Bilateral crackles in the lungs C: Jugular vein distention D: Dry mucous membranes E: Hepatomegaly

B: Bilateral crackles in the lungs C: Jugular vein distention E: Hepatomegaly

A nurse is reviewing laboratory reports of a client who had HHS. Which of the following findings should the nurse expect? A: Blood pH 7.2 B: Blood osmolarity 350 mOsm/L C: Blood potassium 3.8mg/dL D: Blood creatinine 0.8 mg/dL

B: Blood osmolarity 350 mOsm/L

For a client with an 8-cm abdominal aortic aneurysm, which problem must be addressed immediately to prevent rupture? A: Heart rate 52 beats/min B: Blood pressure (BP) 192/102 mm Hg C: Report of constipation D: Anxiety

B: Blood pressure (BP) 192/102 mm Hg

A nurse is caring for a client following peripheral bypass graft sx of the left lower extremity. Which of the following findings pose an immediate concern? (select all) A: Trace of bloody drainage on dressing B: Capillary refill of affected limb of 6 seconds C: Mottled appearance of the limb D: Throbbing pain of affected limb that is decreased following IV bolus analgesic E: Pulse of 2+ in the affected limb

B: Capillary refill of affected limb of 6 seconds C: Mottled appearance of the limb

A client newly diagnosed with diabetes is not ready to learn diabetes control during the hospital stay. Which information is the priority for the nurse to teach the client and the client's family? Select all that apply. A: Pathophysiology of diabetes B: Causes and treatment of hypoglycemia C: Dietary control of blood glucose D: Insulin administration E: Physical activity and exercise

B: Causes and treatment of hypoglycemia D: Insulin administration

A client has just returned from coronary artery bypass graft surgery. For which finding does the nurse contact the surgeon? A: Temperature 98.2°F (36.8°C) B: Chest tube drainage 175 mL last hour C: Serum potassium 3.9 mEq/L (3.9 mmol/L) D: Incisional pain 6 on a scale of 0 to 10

B: Chest tube drainage 175 mL last hour

A nurse in a providers office is obtaining a health history from a client who has cluster headaches. Which of the following are expected findings? (select all) A: Pain is bilateral across the posterior occipital area B: Client experiences altered sleep wake cycle C: Headache occurs appro. 1-8 times daily D: Client describes headache pain as dull and throbbing E: Nasal congestion and drainage occur

B: Client experiences altered sleep wake cycle C: Headache occurs appro. 1-8 times daily E: Nasal congestion and drainage occur

The nurse has just taken change-of-shift report on a group of clients on the medical-surgical unit. Which client does the nurse assess first? A: Client taking repaglinide (Prandin) who has nausea and back pain B: Client taking glyburide (Diabeta) who is dizzy and sweaty C: Client taking metformin (Glucophage) who has abdominal cramps D: Client taking pioglitazone (Actos) who has bilateral ankle swelling

B: Client taking glyburide (Diabeta) who is dizzy and sweaty

The nurse in the coronary care unit is caring for a group of clients who have had a myocardial infarction. Which client does the nurse see first? A: Client with normal sinus rhythm and PR interval of 0.28 second B: Client with third-degree heart block on the monitor C: Client with dyspnea on exertion when ambulating to the bathroom D: Client who refuses to take heparin or nitroglycerin

B: Client with third-degree heart block on the monitor

When administering furosemide (Lasix) to a client who does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels? A: Increase red meat in the diet. B: Consume melons and baked potatoes. C:Add several portions of dairy products each day. D: Try replacing your usual breakfast with oatmeal or Cream of Wheat.

B: Consume melons and baked potatoes.

The nurse is concerned that a client who had myocardial infarction (MI) has developed cardiogenic shock. Which findings indicate shock? Select all that apply. A: Bradycardia B: Cool, diaphoretic skin C: Crackles in the lung fields D: Respiratory rate of 12 breaths/min E: Anxiety and restlessness F: Temperature of 100.4°F (38.0°C)

B: Cool, diaphoretic skin C: Crackles in the lung fields E: Anxiety and restlessness

The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure? A: Urine output of 1500 mL on the preceding day B: Crackles in the lung fields C: Pedal edema D: Expectoration of yellow sputum

B: Crackles in the lung fields

Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? Select all that apply. A: Sharp, inspiratory chest pain B: Dyspnea C: Dizziness D: Extreme fatigue E: Anorexia

B: Dyspnea C: Dizziness D: Extreme fatigue

A nurse is screening a client for hypertension. The nurse should identify that which of the following actions by the client increases the risk for hypertension? (select all) A: Drink 8 oz nonfat milk daily B: Eating popcorn at the move theater C: Walking 1 mile daily at 12 min/mile pace D: Consuming 36oz beer daily E: Getting massage once a week

B: Eating popcorn at the move theater D: Consuming 36oz beer daily

The nurse in the endocrine clinic is providing education for a client who has just been diagnosed with diabetes. Which factor is most important for the nurse to assess before providing instruction to the client about the disease and its management? A: Current lifestyle B: Educational and literacy level C: Sexual orientation D: Current energy level

B: Educational and literacy level

After thrombolytic therapy, the nurse working in the cardiac catheterization laboratory would be alarmed to notice which sign? A: A 1-inch (2.5 cm) backup of blood in the IV tubing B: Facial drooping C: Partial thromboplastin time (PTT) 68 seconds D: Report of chest pressure during dye injection

B: Facial drooping

A nurse is assessing a client who had diabetic ketoacidosis and ketones in the urine. The nurse should expect which of the following findings? (select all) A: Weight gain B: Fruity odor of breath C: Abdominal pain D: Kussmaul respirations e: Metabolic acidosis

B: Fruity odor of breath C: Abdominal pain D: Kussmaul respirations e: Metabolic acidosis

A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A: I am allergic to morphine B: I take antacids several times a day for my ulcer C: I had a blood clot in my leg several years ago D: It hurts to take a deep breath

B: I take antacids several times a day for my ulcer

A nurse is providing teaching for a client who has a new diagnosis of hypertension and a new prescription for spironolactone 25mg/day. Which of the following statements by the client indicates an understanding of the teaching? A: I should eat a lot of fruits and vegetables, especially bananas and potatoes B: I will report any changes in heart rate to my provider C: I should replace the salt shaker on my table with salt substitute D: I will decrease the dose of this medication when I no longer have headaches and facial redness

B: I will report any changes in heart rate to my provider

Which characteristics place women at high risk for myocardial infarction (MI)? Select all that apply. A: Premenopausal B: Increasing age C: Family history D: Abdominal obesity E: Breast cancer

B: Increasing age C: Family history D: Abdominal obesity

A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? A: Administers oxygen therapy B: Obtains the client's description of the chest discomfort C: Provides pain relief medication D: Remains calm and stays with the client

B: Obtains the client's description of the chest discomfort

Prompt pain management with myocardial infarction is essential for which reason? A: The discomfort will increase client anxiety and reduce coping. B: Pain relief improves oxygen supply and decreases oxygen demand. C: Relief of pain indicates that the MI is resolving. D: Pain medication would not be used until a definitive diagnosis has been established.

B: Pain relief improves oxygen supply and decreases oxygen demand.

A client is receiving unfractionated heparin (UFH) by infusion. Of which finding does the nurse notify the primary health care provider (PCP)? A: Partial thromboplastin time (PTT) 60 seconds B: Platelets 32,000/mm3 (32 × 109/L) C: White blood cells 11,000/mm3 (11 × 109/L) D: Hemoglobin 12.2 g/dL (122 mmol/L)

B: Platelets 32,000/mm3 (32 × 109/L)

A nurse is assessing a client who has pulmonary embolism. Which of the following manifestations should the nurse expect? (select all) A: Bradypnea B: Pleural friction rub C: Hypertension D: Petechiae E: Tachycardia

B: Pleural friction rub D: Petechiae E: Tachycardia

A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headache. The nurse should recommend that the client avoid which of the following foods? A: Baked salon B: Salted cashews C: frozen strawberries D: Fresh asparagus.

B: Salted cashews

The nurse teaches a client who has had a myocardial infarction (MI) which information regarding diet? A: Less than 30% of the daily caloric intake should be derived from proteins. B: Use canola oil rather than palm oil. C:Consume 10 mg of fiber daily. D: Work toward lowering your high-density lipoprotein (HDL) cholesterol levels.

B: Use canola oil rather than palm oil

A client with typically well controlled diabetes has a glycosylated hemoglobin (HbA1C) level of 9.4%. Which response by the nurse is most appropriate? A: "Keep up the good work." B: "This is not good at all." C: "Have you been doing something differently? D: "You need an increase in your insulin dose."

C: "Have you been doing something differently?

A client expresses fear and anxiety over the life changes associated with diabetes, stating, "I am scared I can't do it all and I will get sick and be a burden on my family." What is the nurse's best response? A: "It is overwhelming, isn't it?" B: "Let's see how much you can learn today, so you are less nervous." C: "Let's tackle it piece by piece. What is most scary to you?" D: "Many people live with diabetes and do it just fine."

C: "Let's tackle it piece by piece. What is most scary to you?"

A client undergoing coronary artery bypass grafting asks why the surgeon has chosen to use the internal mammary artery for the surgery. Which response by the nurse is correct? A: "This way you will not need to have a leg incision." B: "The surgeon prefers this approach because it is easier." C: "These arteries remain open longer." D: "The surgeon has chosen this approach because of your age."

C: "These arteries remain open longer."

Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)? A:"Elevate your legs above heart level to prevent swelling." B: "Inspect your legs daily for brownish discoloration around the ankles." C: "Walk to the point of leg pain, then rest, resuming when pain stops." D: "Apply a heating pad to the legs if they feel cold."

C: "Walk to the point of leg pain, then rest, resuming when pain stops."

The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic? A: "Are you afraid you will not be able to work?" B: "If you control your diabetes, you can avoid amputation." C: "Your concerns are valid; we can review some steps to limit disease progression." D: "What about the situation concerns you most?"

C: "Your concerns are valid; we can review some steps to limit disease progression."

Which of these clients with diabetes will the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit? A: A client with sensory neuropathy who needs teaching about foot care B: A client with diabetic ketoacidosis who has an IV running at 250 mL/hr C: A client who needs blood glucose monitoring and insulin before each meal D: A client who was admitted with fatigue and shortness of breath

C: A client who needs blood glucose monitoring and insulin before each meal

An LPN/LVN is scheduled to work on the inclient "stepdown" cardiac unit. Which client does the charge nurse assign to the LPN/LVN? A: A 60-year-old who was admitted today for pacemaker insertion because of third-degree heart block and who is now reporting chest pain. B: A 62-year-old who underwent open-heart surgery 4 days ago for mitral valve replacement and who has a temperature of 100.8°F (38.2°C). C: A stable 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is stable and scheduled for discharge to a group home later today. D: A 69-year-old who had a stent placed 2 hours ago in the left anterior descending artery and who has bursts of ventricular tachycardia.

C: A stable 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is stable and scheduled for discharge to a group home later today.

A nurse in the emergency department is admitting a client who has a possible dissecting abdominal aortic aneurysm. Which of the following actions is the priority for the nurse to take? A: Administer pain medication as prescribed B: Provide a warm environment C: Administer IV fluid as prescribed D: Initiate a 12-lead ECG

C: Administer IV fluid as prescribed

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states, "I am anxious and unable to get enough air." Vital signs are heart rate 117/min, respirations 38/min, temperature 38.4 (101.2), and blood pressure 100/54. Which of the following nursing actions is the priority? A: Notify the provider B: Administer heparin via IV infusion C: Administer oxygen therapy D: Obtain a CT scan

C: Administer oxygen therapy

An older adult client, 4 hours after coronary artery bypass graft (CABG), has a blood pressure of 80/50 mm Hg. What action does the nurse take? A: No action is required; low blood pressure is normal for older adults. B: No action is required for postsurgical CABG clients. C: Assess pulmonary artery wedge pressure (PAWP). D: Give ordered loop diuretics.

C: Assess pulmonary artery wedge pressure (PAWP).

In the role of client advocate, what does the nurse do first for a client who reports pain? A: Administers pain medication B: Assesses the level of pain C: Believes the client's report of pain D: calls the provider for a medication order

C: Believes the client's report of pain

A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the clients lower back. Which of the following findings should the nurse suspect? A: Retroperitoneal bleeding B: Cardiac tamponade C: Bleeding from the incision site D: Heart failure

C: Bleeding from the incision site

A nurse is monitoring a client who is receiving an opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? (select all) A: Urinary incontinence B: Diarrhea C: Bradypnea D: Orthostatic hypertension E: Nausea

C: Bradypnea D: Orthostatic hypertension E: Nausea

Which activity does the RN team leader on a large medical-surgical unit assign to the LPN/LVN? A: Assessment of a client scheduled for sx who is crying and expressing fear that the pain will be intolerable B: Assessment of a client using transcutaneous electrical nerve stimulation unit to relieve chronic pain C: Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before found care D: Instructions to a postoperative hip replacement client who has just been placed on PCA for pain relief

C: Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before found care

The nurse is teaching a group of teens about prevention of heart disease. Which point is most important for the nurse to emphasize? A: Reduce abdominal fat. B: Avoid stress. C: Do not smoke or chew tobacco. D: Avoid alcoholic beverages.

C: Do not smoke or chew tobacco.

The nurse is caring for a client who is being treated for hypertensive emergency. Which medication prescribed for the client would the nurse question? A: Enalapril (Vasotec) B: Sodium nitroprusside (Nipride) C: Dopamine (Intropin) D: Labetalol (Normodyne)

C: Dopamine (Intropin)

A nurse is preparing to administer morning doses of insulin glargine and regular insulin to a client who has a blood glucose 278 mg/dL. Which of the following actions should the nurse take? A: Draw up the regular insulin and then the glargine insulin in the same syringe B: Draw up the glargine insulin then the regular insulin in the same syringe C: Draw up and administer the regular and glargine in separate syringes D: Administer the regular insulin, wait 1 hour, and then administer the glargine insulin

C: Draw up and administer the regular and glargine in separate syringes

A nurse in a clinic is teaching a client who has a history of migraine headaches about a new prescription for zolmitriptan. Which of the following statements by the client indicates an understanding of the teaching? A: This medication will relieve my symptoms by causing my blood vessels to dilate B: I should take this medication daily to prevent the headache from occurring C: I should expect facial flushing when I take this medication D: This medication will lower my sensitivity to food triggers

C: I should expect facial flushing when I take this medication?

A nurse is caring for a client who is receiving morphine via a patient controlled analgesia infusion device after abdominal sx. Which of the following client statements indicates that the client understands how to use the device? A: Ill wait to use the device until its absolutely necessary B: Ill be careful about pushing the button so I don't get an overdose C: I should tell the nurse if the pain doesn't stop after I use this device D: I will ask my son to push the dose button when I am sleep

C: I should tell the nurse if the pain doesn't stop after I use this device

A nurse is admitting a client who has a suspected occlusion of a graft of the abdominal aorta. Which of the following manifestations should the nurse expect? A: Increase in urine output B: Bounding pedal pulse C: Increase in abdominal girth D: Lower extremities have irregularly shaped cyanotic areas

C: Increase in abdominal girth

A nurse is caring for a client who has a DVT and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin. The client asked about receiving both heparin and warfarin at the same time. Which of the following statements should the nurse give? A: I will remind you provider that you are already receiving heparin B: Your lab findings indicated that two anticoagulants were needed C: It takes 3-4 days before therapeutic effects of warfarin are achieved, and then the heparin can be discontinued D: Only one of the medications is being given to treat you DVT

C: It takes 3-4 days before therapeutic effects of warfarin are achieved, and then the heparin can be discontinued

The visiting nurse is seeing a client postoperative for coronary artery bypass graft. Which nursing action would be performed first? A: Assess coping skills. B: Assess for postoperative pain at the client's incision site. C: Monitor the heart rate for dysrhythmias. D: Monitor mental status.

C: Monitor the heart rate for dysrhythmias.

A nurse is caring for a client who is admitted to the ER with a blood pressure of 266/147. The client reports a headache and double vision. The client states, "I ran out of my diltiazem three days ago, and I am unable to purchase more." Which of the following actions should the nurse take first? A: Administer acetaminophen for headache B: Provide teaching regarding the importance of not abruptly stopping an antihypertensive C: Obtain IV access and prepare to administer an IV antihypertensive D: Call social services for a referral for financial assistance in obtaining prescribed medication

C: Obtain IV access and prepare to administer an IV antihypertensive

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? A: Ankle-brachial index B: Dye allergy C: Pedal pulses D: Gag reflex

C: Pedal pulses

The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity does the nurse suggest? A: The need to increase activities slowly at home B: Planning and participating in a walking program C: Placing a chair in the shower for independent hygiene D: Consultation with social worker for disability planning

C: Placing a chair in the shower for independent hygiene

An intensive care client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. When the cardiac monitor shows ventricular ectopy, which assessment will the nurse make? A: Urine output B: 12-lead electrocardiogram (ECG) C: Potassium level D: Rate of IV fluids

C: Potassium level

The nurse manager for an oncology unit is evaluating a newly hired staff nurse. Which action by the nurse is of greatest concern to the nurse manager? A: Asking a client with chest pain if the pain is sharp and stabbing B: Instructing a confused postoperative client about how to use PCA C: Preparing to administer a placebo to a client with chronic back pain D: Requesting that a client with chronic pain describe the specific location of the pain

C: Preparing to administer a placebo to a client with chronic back pain

A nurse is caring for a client who has blood glucose 52mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform first? A: Recheck blood glucose in 15 minutes B: Provide a carbohydrate and protein food C: Provide 15g of simple carbohydrate D: Report findings to the providers

C: Provide 15g of simple carbohydrate

A nurse is reviewing the medical record for a client who is to begin therapy for DKA. Which of the following prescriptions should the nurse expect? A: Administer an IV infusion of regular insulin at 0.3 unit/kg/hour B: Administer a slow IV infusion of 3% Sodium chloride C: Rapidly administer an IV infusion of 0.9% sodium chloride D: Add glucose to the IV infusion when blood glucose is 350 mg/dL

C: Rapidly administer an IV infusion of 0.9% sodium chloride

Which symptom reported by a client who has had a total hip replacement requires emergency action? A: Localized swelling of one of the lower extremities B: Positive Homans' sign C: Shortness of breath and chest pain D: Tenderness and redness at the IV site

C: Shortness of breath and chest pain

A nurse is presenting a community education program on recommeded lifestlye changes to prevent angina and MI. Which of the following changes should the nurse recommended be made first? A: Diet modification B: Relaxation exercises C: Smoking cessation D: Taking omega-3 capsules

C: Smoking cessation

A client with type 2 diabetes controlled with Metformin is recovering from surgery. The primary health care provider has placed the client on insulin in addition to the metformin. What is the nurse's best response about why the client needs to take insulin? A: "Your diabetes is getting worse, so you will need to take insulin." B: "You can't take your metformin while in the hospital." C: Stress, such as surgery, increases blood glucose levels. You'll need insulin to control your blood glucose temporarily." D: "You must take insulin from now on because the surgery will affect your diabetes."

C: Stress, such as surgery, increases blood glucose levels. You'll need insulin to control your blood glucose temporarily."

A nurse in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the second time in 2 weeks that the client experienced hypoglycemia. Which of the following client data should the nurse report to the provider? A: Takes psyllium daily as a fiber laxative B: Drinking skin milk daily as a bedtime snack C: Take metoprolol daily after meals D: Drink grapefruit juice daily with breakfast

C: Take metoprolol daily after meals

Which sign/symptom is essential for the nurse to report to the primary health care provider (PCP) when caring for a client with Raynaud's phenomenon? A: Nifedipine (Procardia) administration caused the blood pressure to change from 134/76 to 110/68 mm Hg. B: The client's extremity became white, then red temporarily. C: The affected extremity becomes purple and cold. D: The client states that the digits are painful when they are white.

C: The affected extremity becomes purple and cold.

The nurse in the endocrine clinic is reviewing type 1 and type 2 diabetes with a group of nursing students. Which explanation by the students indicates their understanding of the types of diabetes? A: Most clients with type 1 diabetes are born with it. B: People with type 1 diabetes are often obese. C: Those with type 2 diabetes make insulin, but in inadequate amounts. D: People with type 2 diabetes do not develop typical diabetic complications.

C: Those with type 2 diabetes make insulin, but in inadequate amounts

A nurse on a cardiac unit is reviewing the lab findings of a client who has a diagnosis of MI and reports dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the MI occurred 14 days ago? A: CK-MB B: Troponin 1 C: Troponin T D: Myoglobin

C: Troponin T

A postoperative client is requesting medication for pain every 4 hours. In planning effective pain management, what assessment question does the nurse ask the client before administering the medication? A: are you bleeding? B: Are you able to last more than 4 hours C: is your pain controlled between doses? D: What do you do for pain when youre at home?

C: is your pain controlled between doses?

A client with hypertension is started on verapamil (Calan). What teaching does the nurse provide for this client? A: "Consume foods high in potassium." B: "Monitor for irregular pulse." C: "Monitor for muscle cramping." D: "Avoid grapefruit juice."

D: "Avoid grapefruit juice."

Which statement by a client scheduled for a percutaneous transluminal coronary angioplasty (PTCA) indicates a need for further preoperative teaching? A: "I will be awake during this procedure." B: "I will have a balloon in my artery to widen it." C: "I must lie still after the procedure." D: "My angina will be gone for good."

D: "My angina will be gone for good."

During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." What is the nurse's best response? A: "You are right. Work on your diet then." B: "You must find someplace to walk." C: "Walk around the edge of your apartment complex." D: "Where might you be able to walk?"

D: "Where might you be able to walk?"

The intensive care nurse is caring for a client admitted in a hyperglycemic-hyperosmolar state. Which of these prescriptions made by the primary health care provider will the nurse question? A: Add 20 mEq of KCl to each liter of IV fluid B: IV regular insulin at 2 units/hr C: IV normal saline at 100 mL/hr D: 1 ampule Sodium Bicarbonate IV now

D: 1 ampule Sodium Bicarbonate IV now

Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation? A: A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness B: A 64-year-old with chronic venous ulcers who has a temperature of 100.1°F (37.8°C) C: A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness D: A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic

D: A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic

A nurse is orienting a newly licenses nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates understanding? A: Air should be instilled into the monitoring system prior to the procedure B: The client should be positioned on the left side during the procedure C: The transducer should be level with the second intercostal space after the line is placed D: A chest x-ray is needed to verify placement

D: A chest x-ray is needed to verify placement

A nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include? A: Use music therapy for relaxation with the onset of the headache B: Increase physical activity when a headache is present C: Drink beverages that contain artificial sweetener to prevent headaches D: Apply a cool cloth to the face during a headache

D: Apply a cool cloth to the face during a headache

A client with type 2 diabetes who is taking metformin (Glucophage) is seen in the diabetic clinic. The fasting blood glucose is 108 mg/dL (6.0 mmol/L), and the glycosylated hemoglobin (HbA1C) is 8.2%. Which action will the nurse take next? A: Instruct the client to continue with the current diet and metformin use. B: Discuss the need to check blood glucose several times every day. C: Talk about the possibility of adding rapid-acting insulin to the regimen. D: Ask the client about current dietary intake and medication use.

D: Ask the client about current dietary intake and medication use.

Which nursing action will the home health nurse delegate to a home health aide who is making daily visits to a client with newly diagnosed type 2 diabetes? A: Assist the client's spouse in choosing appropriate dietary items. B: Evaluate the client's use of a home blood glucose monitor. C: Inspect the extremities for evidence of poor circulation. D: Assist the client with washing the feet and applying moisturizing lotion.

D: Assist the client with washing the feet and applying moisturizing lotion.

While caring for a client who has received recombinant tissue plasminogen activator (t-PA) for a large deep vein thrombus, the nurse becomes most concerned when the client develops which condition? A: Small amount of blood at the IV insertion site B: Heavy menstrual bleeding C: +1 pitting edema of the affected extremity D: Client stating that the year is 1967

D: Client stating that the year is 1967

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? (select all) A: Hypertension B: Tachycardia C: Bounding right pedal pulses D: Cold right foot E: Numbness and tingling of right foot F: Mottling of right foot and lower leg

D: Cold right foot E: Numbness and tingling of right foot F: Mottling of right foot and lower leg

The nurse is performing an admission assessment on a 52-year-old client admitted with type 2 diabetes.Physical AssessmentDiagnostic FindingsProvider PrescriptionsLungs clearGlucose 179 mg/dL (9.9 mmol/L)Regular insulin 8 units if blood glucose 250 to 275 mg/dL (13.9 to 15.3 mmol/L)Right great toe mottled and cold to touchHemoglobin A1c 6.9%Regular insulin 10 units if glucose 275 to 300 mg/dL (15.3 to 16.7 mmol/L)Client states wears eyeglasses to readAfter completing the above assessment, which complication of diabetes does the nurse report to the primary health care provider? A: Poor glucose control B: Visual changes C: Respiratory distress D: Decreased peripheral perfusion

D: Decreased peripheral perfusion

A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the aura type of migraine headaches? A: Do the headaches occur multiple times each day? B: Is your headache accompanied by profuse facial sweating? C: Does your headache occur on one side of your head? D: Do you have the same manifestations each time the headache occurs?

D: Do you have the same manifestations each time the headache occurs?

A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding? A: Pearly gray tympanic membrane B: Malleus visible behind TM C: Presence of soft cerumen in external canal D: Fluid or bubbles seen behind TM

D: Fluid or bubbles seen behind TM

A nurse is teaching a client who has angina about a new prescription for metoprolol. Which of the following statements by the client indicates understanding of teaching? A: I should place the tablet under my tongue B: I should have my clotting time checked weekly C: I will report any ringing in my ears D: I will call my doctor if my pulse rate is less than 60

D: I will call my doctor if my pulse rate is less than 60

A nurse is teaching a client who has a new diagnosis of an aneurysm. The client asks the nurse to explain what causes an aneurysm to rupture. Which of the following statements should the nurse give? A: This can occur when the wall of the artery becomes thing and flexible B: This can occur when there is turbulence in blood flow in the artery C: It is due to abdominal enlargement D: It is due to hypertension

D: It is due to hypertension

The professional nurse and the nursing student are caring for a group of clients with hypertension. Which problem identified by the nursing student correctly identifies the client at risk for secondary hypertension? A: Psychiatric disturbance B: High sodium intake C: Physical inactivity D: Kidney disease

D: Kidney disease

Which finding in the history of a client with an abdominal aortic aneurysm (AAA) is a risk factor for aneurysm formation? A: peptic ulcer disease B: Deep vein thrombosis (DVT) C: Osteoarthritis D: Marfan syndrome

D: Marfan syndrome

The nurse caring for four clients with diabetes has these activities to perform. Which activity is appropriate to delegate to unlicensed assistive personnel (UAP)? A: Perform a blood glucose check on a client who requires insulin. B: Verify the infusion rate on a continuous infusion insulin pump. C: Assess a client who reports tremors and irritability. D: Monitor a client who is reporting palpitations and anxiety.

D: Monitor a client who is reporting palpitations and anxiety.

A nurse is assessing a client who has chronic peripheral arterial disease. Which of the following findings should the nurse expect? A: Edema around the ankles and feet B: Ulceration around the medial malleoli C: Scaleing eczema of the lower legs with stasis dermatitis D: Pallor on elevation of the limbs, and rubor when the limbs are dependent

D: Pallor on elevation of the limbs, and rubor when the limbs are dependent

A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following findings should the nurse expect? A: Rubor of the affected leg when elevated B: 3+ dorsal pedal pulse in left foot C: Thin, peeling toenails of left foot D: Report of intermittent claudication in the affected leg

D: Report of intermittent claudication in the affected leg

The nurse is caring for a client 36 hours after coronary artery bypass grafting, with a priority problem of intolerance for activity related to imbalance of myocardial oxygen supply and demand. Which finding causes the nurse to terminate an activity and return the client to bed? A: Pulse 60 beats/min and regular B: Urinary frequency C: Incisional discomfort D: Respiratory rate 28 breaths/min

D: Respiratory rate 28 breaths/min

Which vascular assessment by the student nurse requires intervention by the supervising nurse? A: Measuring capillary refill in the fingertips B: Assessing pedal pulses by Doppler C: Measuring blood pressure in both arms D: Simultaneously palpating the bilateral carotids

D: Simultaneously palpating the bilateral carotids

The nurse is assessing a client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI? A: Substernal chest discomfort occurring at rest B: Chest pain brought on by exertion or stress C: Substernal chest discomfort relieved by nitroglycerin or rest D: Substernal chest pressure relieved only by opioids

D: Substernal chest pressure relieved only by opioids

All of these client assignments have been made by the charge nurse. Which assignment is questionable? A: The RN with 3 years of experience caring for a client with a pulmonary embolism (PE) who is receiving heparin therapy B: The LPN/LVN with 5 years of experience caring for a client with leg ulcers who is awaiting nursing home placement C: The RN with 8 years of experience caring for a client with peripheral arterial disease (PAD) and a total cholesterol of 390 mg/dL (10.1 mmol/L) D: The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure (BP) is 210/150 mm Hg

D: The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure (BP) is 210/150 mm Hg

A nurse is teaching foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? (select all) A: Remove calluses using over the counter remedies B: Apply lotion between toes C: Test water temperature with fingers before bathing D: Trim toenails straight across E: Wear closed toed shoes

D: Trim toenails straight across E: Wear closed toed shoes

To validate that a client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests? A: Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase B: Homocysteine and C-reactive protein C: Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol D: Troponin

D: Troponin

A nurse is caring for a client who has suspected Menieres disease. Which of the following is an expected findings? A: Presence of a purulent lesion in the external ear canal B: Feeling of pressure in the ear C: Bulging, red bilateral tympanic membranes D: Unilateral hearing loss

D: Unilateral hearing loss

A client had a hip replacement 2 days ago and reports having a moderate amount of pain, stating that it is "a 7 on a 0-to-10 scale" of intensity. What intervention has the highest priority in the client's nursing care plan? A: Encouraging diversional activities B: Incorportating activities of daily living ASAP C: Teaching key points of the relaxation response D: Using preemptive analgesia

D: Using preemptive analgesia

A client recently admitted with new-onset type 2 diabetes will be discharged with a meter for self-monitoring of blood glucose (SMBG) levels. When is the best time for the nurse to explain to the client the proper use of the glucose monitor? A: Day of discharge B: On admission C: When the client states readiness D: While performing the test in the hospital

D: While performing the test in the hospital

A nurse is teaching a client who is scheduled for coronary angiography. Which of the following statements should the nurse include? A: You should have nothing to eat or drink for 4 hours prior to the procedure B: You will be given general anesthesia during the procedure C: You should not have this procedure done if you are allergic to eggs D: You will need to keep your affected leg straight following the procedure

D: You will need to keep your affected leg straight following the procedure

The nurse is teaching a young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching? A: "I must stop taking my birth control pills." B: "I should drink lots of water so I don't get dehydrated." C: "I should exercise my legs when I have been sitting or standing for a long time." D: if i wear my pantyhouse I don't have to wear hospital legging when I leave - no.

D: if i wear my pantyhouse I don't have to wear hospital legging when I leave - no.

A nurse is discussing pain assessment with a newly licensed nurses. Which of the following information should the nurse include? A: Mont clients exaggerate their level of pain B: Pain must have an identifiable source to justify the use of opioids. C: Objective data are essential in assessing pain D: pain is whatever the patient says it is

D: pain is whatever the patient says it is

The nurse suspects a client is has peripheral venous disease by observing which of the following? a. A left calf that is swollen, tender to palpation, and painful. b. Dorsalis pedis pulses +1 bilaterally with cool skin temperature. c. Loss of hair in the lower calf d. Cramping and muscle discomfort that occurs with activity and is relieved with rest.

a. A left calf that is swollen, tender to palpation, and painful.

A nurse is caring for a client with Type 1 Diabetes. The client's blood glucose is 375 mg/dL and their mental status has decreased rapidly with acute confusion, lethargy and weakness. Their breath is fruity, with rapid, deep respirations. The skin is dry and their urine output is 200 ml/hour. Blood urea nitrogen: 30 mg/dL and creatinine is 1.6 mg/dL. Which of the following interventions would be the first priority for the client? a. Administer 0.9 Normal saline at 200 ml/hour. b. Bicarbonate administration to raise the blood pH from 7.35 to 7.40. c. 5% dextrose in water to prevent cerebral edema. d. Administer lantus insulin, 1 unit, subcutaneous, times one.

a. Administer 0.9 Normal saline at 200 ml/hour.

A client with Type 2 Diabetes is admitted with mental status changes that have declined over the past 48 hours. Their skin is dry. Urine output is high. Their respiratory rate is regular, non-labored, with a rate of 16 breaths per minute. Which of the following collaborative interventions would the nurse initiate first? a. Administer short-acting insulin infusion (intravenous). b. Give the client 10 unit of long-acting insulin subcutaneous. c. Administer sodium bicarbonate intravenously. d. Instruct the client to druink 1/2 cup of orange juice to restore fluid volume.

a. Administer short-acting insulin infusion (intravenous).

Which of the following systems that regulate blood pressure involve reducing blood pressure by vagal stimulation? a. Arterial baroreceptors b. Fluid Volume c. Renin-angiotensin-aldosterone d. Vascular autoregulation

a. Arterial baroreceptors

Which of the following systems that regulate blood pressure involve reducing blood pressure by vagal stimulation? a. Arterial baroreceptors b. Renin-angiotensin-aldosterone c. Fluid Volume d. Vascular autoregulation

a. Arterial baroreceptors

An 80 year old obese client has a history of hypertension, hyperlipidemia, and smoking. The client reports to the nurse that, "My legs hurt when I walk or climb stairs. The pain stops when I sit down." Which of the following interventions would be appropriate for this client? a. Encourage the client to increase their walking duration and pace with a goal of 30 minutes per day, five times per week. b. Massage both legs to reduce muscle cramping. c. Apply very hot blankets or towels to the skin to promote vasodilation and blood flow. d. Apply compression stockings to reduce edema and improve blood return to the heart.

a. Encourage the client to increase their walking duration and pace with a goal of 30 minutes per day, five times per week.

Melody Dixon is hypertensive. Which medications might be prescribed for this condition? Select all that apply. a. Hydrochlorothiazide 25 mg PO every morning b. Docusate sodium 100 mg PO twice daily c. Lisinopril 10 mg PO every day d. Enoxaparin 30 mg SQ every 12 hours

a. Hydrochlorothiazide 25 mg PO every morning c. Lisinopril 10 mg PO every day

You are caring for a patient admitted with cellulitis. His appetite is poor. He has an IV of normal saline and is receiving intermediate-acting insulin and fast-acting insulin on a sliding scale. He is feeling lightheaded, slightly confused, and diaphoretic. What do you suspect is causing the patient's current symptoms? a. Hypoglycemia b. Hyperglycemic Hyperosmolar State c. Diabetic ketoacidosis d. Septicemia

a. Hypoglycemia

Which of the following drug classes contributes to blood pressure reduction by inhibiting sodium chloride and water reabsorption? a. Thiazide diuretics b. Angiotensi-Converting Enzyme (ACE) inhibitors c. Angiotensin II Receptor (ARBs) Antagonists d. Calcium Channel Blockers

a. Thiazide diuretics

Which of the following assessment findings would contribute to a diagnosis of metabolic syndrome for a male client (select 3)? a. Triglycerides 175 mg/dL b. Taking Metformin, a biguanide oral hypoglycemic agent c. High density lipoprotein cholesterol 35 mg/dL d. Waist circumference 37 inches e. Blood pressure 120/80 mmHg

a. Triglycerides 175 mg/dL b. Taking Metformin, a biguanide oral hypoglycemic agent c. High density lipoprotein cholesterol 35 mg/dL

During a patient's last visit, the nurse instructed the patient about headaches and techniques to manage this condition. Which statement by the patient indicates teaching has been successful? a."I have been keeping track of when my headaches occur." b.My doctor told me that my headaches were not very serious." c."My spouse knows the instructions that you gave me." d."I have not had any headaches since we last talked."

a."I have been keeping track of when my headaches occur."

A client with diabetes correctly understands the disease process when they verbalize which of the following? a."Insulin is a hormone that lowers blood sugar." b."Insulin does not convert extra blood sugar to fat." c."What I eat does not effect my insulin production." d."Stress will not increase my blood sugar."

a."Insulin is a hormone that lowers blood sugar."

Mr. Watson was diagnosed with primary hypertension. Following long term management, which statement would indicate that an expected outcome has been met? a."My pants feel looser than last year." b."I only eat potato chips with meals." c."I only drink low calorie beer." d."I don't exercise too much to keep my stress level down."

a."My pants feel looser than last year."

An undesired consequence of acute pain is the progression to a chronic pain syndrome. The correct approach by a nurse to prevent chronic pain syndrome would be to: a.Adequately control acute pain. b.Give ordered opiates infrequently. c.Give pain medication only when requested by the client. d.Prevent physical dependence on the prescribed drug.

a.Adequately control acute pain.

Which statements would be included in an educational program on wellness behaviors for the older adult? (select all that apply) a.Allow at least 10-15 minutes of sun exposure 1-3 times weekly. b.Take one aspirin twice a day. c.Obtain a yearly influenza vaccination. d.Create a hazard-free environment to prevent falls. e.Increased dietary needs including calcium and vitamins A, D, and C. f.Reduce dietary intake of complex carbohydrates and fiber. g.Drink 6-8 glasses of water per day to prevent dehydration.

a.Allow at least 10-15 minutes of sun exposure 1-3 times weekly. c.Obtain a yearly influenza vaccination. d.Create a hazard-free environment to prevent falls. e.Increased dietary needs including calcium and vitamins A, D, and C. g.Drink 6-8 glasses of water per day to prevent dehydration.

•The nurse is interviewing a client reporting chest discomfort that occurs with moderate to prolonged exertion. The client describes the pain as being "about the same over the past several months and going away with nitroglycerine or rest." Based on the patient's description of symptoms, what does the nurse suspect in this client? (Select all that apply) a.Chronic stable angina b.Unstable angina c.Acute coronary syndrome d.Acute myocardial infarction e.Coronary artery disease

a.Chronic stable angina e.Coronary artery disease

The nurse has identified the priority problem of activity intolerance for a client who had an acute myocardial infarction. What is the best expected outcome for this client? a.Client will walk at least 200 feet four times daily without chest discomfort or shortness of breath. b.Client will name three or four activities that will not cause shortness of breath or chest pain. c.Nurse will teach the client to exercise and to take the pulse if symptoms of shortness of breath or pain occur. d.Nurse will assist the client with activities of daily living until shortness of breath or pain resolves.

a.Client will walk at least 200 feet four times daily without chest discomfort or shortness of breath

Which aspect of care is most important for a client with diabetic neuropathy? a.Teach the client to inspect the feet using a mirror. b.Teach the client to wash the feet, then pat dry. c.Have the client moisturize feet with lotion to prevent dryness. d.Teach the client to cut toenails straight across.

a.Teach the client to inspect the feet using a mirror.

The nurse is conducting a home visit in the late afternoon with a client who has type 2 diabetes. The client appears diaphoretic, anxious, confused, and irritable. Their pulse is 130 beats per minute. Which of the following actions should the nurse perform first? a. Adminster glucagon, 1 mg IV immmediately. b. Check the client's blood glucose and adminster oral glucose. c. Check the client's blood glucose and adminsiter regular insulin. d. Begin a 50% IV dextrose infusion at a rate of 400 ml/hour.

b. Check the client's blood glucose and adminster oral glucose.

Which of the following lab values suggests a male, age 45 years, with diagnosed hypertension is experiencing kidney injury/damage? a. Sodium 144 mEq/L b. Creatinine 2.0 mg/dL c. Potassium 4.8 mEq/L d. Blood urea nitrogen 18 mg/dL

b. Creatinine 2.0 mg/dL

A nurse is reviewing the laboratory results of a patient with suspected diabetes mellitus. Which of the following lab values would concern the nurse the most? a. Glycosylated hemoglobin (HgA1C) 6% b. Fasting Blood glucose 150 mg/dL c. Random blood glucose 150 mg/dL d. Oral Glucose Tolerance Test 150 mg/dL

b. Fasting Blood glucose 150 mg/dL

You are caring for a patient with type 1 diabetes. During assessment of the patient you obtain a finger-stick glucose reading. If his glucose reading is 400, what presenting symptoms would you expect? a. Hypertension and bradycardia b. Polyuria and polydipsia c. Diaphoresis and hunger d. Constipation and decreased urine output

b. Polyuria and polydipsia

Which of the following adverse effects of opioid medications would concern the nurse the most? a. The client develops a gastric ulcer. b. The client is confused to person, place, and time. c. The client experiences mild pruritus of the skin. d. The clieng develops impaired liver function due to high drug levels.

b. The client is confused to person, place, and time.

Which of the following symptoms is consistent with hyperglycemic hyperosmolar state? a. The client has a potassium level of 6.5 mEq/L and blood pH 7.30 b. The client's blood glucose is 660 mg/dL c. The client's respiratory rate is 38, characterized by deep breaths d. The client becomes very lethargic during a 1-hour time period

b. The client's blood glucose is 660 mg/dL

A client is admitted to the emergency department with suspected coronary artery disease. Which of the following pain presentations would suggest that the client is experiencing a myocardial infarction? a. The pain lasts less than 15 minutes. b. The pain occurs without a cause. c. The pain only occurs when the client is active. d. The pain is relieved by aspirin, 81 mg orally.

b. The pain occurs without a cause.

Which of the following drug classes contributes to blood pressure reduction by inhibiting sodium chloride and water reabsorption? a. Calcium Channel Blockers b. Thiazide diuretics c. Angiotensi-Converting Enzyme (ACE) inhibitors d. Angiotensin II Receptor (ARBs) Antagonists

b. Thiazide diuretics

Which of the following assessment findings would contribute to a diagnosis of metabolic syndrome for a male client (select 3)? a. High density lipoprotein cholesterol 60 mg/dL b. Triglycerides 175 mg/dL c. Fasting blood glucose 180 mg/dl d. Waist circumference 37 inches e. Blood pressure 160/95 mmHg

b. Triglycerides 175 mg/dL c. Fasting blood glucose 180 mg/dl e. Blood pressure 160/95 mmHg

A client presents to the emergency department with chest pain, diaphoresis, and anxiety. Which pain description would indicate to the nurse the client is progressing from chronic stable angina to unstable angina? a.Chest pain occurs with exertion. b.Chest pain is precipitated by rest. c.Chest pain lasts less than 15 minutes. d.Chest pain is completely relieved with nitroglycerine.

b.Chest pain is precipitated by rest.

Maria is a 47-year-old woman from Mexico. While attending a visit with her primary care provider, she tells the student nurse she feels tired, is very thirsty, and hungry. Which of the following lab values should the student nurse be most concerned about? a.HbA1c 6.0% b.Fasting plasma glucose 160 mg/dL c.Random plasma glucose 160 mg/dL d.Oral glucose tolerance test 160 mg/dL

b.Fasting plasma glucose 160 mg/dL

uA client recovering from surgery the previous day reports his pain is 9/10 and describes the pain as throbbing and localized to his incision. Which of the following interventions would be most appropriate for this client? a.Ibuprofen b.Morphine c.Gabapentin d.Massage

b.Morphine

Which assessment finding should indicate to a nurse that a client has progression (worsening) of intermittent claudication? a.Presence of pedal edema in the legs after sitting 20 minutes. b.The client walks a shorter distance before leg pain begins. c.Peripheral pulses in the affected leg change from 2+ to 3+. d.Skin temperature becomes warmer in the lower extremities.

b.The client walks a shorter distance before leg pain begins.

The client demonstrates a correct understanding of pain when they state which of the following? a. "I will notify the nurse when my pain reaches a severe level and not before." b. "Opioids are the only medication I need to take to control my pain." c. "The pain I feel from my surgical incision should normally decrease when the tissues heal." d. "I expect to have the same amount of pain as my spouse did when they had this procedure last year.

c. "The pain I feel from my surgical incision should normally decrease when the tissues heal."

The nurse suspects a client is has peripheral venous disease by observing which of the following? a. Dorsalis pedis pulses +1 bilaterally with cool skin temperature. b. Loss of hair in the lower calf c. A left calf that is swollen, tender to palpation, and painful. d. Cramping and muscle discomfort that occurs with activity and is relieved with rest.

c. A left calf that is swollen, tender to palpation, and painful

Which of the following assessment findings (objective or subjective) would concern the nurse the most for a client with diagnosed hypertension? a. Blood urea nitrogen (BUN) 18 mg/dL b. Client age c. Frequent headaches and dizziness d. Family history of hypertension

c. Frequent headaches and dizziness

Which of the following non-opioid therapies would benefit the client with numbness, tingling, and burning sensation in their hands and feet? a. Hydromorphone, 2 - 4 mg every 4 - 6 hours for pain. b. Ibuprofen, 200 mg, 3 times daily as needed for pain. c. Gabapentin, 300 mg three times daily for pain. d. Apply ice packs to the hands and feet as needed for pain.

c. Gabapentin, 300 mg three times daily for pain.

Adults who have established careers, become less mobile, and invest in their own families are experiencing which of the following? a. Ego integrity b. Success c. Generativity d. Intimacy

c. Generativity

Which of the following drugs increases myocardial tissue perfusion by prolonging diastole and decreasing myocardial contraction force? a. Verapamil 80mg tid (calcium channel blocker) b. Lisinopril 5 mg orally within 24 hours of symptom onset (angiotensin converting enzyme inhibitor) c. Metoprolol, 5 mg IV every 2 minutes (beta adrenergic blocker) d. Aspirin, 325 mg orally

c. Metoprolol, 5 mg IV every 2 minutes (beta adrenergic blocker)

Which of the following collaborative interventions most effectively treats acute pain for a client experiencing a myocardial infarction? a. Four, 81 mg aspirin, times one, orally b. Oxygen 2-4 L nasal cannula c. Morphine 2-10 mg intravenous every 1-2 hours as needed for pain d. Bed rest

c. Morphine 2-10 mg intravenous every 1-2 hours as needed for pain

Which of the following would be included in the teaching plan for a client with hypertension? a. Consuming a diet with 3,000 mg/d of sodium to prevent fluid retention b. Increasing intake of whole fat milk and white bread c. Participating in regular yoga or meditation activities d. Creating a long-term goal of 1, 15-minute low intensity session per week

c. Participating in regular yoga or meditation activities

Which of the following assessment findings related to pain and pain management would concern the nurse the most? a. The client displays a facial grimace during a painful procedure. b. The client has a family history of anxiety. c. The client's pain level has not decreased following scheduled opioid and non-opiod administration. d. The client is able to indicate the specific location of dull pain.

c. The client's pain level has not decreased following scheduled opioid and non-opiod administration.

Which of the following assessment findings would the nurse expect when caring for a client with a stable abdominal aortic aneurysm? a. Pain that increases and decreases with movement or position changes. b. Bilateral posterior tibial pulses +3. c. The presence of a burit upon auscultation of the abdomen near the umbilicus. d. Sudden, severe lower back pain and diaphoresis.

c. The presence of a burit upon auscultation of the abdomen near the umbilicus.

Which of the following assessment findings would the nurse expect when caring for a client with a stable abdominal aortic aneurysm? a. Sudden, severe lower back pain and diaphoresis. b. Bilateral posterior tibial pulses +3. c. The presence of a burit upon auscultation of the abdomen near the umbilicus. d. Pain that increases and decreases with movement or position changes.

c. The presence of a burit upon auscultation of the abdomen near the umbilicus.

Which of the following laboratory results would the nurse be most concerned about for a client with a suspected myocardial infarction? a. Creatine Kinase MB (CKMB) 3 units/L 24 hours after the client began experiencing chest pain. b. Myoglobin 0.9 mcg/L 2 hours after the client began experiencing chest pain. c. Troponin T 2.0 ng/L 4 hours after the client began experiencing chest pain. d. Sodium 140 mg/dL 4 hours after the client began experiencing chest pain.

c. Troponin T 2.0 ng/L 4 hours after the client began experiencing chest pain.

A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first? a.Initiate seizure precautions. b.Tell the client to report vision changes. c.Elevate the head of the client's bed. d.Start a peripheral IV.

c.Elevate the head of the client's bed.

Frank Costanza tells the nurse he is hungry and having double vision. The nurse notices he is sweaty, irritable, and is somewhat confused. Which of the following actions would be most appropriate? a.Give him some water to prevent additional dehydration. b.Check his temperature and pulse. c.Encourage him to drink 4-6 ounces of orange juice. d.Assess for fruity breath and protein in the urine.

c.Encourage him to drink 4-6 ounces of orange juice.

George Watson is attending a blood pressure screening at the local community center. The nurse notices that Mr. Watson has pitting edema in both legs. Which system that regulates blood pressure would primarily contribute to this assessment finding the most? a.Arterial baroreceptors b.Renin-angiotensin-aldosterone c.Fluid volume d.Vascular autoregulation

c.Fluid volume

The nurse is aware that many myths exist regarding pain. Which statements are true? (Select all that apply) a.The intensity of pain experienced by a client directly indicates the degree of tissue injury. b.Consistently administering low dose opioids analgesics to the client with nociceptive pain always leads to drug addiction. c.Pain is whatever the client describes it as, and whenever the client says it occurs. d.Psychogenic pain, such as phantom pain experienced after an amputation is not real. e.If the client is able to sleep, then the client is not experiencing pain. f.Chronic pain is a protective mechanism.

c.Pain is whatever the client describes it as, and whenever the client says it occurs.

A client is admitted for the repair of an abdominal aortic aneurysm later today. What assessment finding would the nurse immediately report to the physician? a.Weak peripheral pulses. b.Pulsating mass in the abdomen. c.Severe abdominal or low back pain. d.Pale extremities.

c.Severe abdominal or low back pain.

uA client in the intensive care unit is intubated and sedated following a motor vehicle accident that caused trauma and injury to several organ systems. The nurse would determine the best strategy to assess the client's pain by: a.Asking the client to self-report their pain because it is the most reliable measure. b.Asking family members to describe the client's usual pain tolerance. c.Utilizing a stepwise process for measuring the client's pain and conduct an analgesic trial to confirm the presence of pain. D: Visualizing the amount of drainage on the client's dressings as an indicator of tissue injury

c.Utilizing a stepwise process for measuring the client's pain and conduct an analgesic trial to confirm the presence of pain.

Antonio Rodrigues is a 42 year-old male. He has high blood pressure, diabetes, and high cholesterol. Which of the following would not be included as a criteria for metabolic syndrome? a.Taking an anti-cholesterol drug. b.High density lipoprotein of 35 mg/dL. c.Waist circumference of 35 inches. d.Fasting glucose of 126 mg/dL.

c.Waist circumference of 35 inches.

Which of the following manifestations are most likely present in adults with type 2 diabetes? a. Hyperactivity and irritability b. The presence of ketones in the urine c. Diaphoresis d. A foot ulcer that does not heal quickly

d. A foot ulcer that does not heal quickly

An 80 year old obese client has a history of hypertension, hyperlipidemia, and smoking. The client reports to the nurse that, "My legs hurt when I walk or climb stairs. The pain stops when I sit down." Which of the following interventions would be appropriate for this client? a. Apply very hot blankets or towels to the skin to promote vasodilation and blood flow. b. Apply compression stokings to reduce edema and improve blood return to the heart. c. Massage both legs to reduce muscle cramping. d. Encourage the client to increase their walking duration and pace with a goal of 30 minutes per day, five times per week.

d. Encourage the client to increase their walking duration and pace with a goal of 30 minutes per day, five times per week.

Which of the following drugs increases myocardial tissue perfusion by prolonging diastole and decreasing myocardial contraction force? a. Aspirin, 325 mg orally b. Lisinopril 5 mg orally within 24 hours of symptom onset (angiotensin converting enzyme inhibitor) c. Verapamil 80mg tid (calcium channel blocker) d. Metoprolol, 5 mg IV every 2 minutes (beta adrenergic blocker)

d. Metoprolol, 5 mg IV every 2 minutes (beta adrenergic blocker)

A client is admitted to the emergency department with suspected coronary artery disease. Which of the following pain presentations would suggest that the client is experiencing a myocardial infarction? a. The pain lasts less than 15 minutes. b. The pain is relieved by aspirin, 81 mg orally. c. The pain only occurs when the client is active. d. The pain occurs without a cause.

d. The pain occurs without a cause.

Which of the following drug classes contributes to blood pressure reduction by inhibiting sodium chloride and water reabsorption? a. Angiotensi-Converting Enzyme (ACE) inhibitors b. Angiotensin II Receptor (ARBs) Antagonists c. Calcium Channel Blockers d. Thiazide diuretics

d. Thiazide diuretics

Evidence based practice can be used in the care of young, middle, and older adults for all of the following except: a. Interventions b. Diagnosis c. Theories d. Traditions

d. Traditions

A client arrives at the emergency department via ambulance. Assessment of the client reveals flushed, dry skin; rapid, labored respirations; breath odor of acetone; confusion; and a finger stick glucose of 360 mg/dL. The nurse should immediately perform which of the following: a.Auscultate the client's lungs for fluid overload. b.Call for a STAT 12-lead ECG. c.Administer sodium bicarbonate. d.Begin an IV infusion of normal saline.

d.Begin an IV infusion of normal saline.

A client recovering from orthopedic surgery 6 months ago reports pain 8 out of 10 with no underlying cause (while resting). He describes the pain as tingling and burning, especially in his hands and feet. Which type of pain is this client most likely experiencing? a.Nociceptive, somatic pain b.Nociceptive, visceral pain c.Chronic cancer pain d.Chronic non-cancer pain

d.Chronic non-cancer pain

Which of the following assessment findings would concern the nurse the most for a client receiving patient controlled analgesia with fentanyl? a.Respiratory rate of 14. b.Diarrhea/frequent bowel movements. c.Loss of appetite. d.Difficulty arousing/sleepy.

d.Difficulty arousing/sleepy.

A female client is admitted to the emergency department with chest pain that occurs without cause, has lasted 45 minutes and radiates between their shoulders. The client is fatigued and nauseated. The client becomes profusely diaphoretic and apprehensive. What should be the initial intervention by the nurse? a.Increase the nasal oxygen from 2 liters/min to 6 liters/min. b.Check the troponin and myoglobin levels on the chart. c.Obtain a 12-lead ECG. d.Give the as needed dose of morphine sulfate 3 mg IV push.

d.Give the as needed dose of morphine sulfate 3 mg IV push.

Which of the following would be included in the teaching plan of an older adult recently diagnosed with Type 2 Diabetes? a.Consume a diet high in protein and calories to avoid increases in blood glucose. b.Begin a high intensity exercise program to reduce body weight and improve insulin sensitivity. c.The prescribed Insulin Asparte/Novolog has a 24-42 hour duration. d.The prescribed Sulfonylurea will help trigger insulin release from their pancreas.

d.The prescribed Sulfonylurea will help trigger insulin release from their pancreas.

A hospitalized client with a history of hypertension, smoking and oral contraceptive use is complaining of pain in her left inner thigh. The nurse observes that the left inner thigh is edematous and tender to the touch. Which of the following strategies should the nurse plan to implement? a.Place the leg in a dependent position to decrease swelling. b.Massage the area to improve circulation. c.Palpate bilateral dorsalis pedis pulses to verify adequate tissue perfusion. d.Verify IV patency for unfractionated heparin administration.

d.Verify IV patency for unfractionated heparin administration.