4th Level Exam 4 nclex style questions

A pt has a thrombus in their calf. What would you expect to see in the pt? (SATA) A. No pain B. Pallor C. Absent pulsation beyond embolus D. Polikilothermia

B, C, D

A potentially life-threatening condition in which air and pressure rapidly accumulate in the pleural space and, if not treated, can result in a mediastinal shift is called: A. An open pneumothorax B. A tension pneumothorax C. An iatrogenic pneumothorax D. A spontaneous pneumothorax

B.

Hodgkin lymphoma may be cured with chemotherapy with almost no incidence of secondary acute nonlymphocytic leukemia within 10 years. A. True B. False

False

"In formulating a nursing diagnosis of risk for infection for a client with chronic lymphoid leukemia (CLL), nursing measures should include: (Select all that apply.) "A. Maintaining a clean technique for all invasive procedures. B. Placing the client in protective isolation. C. Limiting visitors who have colds and infections. D. Ensuring meticulous handwashing by all persons coming in contact with the client."

"Correct Answers: B, C, D Rationale: Chronic lymphoid leukemia (CLL) is characterized by a proliferation and accumulation of small, abnormal mature lymphocytes in bone marrow, peripheral blood, and body tissues. Infections and fever are frequent complications of CLL."

Barry is being assessed for PVD. He complains of aching pain. His skin feels warm and there is edema present. He has a pedal pulse. His skin feels thick and dry. What would his s/s indicate? 1. Acute venous PVD 2. Chronic arterial PVD 3. Chronic venous PVD 4. Acute arterial PVD

3 - chronic venous PVD

Maria has PVD. If Maria has cool skin with no edema, what type of PVD does she have? A. Chronic arterial PVD B. Acute arterial PVD C. Chronis venous PVD D. Acute arterial PVD

A. Chronic arterial PVD

After a client is admitted to the pediatric unit with a diagnosis of acute lymphocytic leukemia, the laboratory test indicates that the client is neutropenic. The nurse should perform which of the following?" A. advise the client to rest and avoid exertion B. prevent client exposure to infections C. monitor the blood pressure frequently D. observe for increased bruising

Answer: B Rationale: Neutropenia is a decreased number of neutrophil cells in the blood which are responsible for the body's defense against infection. Rest and avoid exertion would be related to erythrocytes and oxygen carrying properties. Monitoring the blood pressure, and observing for bruising would be related to platelets and sign and symptoms of bleeding

In self-contained, disposable chest drains, the manual high negative pressure relief valve A. Allows water to be added to the system without disconnecting the patient tubing B. Alerts the nurse to a situation of high pressure within the system and automatically vents C. Allows filtered atmospheric air into the system to offset a rise in negative pressure D. Alerts the nurse to high suction levels accumulating in the system

C.

A client had undergone radiation therapy (external). The expected side effects include the following apart from: A Hair loss B Ulceration of oral mucous membranes C Constipation D Headache

C. Diarrhea not constipation is the side effect of radiation therapy.

Which of the following causes of fluid volume loss is considered to be Absolute Hypovolemia? A. Ascites B. Burns C. GI Bleed D. Bowel obstruction

C. GI bleed

What is the primary cause of septic shock? A. Bleeding B. Medication Allergy C. Infection D. Poison

C. Infection *Also caused by dilation of small blood vessels and pooling of blood in the small capillaries

Which assessment finding indicates that an infusion of intravenous epinephrine 4 mcg/min is effective in the treatment of a patient with anaphylactic shock? 1. Reduced wheezing 2. Heart rate 55 and regular 3. Blood pressure 98/50 mm Hg 4. Respiratory rate 28

Correct Answer: 1 Rationale 1: An expected action for epinephrine is bronchodilation as evidenced by less wheezing. Rationale 2: Epinephrine increases heart rate. Rationale 3: Epinephrine increases blood pressure. Rationale 4: Epinephrine lowers the respiratory rate. This respiratory rate indicates that epinephrine has not been effective.

Examples of venous insufficiency would be: A. DVT B. Thrombophlebitis C. Varicose veins D. All the above E. None of the above

D. All of the above

A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and chemotherapy is planned to begin immediately. The mother of the child asks the nurse why radiation therapy was not prescribed as a part of the treatment. Which of the following is the appropriate and supportive response to the mother? 1. I'm not sure. I'll discuss it with the physician. 2. The child is too young to have radiation therapy. 3. It's very costly, and chemotherapy works just as well. 4. The physician would prefer that you discuss the treatment options with the oncologist

ANSWER: 2 Rationale: Radiation therapy is usually delayed until a child is 8 years of age, if posssible, to prevent retardation of bone growth and soft tissue development. Options 1,3, and 4 are inappropriate responses to the mother

Which statement is correct about the rate of cell growth in relation to chemotherapy? 1. Faster growing cells are less susceptible to chemotherapy. 2. Nondividing cells are more susceptible to chemotherapy. 3. Faster growing cells are more susceptible to chemotherapy. 4. Slower growing cells are more susceptible to chemotherapy

Answer 3 The faster the cell grows, the more susceptible it is to chemotherapy and radiation therapy. Slow-growing and nondividing cells are less susceptible to chemotherapy. Repeated cycles of chemotherapy are used to destroy nondividing cells as the begin active cell division

The nurse is aware that the following symptoms is most commonly an early indication of stage 1 Hodgkin's disease? A. Persistent hypothermia B. Night sweat C. Pericarditis D. Splenomegaly

B. In stage 1, symptoms include a single enlarged lymph node (usually), unexplained fever, night sweats, malaise, and generalized pruritis. Although splenomegaly may be present in some clients, night sweats are generally more prevalent. Pericarditis isn't associated with Hodgkin's disease, nor is hypothermia. Moreover, splenomegaly and pericarditis aren't symptoms. Persistent hypothermia is associated with Hodgkin's but isn't an early sign of the disease.

Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia? A. Oral mucous membrane, altered related to chemotherapy B. Risk for injury related to thrombocytopenia C. Fatigue related to the disease process D. Interrupted family processes related to life-threatening illness of a family member

B. The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses : Oral mucous membrane, altered related to chemotherapy ,Fatigue related to the disease process and Interrupted family processes related to life-threatening illness of a family member .

Arterial insufficiency is well treated by Heparin and Coumadin? A. True B. False

B. False

A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client? a. Clamp the chest tubes when suctioning. b. Palpate the surrounding area for crepitus. c. Change the dressing daily using aseptic technique. d. Empty the drainage chamber at the end of the shift.

B. palpate for crepitus (subcutaneous emphysema)

PVD can be most modified by: A. Taking medication B. Losing weight C. Quitting smoking D. Monitoring BP

C - quitting smoking

A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: sinus tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret this assessment about the patient's aneurysm? a Tamponade will soon occur. b The renal arteries are involved. c Perfusion to the legs is impaired. d He is bleeding into the abdomen.

Correct Answer: D Rationale: The lack of back pain indicates the patient is most likely exsanguinating into the abdominal space, and the bleeding is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement, but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There is no assessment data indicating decreased perfusion to the legs.

A client has a chest tube for a pneumothorax. The nurse finds the client in respiratory difficulty, with the chest tube separated from the drainage system. What should the nurse do? a. Obtain a new sterile drainage system. b. Use two clamps to close the drainage tube. c. Place the client in the high-Fowler position. d. Reconnect the client's tube to the drainage system.

D.

A significant cause of venous thrombosis is: A-Altered blood coagulation B-Stasis of blood C-Vessel wall injury D-All of the above

D. **associated with stasis, injury, and hyper coagulability

Nifedipine has which of the following side effects? A. Facial flushing B. Reflex tachycardia C. Sweating D. None of the above E. All of the above

E - all of the above side effects in CCB nifedipine

A client with iron deficiency anemia is having trouble selecting food items from the hospital menu. Which food is best for the nurse to suggest for satisfying the client's nutritional needs and personal preferences? A. Egg yolks B. Brown rice C. Vegetables D. Tea

Question 16 Explanation: B Brown rice is a source of iron from plant sources (nonheme iron). Other sources of non heme iron are whole-grain cereals and breads, dark green vegetables, legumes, nuts, dried fruits (apricots, raisins, dates), oatmeal, and sweet potatoes. Egg yolks have iron but it is not as well absorbed as iron from other sources. Vegetables are a good source of vitamins that may facilitate iron absorption.**Sources of iron - red meat, poultry, pork, seafood, fortified cereals, wheats, and pastas, peas, green leafy veggies (spinach) dried fruit (raisins)

Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate? A Do nothing, because this is an expected finding B Immediately clamp the chest tube and notify the physician C Check for an air leak because the bubbling should be intermittent D Increase the suction pressure so that the bubbling becomes vigorous

Question 17 Explanation: A Continuous gentle bubbling should be noted in the suction control chamber. Option b is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option c is incorrect. Bubbling should be continuous and not intermittent. Option d is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.

Which statements by the mother of a toddler would lead the nurse to suspect that the child has iron-deficiency anemia? Select all that apply. A "He drinks over 3 cups of milk per day." B "I can't keep enough apple juice in the house; he must drink over 10 ounces per day." C "He refuses to eat more than 2 different kinds of vegetables." D "He doesn't like meat, but he will eat small amounts of it." E "He sleeps 12 hours every night and take a 2-hour nap."

Question 32 Explanation: A & B Toddlers should have between 2 and 3 cups of milk per day and 8 ounces of juice per day. If they have more than that, then they are probably not eating enough other foods, including iron-rich foods that have the needed nutrients.

The nurse is caring for a 78-year-old client with active alcoholism who has a vitamin B12 deficiency. The nurse plans to teach the client to select which of the following food choices? (Select all that apply) 1.Apples 2.Carrots 3.Liver 4.Oranges 5.Spinach

answers: 3, 4, 5 Oranges, Spinach, Liver Rationale: Clients with vitamin B12 deficiency would be encouraged to eat spinach, oranges, and liver as good sources of the vitamin. Apples and carrots are not good sources for vitamin B12.

Which of the following findings yields a poor prognosis for a pediatric patient with leukemia? 1) Presence of a mediastinal mass 2) Late CNS leukemia 3) Normal WBC count at diagnosis 4) Disease presents between age 2 and 10

1) Presence of a mediastinal mass indicates a poor prognosis. The rest of the choices refer to diagnosis not prognosis.

Essential hypertension would be diagnosed in a 40-year-old male whose blood pressure readings were consistently at or above which of the following? 1. 120/ 90 mm Hg. 2. 130/ 85 mm Hg. 3. 140/ 90 mm Hg. 4. 160/ 80 mm Hg.

3. American Heart Association standards define hypertension as a consistent systolic blood pressure level greater than 140 mm Hg and a consistent diastolic blood pressure level greater than 90 mm Hg.

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? 1. Impaired gas exchange related to increased blood flow 2. Excess fluid volume related to peripheral vascular disease 3. Risk for injury related to edema 4. Ineffective peripheral tissue perfusion related to venous congestion

4. Ineffective peripheral tissue perfusion related to venous congestion- rationale: ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with dvt. impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. excess fluid volume related to peripheral vascular disease is inappropriate because theres no evidence that this client has an excess fluid volume. risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion

A nurse is assessing a client newly diagnosed with Stage I Hodgkin's lymphoma. Which area of the body would the nurse most likely find involved? 1. Back 2. Chest 3. Groin 4. Neck

4. Neck is correct At the time of diagnosis of stage I Hodgkin's lymphoma, a painless cervical lesion is often present. The back, chest, and groin areas may be involved in later stages

The nurse is preparing Cyclophosphamide (Cytoxan). Safe handling of the drug should be implemented to protect the nurse from injury. Which of the following action by the nurse should be corrected? A The nurse should wear mask and gloves. B Air bubbles should be expelled on wet cotton. C Label the hanging IV bottle with "ANTINEOPLASTIC CHEMOTHERAPY" sign. D Vent vials after mixing

A. The nurse should be corrected if she is only wearing mask and glove because gowns should also be worn in handling chemotherapeutic drugs. The vials should be vent after mixing to reduce the internal pressure. Air bubbles are expelled on wet cotton to prevent the spread of the chemotherapeutic agent particles.

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

ANS: C The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril.

The most common signs and symptoms of leukemia related to bone marrow involvement are which of the following? A. Petechiae, fever, fatigue B. Headache, papilledema, irritability C. Muscle wasting, weight loss, fatigue D. Decreased intracranial pressure, psychosis, confusion

Answer A is Correct. Signs of infiltration of the bone marrow are petechiae from lowered platelet count, fever related to infection from the depressed number of effective leukocytes, and fatigue from the anemia

The mother of a child diagnosed with a potentially life-threatening form of cancer says to the nurse, ""I don't understand how this could happen to us. We have been so careful to make sure our child is healthy."" Which response by the nurse is most appropriate? "A. Why do you say that? Do you think that you could have prevented this?"" B. ""This must be a difficult time for you and your family. Would you like to talk about how you are feeling?"" C. ""You shouldn't feel that you could have prevented the cancer. It is not your fault."" D.""Many children are diagnosed with cancer. It is not always life-threatening

Answer B Parents of children diagnosed with cancer require major emotional support, and should be allowed to express their feelings. Prevention and blaming oneself is not supportive, nor is telling the parents that there are many other children with cancer

During history taking of a client admitted with newly diagnosed Hodgkin's disease, which of the following would the nurse expect the client to report? a) weight gain B) night sweats C) Severe lymph node pain D) Headache with minor visual changes

B - Assessment of a client with Hodgkin's disease most often reveals enlarged, painless lymph nodes, fever, malaise, and night sweats. Weight loss may be present if metastatic disease occurs. Headache and visual changes may occur if brain metastasis is present

Matt has PVD. The nurse shows an understanding of PVD when the nurse states: A. In PVD, skin temperature is not important. B. Do not elevate lower limb positioning for arterial PVD C. No hair on lower legs with venous PVD D. Elevate lower limb positioning for venous PVD

B and D **no elevation with arterial, can elevate with venous, but not above level of the heart. **no hair on legs for arterial PVD

The following are teaching guidelines regarding radiation therapy except: A. The therapy is painless B. To promote safety, the client is assisted by therapy personnel while the machine is in operation. C The client may communicate all his concerns or needs or discomforts while the machine is operating. D Safety precautions are necessary only during the time of actual irradiation.

B. To promote safety to the personnel, the client will remain alone in the treatment room while the machine is in operation. The client may voice out any concern throughout the treatment because a technologist is just outside the room observing through a window or closed circuit TV. There is no residual radioactivity after radiation therapy. Safety precautions are necessary only during the time of actual irradiation. The client may resume normal activities of daily living afterwards.

PVD often affects the blood flow usually where? A. Arms B. Legs C. Heart D. Kidney

B. legs **venous ulcers will appear on legs, arterial ulcers on toes

In a self-contained, disposable chest drain, the amount of negative pressure transmitted to the patient by suction is determined by: A. The amount of suction set on the wall vacuum regulator B. The sensitivity of the high negative pressure relief valve C. The dial setting on the suction control chamber D. The level of water in the water seal chamber

C.

Nurse Janet is assigned in the oncology section of the hospital. Which of the following orders should the nurse question if a client is on radiation therapy? A Analgesics before meals B Saline rinses every 2 hours C Aspirin every 4 hours D Bland diet

C. Radiation therapy makes the platelet count decrease. Thus, nursing responsibilities should be directed at promoting safety by avoiding episodes of hemorrhage or bleeding such as physical trauma and aspirin administration. Analgesics are given before meals to alleviate the pain caused by stomatitis. Bland diet and saline rinses every 2 hours should also be done to manage stomatitis.

Which laboratory level is a common finding associated with peripheral vascular disease (PVD)? a. Low serum albumin b. Potassium level of 3.1 c. High serum lipids d. Total calcium level of 15 mg/dL

C. High serum lipids, especially the low-density (LDL) and very-low density (VLDL) types, are associated with peripheral vascular disease (PVD). Other listed laboratory findings have not been associated with PVD.

A client has undergone a lymph node biopsy. the nurse anticipates that the report will reveal which result if the client has Hodgkin's lymphoma? 1. Reed-Sternberg cells. 2. Philadelphia chromosome. 3. Epstein-Barr virus. 4. Herpes simplex virus

CORRECT #1. RATIONALE: histological isolation of Reed-Sternberg cells in lymph node biopsy examination is a diagnostic feature of Hodgkin's lymphoma. Philadelphia chromosome is attribted to chronic myelogenous leukemia. viruses are much smaller than can be visualized with cytology.

The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy . The nurse notes that the platelet count is 20,000/ul. Based on the laboratry result, which intervention will the nurse document in the plan of care? 1 Mointor closely for signs of infection 2. Mointor the temperature every 4hours 3. Initate prptective isolation precautions 4. Use soft small toothbrush for mouth care

Correct Ans 4 If a child is severely thrombocytopenic and has a platelet count less than 20,000/ul, bleeding precautions need to be initated because of increased risk of bleeding or hemorrhage. Options 1,2,3 are related to the prevention of infection rather than bleeding

The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to correctly administer this medication? a. Spread the skin before inserting the needle. b. Leave the air bubble in the prefilled syringe. c. Use the back of the arm as the preferred site. d. Sit the patient at a 30-degree angle before administration.

Correct Answer: B Rationale: The nurse should not expel the air bubble from the prefilled syringe because it should be injected to clear the needle of medication and avoid leaving medication in the needle track in the tissue.

A patient with varicose veins has been prescribed compression stockings. How should the nurse teach the patient to use these? a. "Try to keep your stockings on 24 hours a day, as much as possible." b. "While you're still lying in bed in the morning, put on your stockings." c. "Dangle your feet at your bedside for 5 minutes before putting on your stockings." d. "Your stockings will be most effective if you can remove them for a few minutes several times a day."

Correct Answer: B Rationale: The patient with varicose veins should apply stockings in bed, before rising in the morning. Stockings should not be worn continuously, but they should not be removed several times daily. Dangling at the bedside prior to application is likely to decrease their effectiveness.

What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? a. Application of topical antibiotics to venous ulcers b. Maintaining the patient's legs in a dependent position c. Administration of oral and/or subcutaneous anticoagulants d. Teaching the patient the correct use of compression stockings

Correct Answer: D CVI requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent position. **Put on in the morning before getting out of bed

A client diagnosed with leukemia is being admitted for an induction course of chemotherapy. Which laboratory values indicate a diagnosis of leukemia? 1. A left shift in the white blood cell count differential. 2. A large number of WBCs that decrease after the administration of antibiotics. 3. An abnormally low hemoglobin (Hb) and hematocrit (Hct) level. 4. Red blood cells that are larger than normal

Correct answer is 1. 1. A left shift indicates immature white blood cells are being produced and released into the circulating blood volume. This should be investigated for the malignant process of leukemia

Which of the following manifestations would be directly associated with Hodgkin's disease? "a. bone pain b. generalized edema c. petechiae and purpura d. painless, enlarged lymph nodes"

Correct answer: D Rationale: Hodgkin's disease usually presents as painless enlarged lymph nodes. The diagnosis is made by lymph node biopsy."

The nurse and the unlicensed assistive personnel (UAP) are caring for clients in a bone marrow transplantation unit. Which nursing task should the nurse delegate? A. Take the hourly vital signs on a client receiving blood transfusions. B. Monitor the infusion of antineoplastic medications. C. Transcribe the HCP's orders onto the Medication Administration Record. D. Determine the client's reponse to the therapy

Correct: A. Explanation: A. After the first 15 minutes during which the client tolerates the blood transfusion, it is appropriate to ask the UAP to take the vital signs as long as the UAP has been given specific parameters for the vital signs. Any vital sign outside the normal parameters must have an intervention by the nurse. B. Antineoplastic medication infusions must be monitored by a chemotherapy-certified, competent nurse. C. This is the responsibility of the word secretary or the nurse, not the unlicensed personnel. D. This represents the evaluation portion of the nursing process and cannot be delegated

A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use? A. Body temperature of 99°F or less B. Toes moved in active range of motion C. Sensation reported when soles of feet are touched D. Capillary refill of < 3 seconds

D. It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, body temperature of 99°F or less , toes moved in active range of motion, and sensation reported when soles of feet are touched are incorrect.

Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend? Discuss A. A family vacation in the Rocky Mountains B. Chaperoning the local boys club on a snow-skiing trip C. Traveling by airplane for business trips D. A bus trip to the Museum of Natural History

D. Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided.

The nurse is teaching a group of parents whose children have sickle cell anemia. When a parent asks the cause of the symptoms, the nurse responds with which of the following? 1."Sickled cells clump in the smaller blood vessels and obstruct blood flow." 2."Sickled cells cause bone marrow depression." 3."The sickled cells mix with normal cells, which causes the immune system to be depressed." 4."Sickled cells increase the blood flow through the body, which causes pain."

Your Answer: "Sickled cells clump in the smaller blood vessels and obstruct blood flow." Rationale: All the symptoms of sickle cell are a result of the clumping of the sickled cells in the microvasculature, causing obstruction of blood flow. The other statements are inaccurate.

A client with iron deficiency anemia has been placed on an iron supplement. Which of the following would the nurse include in the teaching plan about this form of therapy? 1.Iron may cause the stools to be tarry. 2.Iron should be taken in the afternoon. 3.Iron can cause severe headaches. 4.Iron can cause the urine to be orange.

Your Answer: A. Iron may cause the stools to be tarry. Rationale: The client is taught that stools may be black and tarry while taking iron. Orange urine and headaches are not associated with taking iron. Iron should be taken with food to reduce gastric distress.

A nurse is planning care for a client who has a Hgb of 7.5 and a Hct of 21.5. Which of the following should the nurse include in the plan of care? select all that apply a. provide assistance with ambulation b. monitor oxygen saturation c. weigh client weekly d. obtain stool specimen for occult blood e. schedule daily rest periods

a,b,d,e rationale: a client with anemia may be dizzy and should be assisted to prevent falls, o2 should be monitored due to decreased o2 carrying capacity in the blood, they should be weight dialy, stool testing is performed to id cause of anemia due to gi bleeding, a client may experience fatigue so rest period should be planned to conserve energy

A nurse is providing discharge teaching to a chilent who has a gastrectomy for stomach cancer. Which of the following information should be included in the teaching? select all that apply a. you will need a monthly injection of vitamin b12 for the rest of your life b. using nasal spray of vitamin b12 may be an option daily c. an oral supplement of vitamin b12 may be taken as an option daily d. u should increase animal proteins, legumes, dairy to increase vitamin b12 e. add soy milk with vitamin b12 to your diet to decrase risk of pernisious anemia

answer a and b a client with gastrectomy will require monthly injections of vitamin b12 for the rest of his life, cyanocoblamin nasal spray is an option for a client with gastrectomy. the rest will not be absorbed due to lack of intrinisctfactor produced by stomach

A home care nurse is instructing the parents of a child with iron deciciency anemia regarding the administration of a liquid oral iron supplement. The nurse tells the mother to 1. administer the iron through a straw 2. administer iron at meal times 3. add the iron to the formula for easy administration 4. mix the iron with cereal to administer

answer: 1 Iron should be administered through the straw or with a medicine dropper placed at the back of the mouth because the iron will stain the teeth. the parent should be instructed to brush or wipe the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in duodenum. Iron is not added to formula or mixed with cereal or other food items.

A nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would inspect the surgical site most closely for signs of: a. Thrombosis and infection b. Bleeding and infection c. Bleeding and wound dehiscence. d. Wound dehiscence and evisceration.

b. After inferior vena cava insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Otherwise, care is the same as for any post-op client

A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to the aneurysm? a. Pulsatile abdominal mass b. Hyperactive bowel sounds in that area c. Systolic bruit over the area of the mass d. Subjective sensation of "heart beating" in the abdomen.

b. Not all clients with abdominal aortic aneurysms exhibit symptoms. Those who do describe a feeling of the "heart beating" in the abdomen when supine or be able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm.

Which are probable clinical findings in a person with an acute lower extremity VTE (select all that apply)? a.Pallor and coolness of foot and calf b.Mild to moderate calf pain and tenderness c.Grossly diminished or absent pedal pulses d.Unilateral edema and induration of the thigh e.Palpable cord along a superficial varicose vein

b.Mild to moderate calf pain and tenderness d.Unilateral edema and induration of the thigh The patient with lower extremity venous thromboembolism (VTE) may or may not have unilateral leg edema, extremity pain, a sense of fullness in the thigh or calf, paresthesias, warm skin, erythema, or a systemic temperature greater than 100.4 F (38 C). If the calf is involved, it may be tender to palpation. **common symptoms include calf or groin pain or tenderness with unilateral swelling on affected side

A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that his aneurysm has ruptured? a.Sudden shortness of breath and hemoptysis b.Sudden, severe low back pain and bruising along his flank c.Gradually increasing substernal chest pain and diaphoresis d.Sudden, patchy blue mottling on feet and toes and rest pain

b.Sudden, severe low back pain and bruising along his flank The clinical manifestations of a ruptured abdominal aortic aneurysm include severe back pain, back or flank ecchymosis (Grey Turner's sign), and hypovolemic shock (tachycardia, hypotension, pale clammy skin, decreased urine output, altered level of consciousness, and abdominal tenderness).

The nurse diagnoses an overweight client taking wafarin (Coumadin) with Ineffective tissue perfusion related to decreased arterial blood flow. Which teaching point would not be appropriate to include in the plan of care for this client? a. Inspecting skin daily b. Encouraging a reduced-calorie, reduced-fat diet c. limiting ADLs d. using an electric razor

c. limiting activities of daily living

A 50-year-old woman weighs 95 kg and has a history of tobacco use, high blood pressure, high sodium intake, and sedentary lifestyle. When developing an individualized care plan for her, the nurse determines that the most important risk factors for peripheral artery disease (PAD) that need to be modified are a.weight and diet. b.activity level and diet. c.tobacco use and high blood pressure. d.sedentary lifestyle and high blood pressure.

c. tobacco use and high blood pressure Significant risk factors for peripheral artery disease include tobacco use, hyperlipidemia, elevated levels of high-sensitivity C-reactive protein, diabetes mellitus, and uncontrolled hypertension; the most important is tobacco use. Other risk factors include family history, hypertriglyceridemia, hyperuricemia, increasing age, obesity, sedentary lifestyle, and stress.

Which of the following signs and symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm? A. Abdominal pain. B. Absent pedal pulses. C. Chest pain. D. Lower back pain.

d. lower back pain Lower back pain results from expansion of the aneurysm. The expansion applies pressure in the abdomen, and the pain is referred to the lower back. Abdominal pain is the most common symptom resulting from impaired circulation. Absent pedal pulses are a sign of no circulation and would occur after a ruptured aneurysm or in peripheral vascular disease. Chest pain usually is associated with coronary artery or pulmonary disease.

A client is taking clonidine (Catapres) for treatment of hypertension. The nurse should teach the client about which of the following common adverse effects of this drug? Select all that apply. 1. Dry mouth. 2. Hyperkalemia. 3. Impotence. 4. Pancreatitis. 5. Sleep disturbance.

1, 3, 5. Clonidine (Catapres) is a central-acting adrenergic antagonist. It reduces sympathetic outflow from the central nervous system. Dry mouth, impotence, and sleep disturbances are possible adverse effects. Hyperkalemia and pancreatitis are not anticipated with use of this drug.

A client treated for hypertension with furosemide (Lasix), atenolol (Tenormin), and ramipril (Altace) develops a second degree heart block Mobitz type 1. Which of the following actions should the nurse take? 1. Administer a 250 mL fluid bolus. 2. Withhold the atenolol. 3. Prepare for cardioversion. 4. Set up for an arterial line.

2. The client may be asymptomatic and the underlying cause should be assessed. Drugs that block the AV node should be avoided, such as beta blockers (Atenolol), calcium channel blockers, digoxin, and amiodarone. Symptomatic clients are treated with atropine and transcutaneous pacing. There is no indication for a fluid bolus, cardioversion, or arterial line.

The client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan? 1. Review the negative effects of smoking on the body. 2. Discuss the effects of passive smoking on environmental pollution. 3. Establish the client's daily smoking pattern. 4. Explain how smoking worsens high blood pressure.

3. A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.

The most important long-term goal for a client with hypertension would be to: 1. Learn how to avoid stress. 2. Explore a job change or early retirement. 3. Make a commitment to long-term therapy. 4. Lose weight.

3. Compliance is the most critical element of hypertension therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without drug therapy. Stress management is an important component of hypertension therapy, but the priority goal is related to compliance. It is not necessary for the client to change jobs or retire, but rather to learn to manage stress if the job is stressful. Losing weight may be necessary and will contribute to lower blood pressure, but the client must first accept the need for a lifelong management plan to control the hypertension.

The nurse teaches a client, who has recently been diagnosed with hypertension, about dietary restrictions: a low-calorie, low-fat, low-sodium diet. Which of the following menu selections would best meet the client's needs? 1. Mixed green salad with blue cheese dressing, crackers, and cold cuts. 2. Ham sandwich on rye bread and an orange. 3. Baked chicken, an apple, and a slice of white bread. 4. Hot dogs, baked beans, and celery and carrot sticks.

3. Processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high in both fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet. Dietary restrictions of all types are complex and difficult to implement with clients who are basically asymptomatic.

An exercise program is prescribed for the client with hypertension. Which intervention would be most likely to assist the client in maintaining an exercise program? 1. Giving the client a written exercise program. 2. Explaining the exercise program to the client's spouse. 3. Reassuring the client that he or she can do the exercise program. 4. Tailoring a program to the client's needs and abilities

4. Tailoring or individualizing a program to the client's lifestyle has been shown to be an effective strategy for changing health behaviors. Providing a written program, explaining the program to the client's spouse, and reassuring the client that he or she can do the program may be helpful but are not as likely to promote adherence as individualizing the program.

Which of the following could be a sign of septic shock upon assessment? SATA .A. Hyperthermia (fever) or hypothermia B. Confusion C. Tachycardia D. Poor Skin Turgor

A, B, C *Change in affect/behavior is usually fist sign that something is going on (sepsis - early stage) Other signs: Hyperthermia (over 101) or hypothermia (below 96.80; Tachycardia, and Tachypnea (over 20) - loss of oxygenation can cause confusion. Organs are starting to shut down in septic shock.

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 that apply.) A. Has maintained a low-sodium, no-added-salt diet B. Has lost 3 pounds 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, B, E Clients with hypertension should consume low-sodium foods and should avoid adding salt. Weight loss can result in lower blood pressure. Caffeine promotes vasoconstriction, thereby elevating blood pressure.

A patient presenting to the ER with a hypertensive crisis (BP greater than 180/120), may have damage to which of the following? A. Brain B. Kidney C. Liver D. Heart E. Stomach F. Eyes

A, B. D. F CVA retinopathy heart failure renal failure IV beta blocker will be ordered immediately for a pt in a hypertensive crisis

The patient understand that which of the following are factors that he can change to decrease his risk of HTN? Select All That Apply A. smoking B. family history C. Alcohol consumption D. increased LDL E. Sedentary lifestyle

A, C. D, E Pt can change all but his family history

A patient is diagnosed with hypertension and nadolol (Corgard) is prescribed. The nurse should consult with the health care provider before giving this medication upon finding a history of a. asthma. b. peptic ulcer disease. c. alcohol dependency. d. myocardial infarction (MI).

ANS: A Nonselective β-blockers block β1- and β2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. β-blockers will have no effect on the patient's peptic ulcer disease or alcohol dependency. β-blocker therapy is recommended after MI.

A 52-year-old patient who has no previous history of hypertension or other health problems suddenly develops a BP of 188/106 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that a. a BP recheck should be scheduled in a few weeks. b. the dietary sodium and fat content should be decreased. c. there is an immediate danger of a stroke and hospitalization will be required. d. more diagnostic testing may be needed to determine the cause of the hypertension.

ANS: D A sudden increase in BP in a patient over age 50 with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need rapid treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP, and reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.

A patient presents with prehypertension to the outpatient office with a BP of 138/88. They are obese, work from home and have minimal activity, consume a large amount of soda and processed foods. What will the physician recommend? A) 20 mg lisinporil PO daily, first dose now B) Dietary and exercise changes C) Send to the emergency department to treat this hypertensive crisis/emergency D) Nothing

B) Dietary and exercise changes

Nursing assessment of a client receiving serum albumin for treatment of shock should include: a.) Assessing lung sounds. b.) Monitoring glucose. c.) Monitoring the potassium level. d.) Monitoring hemoglobin and hematocrit.

a.) Assessing lung sounds. Rationale: Colloids pull fluid into vascular space. Circulatory overload could occur. The nurse should assess the client for symptoms of heart failure.

An industrial health nurse at a large printing plant finds a male employee's blood pressure to be elevated on two occasions 1 month apart and refers him to his private physician. The employee is about 25 lb overweight and has smoked a pack of cigarettes daily for more than 20 years. The client's physician prescribes atenolol (Tenormin) for the hypertension. The nurse should instruct the client to: 1. Avoid sudden discontinuation of the drug. 2. Monitor the blood pressure annually. 3. Follow a 2-g sodium diet. 4. Discontinue the medication if severe headaches develop.

1. Atenolol is a beta-adrenergic antagonist indicated for management of hypertension. Sudden discontinuation of this drug is dangerous because it may exacerbate symptoms. The medication should not be discontinued without a physician's order. Blood pressure needs to be monitored more frequently than annually in a client who is newly diagnosed and treated for hypertension. Clients are not usually placed on a 2-g sodium diet for hypertension.

The client has had hypertension for 20 years. The nurse should assess the client for? 1. Renal insufficiency and failure. 2. Valvular heart disease. 3. Endocarditis. 4. Peptic ulcer disease.

1. Renal disease, including renal insufficiency and failure, is a complication of hypertension. Effective treatment of hypertension assists in preventing this complication. Valvular heart disease, endocarditis, and peptic ulcer disease are not complications of hypertension.

What type of sensitivity reaction is anaphalactic shock? A. Type I, Immediate Hypersensitivity Disorder B. Type II, Antibody-mediated Disorder C. Type III, Immune Complex-Mediated Disorder D. Type IV, Cell Mediated Hypersensitivity Disorder

A. Type I, Immediate Hypersensitive Disorder *Most common are insect stings, foods, and medicines.

Which assessment finding for a patient who is receiving furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider? a. Blood glucose level of 180 mg/dL b. Blood potassium level of 3.0 mEq/L c. Early morning BP reading of 164/96 mm Hg d. Orthostatic systolic BP decrease of 12 mm Hg

ANS: B Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider should be notified of the potassium level immediately and administration of potassium supplements initiated. The elevated blood glucose and BP also indicate a need for collaborative interventions but will not require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg is common and will require intervention only if the patient is symptomatic.

Which information should the nurse include when teaching a patient with newly diagnosed hypertension? a. Dietary sodium restriction will control BP for most patients. b. Most patients are able to control BP through lifestyle changes. c. Hypertension is usually asymptomatic until significant organ damage occurs. d. Annual BP checks are needed to monitor treatment effectiveness.

ANS: C Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes and sodium restriction are used to help manage blood pressure, but drugs are needed for most patients. BP should be checked by the health care provider every 3 to 6 months.

The RN is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside (Nipride). Which of the following nursing actions can the nurse delegate to an experienced LPN/LVN? a. Titrate nitroprusside to maintain BP at 160/100 mm Hg. b. Evaluate effectiveness of nitroprusside therapy on BP. c. Set up the automatic blood pressure machine to take BP every 15 minutes. d. Assess the patient's environment for adverse stimuli that might increase BP.

ANS: C LPN/LVN education and scope of practice include correct use of common equipment such as automatic blood pressure machines. The other actions require more nursing judgment and education and should be done by RNs.

Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient? a. Obtain a BP reading in each arm and average the results. b. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. c. Have the patient sit in a chair with the feet flat on the floor. d. Assist the patient to the supine position for BP measurements.

ANS: C The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, but the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.

What is the treatment of choice to correct Hypovolemic Shock? A. Have the patient drink a large bottle of Gatorade. B. Replace fluids intravenously as quickly as possible. C. Administer a vasopressor (ex: Dopamine or Norepinephrine) D. All of the above

B. replace fluids intravenously as quickly as possible **Have two nurses starting 2 large bore IVs (16/18g). Will administer LR and NS, possible crystalloid too (albumin). *Oxygen first while getting stuff together for IVs. If its hemorrhagic shock - would replace with blood/blood products

A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in instructions? A Walk barefoot whenever possible. B Use a heating pad to keep feet warm. C Avoid crossing the legs. D Use antibacterial ointment to treat skin lesions at risk of infection

C. Patients with peripheral vascular disease should avoid crossing the legs because this can impede blood flow. Walking barefoot is not advised, as foot protection is important to avoid trauma that may lead to serious infection. Heating pads can cause injury, which can also increase the risk of infection. Skin lesions at risk for infection should be examined and treated by a physician.

Which finding indicates that rehydration is complete and hypovolemic shock has been successfully treated in a patient? 1. CVP = 8 mm Hg 2. MAP = 45 mm Hg 3. Urinary output of 0.1 mL/kg/hr 4. Hct = 54%

Correct Answer: 1 Rationale 1: A CVP reading of 8 mm Hg is within normal range(2-8) and rehydration has been restored. Rationale 2: The mean arterial pressure (MAP) should be between 60 to 70 mm Hg as evidence of positive fluid resuscitation efforts. Rationale 3: Urinary output to reflect adequate rehydration begins at 0.5 to 1 mL/kg/hr. Therefore, 0.1 mL is too small and renal insufficiency may be present due to inadequate circulating blood volume. Rationale 4: Hematocrit (Hct) is the percentage of the number of RBCs per fluid volume. The normal range is 35% to 45% for an adult. The higher percentage represents a decreased fluid-to-cell ratio, which implies a fluid deficit and rehydration is not complete. An Hct of 54% is critical and increases the risk of clots, strokes, and other vessel obstruction from potential hemolysis and sluggishness of cellular movements.

A patient with cardiomyopathy is demonstrating signs of cardiogenic shock. The nurse realizes that this type of shock is due to: 1. Reduced cardiac output 2. Increased stroke volume 3. Reduced blood volume 4. Blood flow blocked in the pulmonary circulation

Correct Answer: 1 Rationale 1: In cardiogenic shock, cardiac output is reduced, leading to poor tissue perfusion. Rationale 2: In cardiogenic shock, stroke volume is decreased. Rationale 3: There is not a reduction of blood volume in cardiogenic shock. Rationale 4: There is not a blockage of blood flow through the pulmonary circulation in cardiogenic shock.

The nurse is caring for a patient recovering from a spinal cord injury sustained during a motor vehicle crash. What assessment findings indicate that the patient is developing neurogenic shock? Select all that apply. 1. Hypotension 2. Bradycardia 3. Warm dry skin 4. Abdominal cramps 5. Palpitations

Correct Answer: 1,2, - nclex book says 3 too, but not in her lecture!!! Go with her lecture. Rationale 1: Hypotension is a manifestation of neurogenic shock because of the loss of autonomic reflexes. Rationale 2: Bradycardia occurs because of the loss of sympathetic innervation. Rationale 3: Warm dry skin occurs because of a loss of cutaneous control of sweat glands. Rationale 4: Abdominal cramping is not a manifestation of neurogenic shock. Rationale 5: Palpitations are not seen in neurogenic shock.

A patient is experiencing acute respiratory distress after eating an item of a known food allergy. What interventions will the nurse implement when providing emergency care to this patient? Select all that apply. 1. Administer epinephrine 1:1000 intramuscularly. 2. Apply oxygen via face mask as prescribed. 3. Provide diphenhydramine 25 mg intravenous. 4. Administer vasopressin. 5. Prepare to administer antithrombolytic agents as prescribed.

Correct Answer: 1,2,3 Rationale 1: Epinephrine produces bronchodilation, improving the respiratory status. The route of administration is initially intramuscular. Rationale 2: Supplemental oxygen is used in the treatment of anaphylactic shock. Rationale 3: Hydrogen ion blockers such as diphenhydramine may be administered to block the histamine effects. Rationale 4: Vasopressin is not used in the treatment of anaphylactic shock. Rationale 5: Antithrombolytic agents are not used in the treatment of anaphylactic shock.

During an assessment the nurse is concerned that a patient is developing cardiogenic shock. What did the nurse assess in this patient? Select all that apply. 1. Systolic blood pressure 82 mm Hg 2. Capillary refill 10 seconds 3. Crackles bilateral lung bases 4. Heart rate 55 and regular 5. Warm dry skin

Correct Answer: 1,2,3 Rationale 1: Hypotension is a manifestation of cardiogenic shock. Rationale 2: Delayed capillary refill is a manifestation of cardiogenic shock. Rationale 3: Crackles are a manifestation of cardiogenic shock. Rationale 4: Bradycardia is not a manifestation of cardiogenic shock. (It is for hypovolemia and neurogenic) Rationale 5: Warm dry skin is not a manifestation of cariogenic shock (it is for anaphylactic and septic)

A patient being treated for cardiogenic shock is being hemodynamically monitored. Which findings are consistent with the patient's diagnosis? Select all that apply. 1. Elevated pulmonary arterial wedge pressure 2. Elevated central venous pressure 3. Elevated systemic vascular resistance index 4. Elevated mean arterial pressure 5. Elevated stroke volume

Correct Answer: 1,2,3 Rationale 1: This finding is consistent with pulmonary vascular congestion. Rationale 2: This finding is consistent with fluid volume overload. Rationale 3: This finding is consistent with pulmonary vascular congestion. Rationale 4: This finding is not consistent with cardiogenic shock. Rationale 5: This finding is not consistent with cardiogenic shock.

A patient is brought to the emergency department with manifestations of anaphylactic shock. What will the nurse assess as possible causes for this disorder? Select all that apply. 1. Recent bee sting 2. Ingestion of drugs 3. History of latex allergy 4. Recent diagnostic imaging tests 5. Recent myocardial infarction

Correct Answer: 1,2,3,4 Rationale 1: Venoms such as bee stings can trigger anaphylactic shock. Rationale 2: Drugs can trigger anaphylactic shock. Rationale 3: Latex can trigger anaphylactic shock. Rationale 4: Contrast media for diagnostic tests can trigger anaphylactic shock. Rationale 5: Myocardial infarction is not a trigger for anaphylactic shock.

Which finding indicates that a patient is experiencing increased peripheral resistance and vasoconstriction? 1. Strong bounding pulse with deep red coloring 2. Pale, cool extremities with decreased pulses 3. Increased venous engorgement with strong pulses 4. Faster than normal capillary refill time

Correct Answer: 2 Rationale 1: An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and is not present with increased peripheral resistance and vasoconstriction. Rationale 2: Increased peripheral resistance causes the blood supply to decrease and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply. ***Blood is shunting Rationale 3: Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance. Rationale 4: Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance.

The nurse should warm intravenous fluids when a rapid infuser is being utilized to prevent which complication? 1. Hemorrhagic shock 2. Hypothermia 3. Sepsis 4. Cardiogenic shock

Correct Answer: 2 Rationale 1: Hemorrhagic shock is caused by a loss of cells or blood volume and is not a result of infusing fluids too quickly. Rationale 2: Hypothermia can result when providing room temperature fluids at a faster pace than the body can warm them. Rationale 3: Bacterial contamination can be avoided by sterile technique, and sepsis is not caused by the rate or temperature of the fluid being administered. Rationale 4: Cardiogenic shock results from poor ventricular functioning, not from the temperature of the intravenous fluids being administered too rapidly.

Which laboratory finding should cause the nurse to suspect that a patient is developing hypovolemic shock? 1. Serum sodium of 130 mEq/L (130 mmol/L) 2. Metabolic acidosis validated by arterial blood gases 3. Serum lactate of 3 mmol/L 4. SvO2 greater than 80%

Correct Answer: 2 Rationale 1: The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145 mEq/L, not reduced. Rationale 2: Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion. Rationale 3: Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Rationale 4: SvO2 (mixed venous oxygen saturation) would be less than 60% due to decreased circulating blood volume or decrease in cells to carry the oxygen. Therefore, O2 is carried less efficiently and decreased, not increased.

Which solution would be the most appropriate initial volume replacement for a patient with severe GI bleeding? 1. 200 mL of normal saline (NS) per hour for 5 hours 2. A liter of Ringer's lactate (RL) over 15 minutes 3. Two liters of D5W over half an hour 4. 500 mL of 0.45% normal saline (1/2 NS) over half an hour

Correct Answer: 2 Rationale 1: This is not an adequate amount of fluid replacement. Rationale 2: The patient requires immediate infusion of an adequate amount of fluid. Fluid resuscitation begins with 500 to 1,000 mL of an isotonic solution. Rationale 3: This is a hypotonic solution and would not help with fluid resuscitation. Rationale 4: This is a hypotonic solution and would not help with fluid resuscitation.

Which life-threatening complications would the nurse anticipate developing in the patient being treated for hypovolemic shock? Select all that apply. 1. Fluid volume overload 2. Renal insufficiency 3. Cerebral ischemia 4. Gastric stress ulcer 5. Pulmonary edema

Correct Answer: 2,3 Rationale 1: Fluid volume overload is not an identified complication of hypovolemic shock. Rationale 2: Renal insufficiency is a serious complication because of the prerenal etiology of hypovolemia. Rationale 3: Early identification and correction of the fluid volume deficit in hypovolemic shock is necessary to prevent cerebral ischemia. Rationale 4: Although physiologic stress can increase the risk for the development of stress ulcers, it is not considered one of the common or life-threatening complications of hypovolemic shock. Rationale 5: Pulmonary edema is not an identified complication of hypovolemic shock.

What will the nurse identify as symptoms of hypovolemic shock in a patient? Select all that apply. 1. Temperature of 97.6°F (36.4°C) 2. Restlessness 3. Decrease in blood pressure of 20 mm Hg when the patient sits up 4. Capillary refill time greater than 3 seconds 5. Sinus bradycardia of 55 beats per minute

Correct Answer: 2,3,4 Rationale 1: Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate. ***Temp <96.8 is though!!! Rationale 2: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs, leading to a change in mental status. Rationale 3: Orthostatic hypotension is a manifestation of hypovolemic shock. Rationale 4: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, capillary refill time will be reduced. Rationale 5: Bradycardia is not present initially. The compensatory response is to increase the heart rate to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock.

The nurse recognizes that which patient would be most likely to develop hypovolemic shock? A patient with: 1. Decreased cardiac output 2. Severe constipation, causing watery diarrhea 3. Ascites 4. Syndrome of inappropriate ADH (SIADH)

Correct Answer: 3 Rationale 1: Although ECG changes reflect the effectiveness of the heart's pumping when circulating the blood, it is not a risk factor for hypovolemic shock, which reflects a decreased circulating volume from either blood or fluid losses within the intravascular system. Rationale 2: Severe constipation does not affect the circulating blood volume. Rationale 3: Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock. Rationale 4: Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema.

The nurse, caring for a patient in hypovolemic shock, will not utilize a hypotonic solution for fluid resuscitation because hypotonic solutions: 1. Move quickly into the interstitial spaces and can cause third spacing 2. Stay longer to expand the intravascular space but deplete intracellular fluid levels 3. Do not stay in the intravascular space long enough to expand the circulating blood volume 4. Need a smaller bore needle to run at a slower rate to keep the intravascular space low

Correct Answer: 3 Rationale 1: Hypotonic solutions do not cause third spacing. Rationale 2: Hypotonic solutions do not stay in the intravascular space long enough to expand the circulating blood volume. Rationale 3: Hypotonic solutions do not stay in the intravascular space long enough to expand the circulating blood volume. Rationale 4: The bore size of the needle does not affect the displacement or shifting of fluids.

A patient with neurogenic shock is demonstrating bradycardia. What action will the nurse take at this time? 1. Limit patient movement. 2. Prepare to administer crystalloids. 3. Administer phenylephrine as prescribed. 4. Administer atropine as prescribed.

Correct Answer: 4 Rationale 1: Limiting movement will not correct bradycardia in the patient with neurogenic shock. Rationale 2: Crystalloids are used to correct vasodilation. Rationale 3: Phenylephrine is used in the patient with neurogenic shock to correct hypotension. Rationale 4: Bradycardia in neurogenic shock is corrected by the administration of atropine at the dose of 0.5 to 1.0 mg intravenous every 5 minutes to a total dose of 3 mg.

A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following? A - Seating the client with arm bared, supported, and at heart level. B - Measuring the blood pressure after the client has been seated quietly for 5 minutes. C - Using a cuff with a rubber bladder that encircles at least 80% of the limb. D - Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.

D. BP should be taken with the client seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should not have smoked tobacco or taken in caffeine in the 30 minutes preceding the measurement. The client should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured. Gauges other than a mercury sphygmomanometer should be calibrated every 6 months to ensure accuracy.

The most common risk factor for cardiogenic shock is anyone who has had open heart surgery. A. True B. False

False - Most common risk factor is anyone who has had a heart attack

The client in shock is prescribed an infusion of lactated Ringer's solution. The nurse recognizes that the function of this fluid in the treatment of shock is to: a.) Replace fluid, and promote urine output. b.) Draw water into cells. c.) Draw water from cells to blood vessels. d.) Maintain vascular volume

a.) Replace fluid, and promote urine output.

A client comes to the outpatient clinic and tells the nurse that he has had legs pains that begin when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for? a. An acute obstruction in the vessels of the legs b. Peripheral vascular problems in both legs c. Diabetes d. Calcium deficiency

b. Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. If an obstruction were present, the leg pain would persist when the client stops walking. Low calcium levels may cause leg cramps but would not necessarily be related to walking.

In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include: a. Walking several times each day as an exercise program. b. Keeping the heat up so that the environment is warm c. Wearing TED hose during the day d. Using hydrotherapy for increasing oxygenation

b. The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful when preventing vasoconstriction, but TED hose would not be therapeutic. Walking would most likely increase pain. **promote vasolidation - avoid cold exposures (cause vasoconstriction) and provide warmth (avoid direct heat).

An intensive care nurse, is assessing a patient with suspected sepsis. Which predisposing factors would expect to be found in the patient with septic shock? a.) A 45 year old client with a history of renal insufficiency. b.) A client age 65, with a history of cancer who is recovering from an abdominal peritoneal resection. c.) A 27 year old with pyelonephritis responding to treatment with an antibiotic. d.) A 50 year old with community acquired tuberculosis.

b.) A client age 65, with a history of cancer who is recovering from an abdominal peritoneal resection.

A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first? a.) Insert two 14-gauge IV catheters. b.) Administer oxygen at 100% per non-rebreather mask. c.) Place the patient on continuous cardiac monitor. d.) Draw blood to type and crossmatch for transfusions.

b.) Administer oxygen at 100% per non-rebreather mask. Rationale: The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented. **Oxygen then IV - 2 large bore for rapid infusion

A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a.) check the blood pressure. b.) obtain an oxygen saturation. c.) attach a cardiac monitor. d.) check level of consciousness.

b.) obtain an oxygen saturation. Rationale: The initial actions of the nurse are focused on the ABCs, and assessing the airway and ventilation is necessary. The other assessments should be accomplished as rapidly as possible after the oxygen saturation is determined and addressed.

While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding a.) cold, mottled extremities. b.) restlessness and apprehension. c.) a heart rate of 120 and cool, clammy skin. d.) systolic BP less than 90 mm Hg.

b.) restlessness and apprehension. Rationale: Restlessness and apprehension are typical during the compensatory stage of shock. Cold, mottled extremities, cool and clammy skin, and a systolic BP less than 90 are associated with the progressive and refractory stages.

A client is progressing into the third stage of shock. The nurse will expect this client to demonstrate: Choose all that apply: a.) Intractable circulatory failure. b.) Neuroendocrine responses. c.) Demonstrating MODS. d.) Buildup of metabolic wastes. e.) Profound hypotension. f.) Increase in lactic acidosis.

c) Demonstrating MODS. d.) Buildup of metabolic wastes. **Irreversible/Refractory - final stage: rapid LOC, pulselessness, dusky extremities, shallow slow respirations, unmeasurable O2 sat. MODS! and buildup of waste from kidneys not working.

A 4.5 kg infant is admitted to the pediatric intensive care unit after 33 days of watery diarrhea. The infant is diagnosed with severe dehydration. The infant's skin is mottled and turgor is poor. Capillary refill is delayed, and there is an absence of tears with crying. Which intervention should be the priority action by the healthcare provider? a.) Calculate the mean arterial pressure b.) Draw blood for a complete blood count c.) Establish vascular access d.) Take a complete set of vital signs

c.) Establish vascular access Rationale: Vascular access should be established quickly in order to replace lost volume before shock progresses.

When performing a physical assessment of a patient with severe sepsis, what abnormal assessment would the nurse expect to find? a.) A WBC of 8,100 despite the presence of chills. b.) A blood pressure of 100/72 with a capillary refill of <3 seconds. c.) Leucocytosis in a patient with absent bowel sounds. d.) Renal output that fluctuates according to intravenous intake.

c.) Leucocytosis in a patient with absent bowel sounds. Rationale: Leucocytosis in a patient with absent bowel sounds A white count > 12,000/mm3 and a left shift is one of the diagnostic criteria. Absent bowel sounds indicate a possible ileus. This would allow translocation of the intestinal flora into the bloodstream.

Which of the following assessment findings is an early indication of hypovolemic shock? a.) Diminished bowel sounds b.) Increased urinary output c.) Tachycardia d.) Hypertension

c.) Tachycardia Rationale: Tachycardia is an early symptom as the body compensates for a declining blood pressure the heart rate increases to circulate the blood faster to prevent tissue hypoxia.

A patient with massive trauma and possible spinal cord injury is admitted to the ED. The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of a.) cool, clammy skin. b.) shortness of breath. c.) heart rate of 48 beats/min d.) BP of 82/40 mm Hg.

c.) heart rate of 48 beats/min Rationale: The normal sympathetic response to shock/hypotension is an increase in heart rate. The presence of bradycardia suggests unopposed parasympathetic function, as occurs in neurogenic shock. The other symptoms are consistent with hypovolemic shock.

The nurse and licensed practical nurse (LPN) are caring for clients on an oncology floor. Which client should not be assigned to the LPN? 1.The client newly diagnosed with chronic lymphocytic leukemia. 2.The client who is four (4) hours post-procedure bone marrow biopsy. 3.The client who received two (2) units of PRBCs on the previous shift. 4.The client who is receiving multiple intravenous piggyback medications

(CORRECT: 1) The newly diagnosed client will need to betaught about the disease and about treat-ment options. The registered nurse cannot delegate teaching to a an LPN

The nurse is developing a care plan with an older adult and is instructing the client that hypertension can be a silent killer. The nurse should instruct the client to be aware of signs and symptoms of other system failures and encourage the client to report signs of which of the following diseases that are often a result of undeteced high blood pressure? 1. Cerebrovascular accidents (CVAs). 2. Liver disease. 3. Myocardial infarction. 4. Pulmonary disease.

1. Hypertension is referred to as the silent killer for adults, because until the adult has significant damage to other systems, the hypertension may go undetected. CVAs can be related to long-term hypertension. Liver or pulmonary disease is not generally associated with hypertension. Myocardial infarction is generally related to coronary artery disease.

Metoprolol (Toprol XL) is added to the pharmacologic therapy of a diabetic female diagnosed with stage 2 hypertension initially treated with Furosemide (Lasix) and Ramipril (Altace). An expected therapeutic effect is: 1. Decrease in heart rate. 2. Lessening of fatigue. 3. Improvement in blood sugar levels. 4. Increase in urine output.

1. The effect of a beta blocker is a decrease in heart rate, contractility, and afterload, which leads to a decrease in blood pressure. The client at first may have an increase in fatigue when starting the beta blocker. The mechanism of action does not improve blood sugar or urine output.

Amy is being assessed for PVD. Upon her assessment, the nurse finds that Amy has ulceration around her hips, her legs show no edema, she has severe pain, and has no pedal pulse. What would the nurse take away from this assessment? 1. Venous PVD 2. Arterial PVD

2 - Arterial PVD

A client has developed oral mucositis as a result of radiation to the head and neck. The nurse should teach the client to incorporate which of the following measures in his or her daily home care routine? a) oral hygiene should be performed in the morning and evening b) high-protein foods, such as peanut butter, should be incorporated in the diet c) a glass of wine per day will not pose any further harm to the oral cavity d) a combination of a weak saline and water solution should be used to rinse the mouth

2) D Oral mucositis (irritation, inflammation, and/or ulceration of the mucosa) commonly occurs in clients receiving radiation to the head and neck. Measures need to be taken to soothe the mucosa as well as provide effective cleansing of the oral cavity. A combination of a weak saline and water solution is an effective cleansing agent

In teaching the hypertensive client to avoid orthostatic hypotension, the nurse should emphasize which of the following instructions? Select all that apply. 1. Plan regular times for taking medications. 2. Arise slowly from bed. 3. Avoid standing still for long periods. 4. Avoid excessive alcohol intake. 5. Avoid hot baths.

2, 3. Changing positions slowly and avoiding long periods of standing may limit the occurrence of orthostatic hypotension. Scheduling regular medication times is important for blood pressure management but this aspect is not related to the development of orthostatic hypotension. Excessive alcohol intake and hot baths are associated with vasodilation.

A pediatric nurse clinician is discussing the pathophysiology related to childhood leukemia with a class of nursing students. Which statement made by a nursing student indicates a lack of understanding of the pathophysiology of this disease? 1. Normal bone marrow is replaced by blast cells 2. Red blood cell production is affected 3. the platelet count is decreased 4. the presence of a reed-sternberg cell is found on biopsy

4. Reed-sternberg Cell is found in Hodgkins

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 Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances. Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin; PAD results from atherosclerotic occlusion of peripheral arteries.

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 Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria

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 should be concerned if my foot turns blue." C. "I should report a fever or any drainage." D. "Warmness, redness, and swelling are expected."

A Pallor is one of the signs of decreased perfusion along with increased pain, poikilothermia, paresthesia, pulselessness, and paralysis

Which are risk factors that are known to contribute to atherosclerosis-related diseases? (Select all that apply.) A. Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL B. Smoking C. Aspirin (acetylsalicylic acid [ASA]) consumption D. Type 2 diabetes E. Vegetarian diet

A, B, D Having an LDL-C value of less than 100 mg/dL is optimal; 100 to 129 mg/dL is near or less than optimal; with LDL-C 130 to 159 mg/dL (borderline high), the client is advised to modify diet and exercise. Smoking is a modifiable risk factor and should be avoided or terminated, and diabetes is a risk factor for atherosclerotic disease.

A patient is admitted to the emergency department after sustaining abdominal injuries and a broken femur from a motor vehicle accident. The patient is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98 F (36 C), heart rate 130 beats/minute, respiratory rate 34 breaths/minute, blood pressure 50/40 mmHg. The healthcare provider suspects which type of shock? a.) Hypovolemic b.) Cardiogenic c.) Neurogenic d.) Distributive

A - hypovolemic

Women who use oral contraceptives should be educated about: A. Venous insufficiency B. Arterial insufficiency

A - venous insufficiency

The nurse is assigned to all of these clients. Which client should 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 PTA should have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure.

During an assessment of a patient's abdomen, a pulsating abdominal mass is noted by the healthcare provider. Which of the following should be the healthcare provider's next action? A. Assess femoral pulses B. Obtain a bladder scan C. Measure the abdominal circumference D. Ask the patient to perform a Valsalva maneuver

A - assess femoral pulse

Occlusive disease, aortic aneurysm, emboli, arteriospastic disease are either a cause or a symptom of blockage of arterial perfusion? A. Cause B. Symptom

A - cause

What is diastolic blood pressure? A) Pressure in the vessels when the heart rests between beats B) The amount of blood in the left ventricle prior to contraction C) The pressure the heart has to overcome to pump blood to the rest of the body D) Pressure in the blood vessels when the heart beats

A) Pressure in the vessels when the heart rests between beats **amount of pressure or force against the arterial walls during cardiac relaxation

The nurse educates a primary HTN patient on lifestyle changes. Which ones should be included in her teaching? A. consume more fruits/veggies B. Monitor/lose weight C. Limit alchoholic drinks to 3 per day or less D. Regular exercise (walking) E. Limit sodium intake to 3200 mg per day

A, B, D

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? SATA A It results when oxygen demand is greater than oxygen supply. B It is characterized by pain that often occurs during rest. C It is a result of tissue hypoxia. D It is characterized by cramping and weakness.

A, C, D. Claudication describes the pain experienced by a patient with peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. This most often occurs during activity when demand increases in muscle tissue. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.

The silent killer, essential HTN, sometimes doesn't have obvious s/s, but some that may be reported by the patient include: Select All That Apply A. Dizziness B. Kidney disease C. Headache D. Syncope (fainting) E. Hot/flushed F. Nose bleed (epistaxis) G. Diabetes

A, C. D, E, F Kidney disease and diabetes are not s/s and are a factor in secondary HTN, not primary

A patient with an opening in the chest wall, such as from a gunshot, stab wound or impalement, resulting in "sucking chest wound" can be said to have: A. An open pneumothorax B. A closed pneumothorax C. A hemothorax D. A pleural effusion

A. http://www.proprofs.com/quiz-school/user_upload/ckeditor/pneumothorax_open.jpg

What is the most common symptom in a client with abdominal aortic aneurysm? A. Abdominal pain B. Diaphoresis C. Headache D. Upper back pain

A. Abdominal pain in a client with an abdominal aortic aneurysm results from the disruption of normal circulation in the abdominal region. Lower back pain and flank pain, not upper, is a common symptom, usually signifying expansion and impending rupture of the aneurysm. F Headache and diaphoresis aren't associated with abdominal aortic aneurysm.

What is the most common cause of abdominal aortic aneurysm? A. Atherosclerosis B. DM C. HPN D. Syphilis

A. Atherosclerosis accounts for 75% of all abdominal aortic aneurysms. Plaques build up on the wall of the vessel and weaken it, causing an aneurysm. Although the other conditions are related to the development of an aneurysm, none is a direct cause.

A 21-year-old male with Hodgkin's lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client? A. Sexual dysfunction related to radiation therapy B. Anticipatory grieving related to terminal illness C. Tissue integrity related to prolonged bed rest D. Fatigue related to chemotherapy

A. Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin's disease, however, has a good prognosis when diagnosed early. Anticipatory grieving related to terminal illness, Tissue integrity related to prolonged bed rest, and Fatigue related to chemotherapy are incorrect because they are of lesser priority.

If the chest tube is pulled out of the patient's chest, and the patient had an air leak from the lung, after asking a colleague to call a physician STAT, emergency nursing management is to: A. Cover the opening with a sterile dressing, taped on three sides B. Cover the opening with a sterile Vaseline gauze, taped securely on all sides C. Leave the opening alone and monitor the patient until a physician can assess the situation D. Try to put the tube back in place as quickly as possible

A. If there is an air leak from the lung into the pleural space, the dressing applied to the patient's chest should mimic the function of the chest drainage system - allow air to escape from the pleural space while minimizing air re-entering the pleura from the atmosphere. If an occlussive dressing was applied, no air could escape the pleural space and the pneumothorax could develop into a tension pneumothorax. If there was no know air leak and no "sucking" air sounds are noted, a regular dry dressing may be sufficient.

A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of: A. Right pneumothorax B. Pulmonary embolism C. Displaced endotracheal tube D. Acute respiratory distress syndrome

A. Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi.

After receiving the change-of-shift report, which client will you assess first? A. A 20-year-old with possible acute myelogenous leukemia who has just arrived on the medical unit B. A 40-year-old with lymphedema who requests help to put on compression stockings before getting out of bed C. A 38-year-old with aplastic anemia who needs teaching about decreasing infection risk prior to discharge D. A 60-year-old with non-Hodgkin's lymphoma who is refusing the ordered chemotherapy regimen

A. The newly admitted client should be assessed first, because the baseline assessment and plan of care need to be completed. The other clients also need assessments or interventions, but do not need immediate nursing care. Focus: Prioritization

Mike, a 43-year old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike's symptoms as being associated with peripheral arterial occlusive disease. The nursing diagnosis is probably: a. Alteration in tissue perfusion related to compromised circulation b. Dysfunctional use of extremities related to muscle spasms c. Impaired mobility related to stress associated with pain d. Impairment in muscle use associated with pain on exertion.

A. Alteration in tissue perfusion related to compromised circulation

A 50-year-old client with a history of smoking is experiencing symptoms of claudication in his right calf during exercise, in which he participates daily. Which of the following assessment details requires further evaluation? a. Ankle brachial index of 0.65 b. Blood pressure 138/78 c. heart rate of 64 d. PaO2 94% on room air

A. An ankle brachial index is found by dividing the systolic blood pressure in the ankle by the systolic blood pressure in the arm. An index of 0.65 indicates that the pressure in the leg is less than that of the arm, and is suggestive of moderate vascular disease in the client. **If ABI is less than 0.9 - diagnostic of PAD. Exception - DM causes false elevation.

Which medication is used to inactivate thromboplastin? A. Heparin B. Warfarin C. Diazepam D. Streptokinase

A. Heparin

A client taking a chemotherapeutic agent understands the effects of therapy by stating: A. "I will avoid eating hot and spicy foods." B "I should stay in my room all the time." C "I should limit my fluid intake to about 500 ml per day." D "I should notify the physician immediately if a urine color change is observed.

A. The client should prevent hot and spicy food because of the stomatitis side effect. The client should avoid people with infection but should not isolate himself in his room all the time. Fluid intake should be increased. Urine color change is normal.

Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? a. Have the patient record dietary intake for 3 days. b. Give the patient a detailed list of low-sodium foods. c. Teach the patient about foods that are high in sodium. d. Help the patient make an appointment with a dietitian.

ANS: A The initial nursing action should be assessment of the patient's baseline dietary intake through a 3-day food diary. The other actions may be appropriate, but assessment of the patient's baseline should occur first.

Which BP finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of heart failure? a. 108/64 mm Hg b. 128/76 mm Hg c. 140/90 mm Hg d. 136/ 82 mm Hg

ANS: B The goal for antihypertensive therapy for a patient with hypertension and heart failure is a BP of <130/80 mm Hg. The BP of 108/64 may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient's treatment.

The nurse in the emergency department received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a. 52-year-old with a BP of 212/90 who has intermittent claudication b. 43-year-old with a BP of 190/102 who is complaining of chest pain c. 50-year-old with a BP of 210/110 who has a creatinine of 1.5 mg/dL d. 48-year-old with a BP of 200/98 whose urine shows microalbuminuria

ANS: B The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention is needed. The symptoms of the other patients also show target organ damage, but are not indicative of acute processes.

The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? a. Urine output over 8 hours is 200 mL less than the fluid intake. b. The patient is unable to move the left arm and leg when asked to do so. c. Tremors are noted in the fingers when the patient extends the arms. d. The patient complains of a severe headache with pain at level 8/10 (0 to 10 scale).

ANS: B The patient's inability to move the left arm and leg indicates that a hemorrhagic stroke may be occurring and will require immediate action to prevent further neurologic damage. The other clinical manifestations also likely are caused by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes.

The nurse obtains this information from a patient with prehypertension. Which finding is most important to address with the patient? a. Low dietary fiber intake b. No regular aerobic exercise c. Weight 5 pounds above ideal weight d. Drinks wine with dinner once a week

ANS: B The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber, but increasing fiber alone will not prevent hypertension from developing. The patient's alcohol intake will not increase the hypertension risk.

After giving a patient the initial dose of oral labetalol (Normodyne) for treatment of hypertension, which action should the nurse take? a. Encourage oral fluids to prevent dry mouth or dehydration. b. Instruct the patient to ask for help if heart palpitations occur. c. Ask the patient to request assistance when getting out of bed. d. Teach the patient that headaches may occur with this medication.

ANS: C Labetalol decreases sympathetic nervous system activity by blocking both α- and β-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dehydration, and headaches are possible side effects of other antihypertensives.

A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and has a BP of 240/118 mm Hg. Which question should the nurse ask first? a. Did you take any acetaminophen (Tylenol) today? b. Do you have any recent stressful events in your life? c. Have you been consistently taking your medications? d. Have you recently taken any antihistamine medications?

ANS: C Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.

During change-of-shift report, the nurse obtains this information about a hypertensive patient who received the first dose of propranolol (Inderal) during the previous shift. Which information indicates that the patient needs immediate intervention? a. The patient's most recent BP reading is 156/94 mm Hg. b. The patient's pulse has dropped from 64 to 58 beats/minute. c. The patient has developed wheezes throughout the lung fields. d. The patient complains that the fingers and toes feel quite cold.

ANS: C The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the noncardioselective β-blockers) is occurring. The nurse should immediately obtain an oxygen saturation measurement, apply supplemental oxygen, and notify the health care provider. The mild decrease in heart rate and complaint of cold fingers and toes are associated with β-receptor blockade but do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated; however, this is not as urgently needed as addressing the bronchospasm.

The nurse has just finished teaching a hypertensive patient about the newly prescribed quinapril (Accupril). Which patient statement indicates that more teaching is needed? a. "The medication may not work as well if I take any aspirin." b. "The doctor may order a blood potassium level occasionally." c. "I will call the doctor if I notice that I have a frequent cough." d. "I won't worry if I have a little swelling around my lips and face."

ANS: D Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health care provider should be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy.

After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective? a. The patient avoids eating nuts or nut butters. b. The patient restricts intake of dietary protein. c. The patient has only one cup of coffee in the morning. d. The patient has a glass of low-fat milk with each meal.

ANS: D The Dietary Approaches to Stop Hypertension (DASH) recommendations for prevention of hypertension include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.

A patient has just been diagnosed with hypertension and has a new prescription for captopril (Capoten). Which information is important to include when teaching the patient? a. Check BP daily before taking the medication. b. Increase fluid intake if dryness of the mouth is a problem. c. Include high-potassium foods such as bananas in the diet. d. Change position slowly to help prevent dizziness and falls.

ANS: D The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the medication, and the patient is taught to use gum or hard candy to relieve dry mouth. The BP does not need to be checked at home by the patient before taking the medication. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.

A pregnant woman tells the nurse that there is a history of sickle cell disease in her family and she is afraid that the baby will have the disease. The nurse provides the client with which of the following information? 1.Sickle cell is a male disease and would be passed on by the baby's father. 2.The baby needs only one parent to be a carrier to be affected. 3.Both the mother and father must carry the gene for the baby to be affected. 4.Genetic testing will be needed to determine if the baby is affected.

Answer: 3 Both the mother and father must carry the gene for the baby to be affected. Rationale: Sickle cell is inherited as an autosomal recessive disorder. Both parents must carry the gene for the baby to be affected. The other statements are inaccurate.

A child with suspected sickle cell disease (SCD) is in the clinic for laboratory studies. The parents ask the nurse what results will tell the physician that their child has SCD. The nurse responds that which of the following is increased in this disease? 1.Reticulocyte count 2.Hematocrit 3.Hemoglobin 4.Platelet count

Answer: Reticulocyte count Rationale: The reticulocyte count will be increased because the life span of sickled red blood cells is shortened. Hemoglobin, hematocrit, and platelet levels will be decreased. **Hemoglobin or Hgb electrophoresis is the diagnostic test for SCD

The nurse is reviewing laboratory findings for a 2-year-old being treated for anemia. Which of the findings is the best indication that goals for this client have been met? 1.The child is no longer cyanotic. 2.The reticulocyte count is rising. 3.The child is more active. 4.Stools are black, indicating iron intake.

Answer: 2 The reticulocyte count is rising. Rationale: An increase in the reticulocyte number means that the body is producing new RBC's. While improved oxygenation, increased activity, and indications of iron intake are desirable outcomes for the child with anemia, they are not laboratory data.

The nurse writes a nursing problem of "altered nutrition" for a client diagnosed with leukemia who has received a treatment regimen of chemotherapy and radiation. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication prior to meals 2. Monitor the client's serum albumin levels 3. Assess for signs and symptoms of infection 4. Provide skin care to irradiated areas

Answer: 2 1. The nurse should administer an antiemetic prior to meals, not an antidiarrheal medication 2. Serum albumin is a measure of the protein content in the blood that is derived form food eaten; albumin monitors nutritional status 3. Assessment of the nutritional status is indicated for this problem, not assessment of the s/sx of infections. 4. This addresses an altered skin integrity problem

The nurse is planning care for a child who is newly diagnosed with sickle cell disease. Which of the following would the nurse plan with the family to best promote the child's growth and development? 1.Renal health plan 2.Emergency care in the school setting 3.Nutritional support during hospitalizations 4. Individualized school health plan

Answer: 4 Individualized school health plan Rationale: Children with sickle cell disease will have sickle cell crises no matter how well the child is protected, and may miss a great deal of school. Planning ahead with the school system and parents to continue schooling during recuperation can help the child maintain developmental progress. Most schools are equipped to deal with emergencies that children have. Nutrition is important to development, but a long-range plan with the school will better promote development and learning. Renal health plan is not an appropriate answer.

The nurse is caring for a child who is in the hospital experiencing sickle cell crisis. The parents are asking the nurse which treatment will help cure the child. The nurse responds with which of the following? 1. Treatment with an exchange transfusion of blood will cure the child. 2. Treatment with morphine will cure sickle cell disease. 3. There is no treatment for sickle cell crisis. 4. Treatment is aimed at pain control, oxygen therapy, and hydration, but does not provide a cure.

Answer: 4 Treatment is aimed at pain control, oxygen therapy, and hydration, but does not provide a cure. Rationale: Treatment for sickle cell crisis is pain control, oxygenation, and fluid resuscitation. There is no cure for sickle cell disease. The nurse teaches families how to prevent sickle cell crisis.

A pediatric nursing instructor asks a nursing student to describe the cause of the clinical manifestations that occur in sickle cell disease. The student responds correctly by telling the instructor that 1. Sickled cells increase the blood flow through the body and cause a great deal of pain. 2. sickled cells mix with the unsickled cells and cause the immune system to become depressed. 3. bone marrow depression occurs because of the development of sickled cells. 4. sickled cells are unable to flow easily through the microvasculature and their clumping obstructs blood flow.

Answer: 4 Rationale: all of the clinical manifestations of sickle cell disease result from the sickled cells being unable to flow easily through the microvasculature, and their clumping obstructs blood flow. With re-oxygenation, most of the sickled red blood cells resume their normal shape. Options 1, 2, and 3 are incorrect statements.

What nursing diagnosis is seen with acute lymphocytic leukemia and thromocytopenia? "A. potential for injury B. self-care deficit C. potential for self harm D. alteration in comfort"

Answer: A potential for injury Low platelet increases risk of bleeding from even minor injuries. Safety measures: shave with an electric razor, use soft tooth brush, avoid SQ or IM meds and invasive procedures (urinary drainage catheter or a nasogastric tube), side-rails up, remove sharp objects, frequently assess for signs of bleeding, bruising, hemorrhage. "

When caring for a client with a diagnosis of thrombocytopenia, the nurse should plan to: a.Discourage the use of stool softeners b.Assess temperature readings every six hours c.Avoid invasive procedures d.Encourage the use of a hard, brittle toothbrush

Answer: C Rationale: Thrombocytopenia is a deficiency of platelets, and leaves the patient more prone to hemmorrhage. For this reason, avoiding invasive procedures will limit the risk of hemorrhage. Stool softeners should be encouraged, while hard brittle toothbrushes should be avoided. Temperature is not the most important vital to track in this patient

The nurse has admitted a child newly diagnosed with anemia of unknown origin. Which of the following is a priority intervention for the nurse to initiate? 1. Administer fluids to increase cardiac output. 2. Plan for safe care due to weakness. 3.Teach the client about foods with iron. 4. Assess pain level.

Answer: Plan for safe care due to weakness. Rationale: The client with anemia is weak and the nurse would address safe care due to weakness. Since the cause of the anemia is undetermined, the nurse would not administer fluids or complete nutritional teaching without additional information. Clients with anemia do not normally have pain; pain is assessed in every client, but is not the priority of care in this client.

The nurse is working with a woman who is pregnant and her husband. The husband asks the nurse why his wife has a folic acid deficiency when she eats healthy meals. The nurse best responds with which of the following? 1.Pregnancy increases metabolic requirements for folic acid. 2.There is inadequate dietary intake of folic acid. 3.Pregnancy causes malabsorption of folic acid. 4.The client has some form of impaired metabolism

Answer: Pregnancy increases metabolic requirements for folic acid. Rationale: Pregnancy increases the metabolic requirements for folic acid. Since the husband states that they eat healthy meals, inadequate intake of folic acid is a less likely cause of the deficiency. Malabsorption and impaired metabolism are causes of folic acid deficiency that are not associated with pregnancy.

The nurse notes that the client has a low red blood cell count and anticipates which of the following subjective manifestations on assessment? 1.Chest pain 2.Nausea 3.Sore throat 4. Fatigue

Answer:Fatigue Rationale: Fatigue would signify that the body's tissues are not receiving enough oxygenation. Sore throat is a sign of infection. Chest pain may indicate an impending myocardial infarction. Nausea is a symptom for many disease processes, but is not typical for anemia.

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 192/102 mm Hg C. Report of constipation D. Anxiety

B Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture.

In which of the following areas is an abdominal aortic aneurysm most commonly located? A. Distal to the iliac arteries B. Distal to the renal arteries C. Adjacent to the aortic branch D. Proximal to the renal arteries

B. The portion of the aorta distal to the renal arteries is more prone to an aneurysm because the vessel isn't surrounded by stable structures, unlike the proximal portion of the aorta. Distal to the iliac arteries, the vessel is again surrounded by stable vasculature, making this an uncommon site for an aneurysm. There is no area adjacent to the aortic arch, which bends into the thoracic (descending) aorta. **Notes say AAA usually between renal arteries and aortic bifurcation, below the diaphragm

The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia? A. BP 146/88 B. Respirations, 28, shallow C. Weight gain of 10 pounds in 6 months D. Pink complexion

B. When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in respirations, 28, shallow . The client with anemia is often pale in color, has weight loss, and may be hypotensive. BP of 146/88 , weight gain of 10 pounds in 6 months , and pink complexion are within normal and, therefore, are incorrect.

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 Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA.

Which of the following blood components is decreased in anemia? A Erythrocytes B Granulocytes C Leukocytes D Platelets

Question 21 Explanation: A Anemia is defined as a decreased number of erythrocytes (red blood cells). Leukopenia is a decreased number of leukocytes (white blood cells). Thrombocytopenia is a decreased number of platelets. Lastly, granulocytopenia is a decreased number of granulocytes (a type of white blood cells)

Which of the following control systems play a major role in maintaining blood pressure? Select All That Apply A. Renovascular system B. Arterial baroreceptor system C. Regulation of body fluid volume D. Respiratory System E. Renin-angiotensin-aldosterone system F. Vascular autoregulation G. Pulmonary system

B, C, E, F

Which of the following situations is likely to result in an absence of fluctuations in the chest drainage tubing? A. The tubing is coiled on the bed with a straight path to the chest drain B. The tubing is blocked in some way C. The patient is receiving positive pressure ventilation D. The patient is ambulatory

B.

Which of the following foods should a client with leukemia avoid? A White bread B Carrot sticks C Stewed apples D Medium rare steak

B. A low-bacteria diet would be indicated with excludes raw fruits and vegetables.

A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client? A. Taking hourly blood pressures with mechanical cuff B. Encouraging fluid intake of at least 200mL per hour C. Position in high Fowler's with knee gatch raised D. Administering Tylenol as ordered

B. It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Taking hourly blood pressures with mechanical cuff is incorrect because a mechanical cuff places too much pressure on the arm. Position in high Fowler's with knee gatch raised is incorrect because raising the knee gatch impedes circulation. Administering Tylenol as ordered is incorrect because Tylenol is too mild an analgesic for the client in crisis.

A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire? A. "Have you noticed a change in sleeping habits recently?" B. "Have you had a respiratory infection in the last 6 months?" C. "Have you lost weight recently?" D. "Have you noticed changes in your alertness?"

B. The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations.

A male patient has a sucking stab wound to the chest. Which action should the nurse take first? A Drawing blood for a hematocrit and hemoglobin level B Applying a dressing over the wound and taping it on three sides C Preparing a chest tube insertion tray D Preparing to start an I.V. line

B. The nurse immediately should apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

With peripheral arterial insufficiency, leg pain during rest can be reduced by: a. Elevating the limb above heart level b. Lowering the limb so it is dependent c. Massaging the limb after application of cold compresses d. Placing the limb in a plane horizontal to the body

B. Lowering the limb so it is dependent

Which of the following complications is of greatest concern when caring for a preoperative abdominal aneurysm client? A. HPN B. Aneurysm rupture C. Cardiac arrythmias D. Diminished pedal pulses

B. Rupture of the aneurysm is a life-threatening emergency and is of the greatest concern for the nurse caring for this type of client. Hypertension should be avoided and controlled because it can cause the weakened vessel to rupture. Diminished pedal pulses, a sign of poor circulation to the lower extremities, are associated with an aneurysm but isn't life threatening. Cardiac arrhythmias aren't directly linked to an aneurysm. **NOTES - aneurysms >6cm diameter = 50% chance rupture in 1 year; aneurysms <6cm = 15-20% chance of rupture in 1 yr **If rupture = treat for hypovolemic shock

A pt has arterial insufficiency. What should the nurse not do? A. Apply heat compresses B. Apply cold compresses C. Instruct the use of loose fitting clothing D. Educate of the potential for burns

B. apply cold compresses

A 22-year-old with stage I Hodgkin's disease is admitted to the oncology unit for radiation therapy. During the initial assessment, the client tells you, "Sometimes I am afraid of dying." Which response is most appropriate at this time? Discuss A. "Many individuals with this diagnosis have some fears." B. "Perhaps you should ask the doctor about medication." C. "Tell me a little bit more about your fear of dying." D. "Most people with stage I Hodgkin's disease survive."

C. Tell me a little bit more about your fear of dying. Most assessment about what the client means is needed before any interventions can be planned or implemented. All of the other statements indicate a conclusion that the client is afraid of dying of Hodgkins disease. Focus: Prioritization

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 Exercise may improve arterial blood flow by building collateral circulation; instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther.

Which of the following does the nurse recognize as a contributing factor to high BP? A. decreased CO B. pulse rate of 100 C. increased afterload D. decreased stroke volume

C Increased afterload=increased PVR and BP = CO x PVR so if PVR increases then BP increases

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 It is important to validate the client's concern and offer needed information. Asking the client if he is afraid may identify fear but does not allow the client to discuss his specific concern.

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 Priority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring for distal pulses. Pulse checks must be assessed postprocedure to detect improvement (stronger pulses) or complications (diminished or absent pulses).

A nurse is teaching a client who has a new script for ferrous sulfate. Which of the following should be included in the teaching? a. stools will be dark red in color b. take with milk if gi distress occurs c. foods high in vitamin c will promote absorption d. take for 14 days

C. Vitamin c enhances the absorption of iron by the intestinal trat, stools will be dark green to black, milk binds with iron and decreases absorption, iron therapy can take 4-6 weeks for hgb and hct to return to normal referene range

Varicose veins can cause changes in what component of Virchow's triad? A-Blood coagulability B-Vessel walls C-Blood flow D-Blood viscosity

C - Blood flow. **goal of treatment is to improve venous return (elastic compression, elevation, exercise)

Keith is having a photoelectric test down to detect PVD. When educating Keith about the process, the nurse would include: A. A conscious block will be used B. This measures the MAP C. Measures finger and toe pulses commonly D. Pain management and medication for after procedure

C - measures finger and toe pulses commonly

Which of the following signs indicates a chest tube may be removed? A. Drainage is approximately 100mL/hr in a patient with pleural chest tube following spinal surgery B. The chest radiograph shows only a small residual pneumothorax in a patient requiring mechanical ventilation C. Bubbling in the water seal has been absent for 24 hours following iatrogenic pneumothorax from CVP placement D. Fluctuations in the water seal are approximately 2 to 4cmH2O with each breathing cycle

C.

After attempting lifestyle changes with no improvement in the HTN, the nurse should expect the physician to prescribe which medication first? A. Calcium Channel Blocker B. ARB C. Thiazide diuretic D. Renin inhibitor

C. Diuretics are first line of defense. Thiazide diuretic is the first med to give, sometimes will be combined with a beta blocker. This combo is done so a lower dose of each med can be given.

The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select? A. Roast beef, gelatin salad, green beans, and peach pie B. Chicken salad sandwich, coleslaw, French fries, ice cream C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie D. Pork chop, creamed potatoes, corn, and coconut cake

C. Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not.

A nurse is assessing a patient for essential hypertension. She will expect him to report which symptom? A. Chest tightness B. Shortness of Breath C. No symptoms to report D. Anxious

C. Primary (essential) HTN is the silent killer and s/s are not obvious

A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention. Discuss A. Adjust the room temperature B. Give a bolus of IV fluids C. Start O2 D. Administer meperidine (Demerol) 75mg IV push

C. The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. Adjusting the room temperature is incorrect because although a warm environment reduces pain and minimizes sickling, it would not be a priority. Giving a bolus of IV fluids is incorrect because although hydration is important, it would not require a bolus. Administering meperidine (Demerol) 75mg IV push is incorrect because Demerol is acidifying to the blood and increases sickling.

Which of the following foods would the nurse encourage the client in sickle cell crisis to eat? A. Peaches B. Cottage cheese C. Popsicle D. Lima beans

C. Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in peaches , cottage cheese , and lima beans do not aid in hydration and are, therefore, incorrect.

According to a standard staging classification of Hodgkin's disease, which of the following criteria reflects stage II? A Involvement of extralymphatic organs or tissues B Involvement of single lymph node region or structure C Involvement of two or more lymph node regions or structures. D Involvement of lymph node regions or structures on both sides of the diaphragm.

C. Question 4 Explanation: Stage II involves two or more lymph node regions. Stage I only involves one lymph node region; stage III involves nodes on both sides of the diaphragm; and stage IV involves extralymphatic organs or tissues.

Which of the following laboratory values is expected for a client just diagnosed with chronic lymphocytic leukemia? A Elevated sedimentation rate B Uncontrolled proliferation of granulocytes C Thrombocytopenia and increased lymphocytes D Elevated aspartate aminotransferase and alanine aminotransferase levels.

C. Chronic lymphocytic leukemia shows a proliferation of small abnormal mature B lymphocytes and decreased antibody response. Thrombocytopenia also is often present. Uncontrolled proliferation of granulocytes occurs in myelogenous leukemia.

A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment? A. The client collects stamps as a hobby. B. The client recently lost his job as a postal worker. C. The client had radiation for treatment of Hodgkin's disease as a teenager D. The client's brother had leukemia as a child

C. Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, collecting stamps as a hobby and losing job as a postal worker are incorrect. The client's brother had leukemia as a child is incorrect because the incidence of leukemia is higher in twins than in siblings.

What are the three most important prognostic factors in determining long-term survival for children with acute leukemia? A Histologic type of disease, initial platelet count, and type of treatment B Type of treatment and client's sex C Histologic type of disease, initial WBC count, and client's age at diagnosis D Progression of illness, WBC at the time of diagnosis, and client's age at the time of diagnosis.

C. The factor whose prognostic value is considered to be of greatest significance in determining the long-range outcome is the histologic type of leukemia. Children with a normal or low WBC count appear to have a much better prognosis than those with a high WBC count. Children diagnosed between ages 2 and 10 have consistently demonstrated a better prognosis because age 2 or after 10.

An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator? A. Conjunctiva of the eye B. Soles of the feet C. Roof of the mouth D. Shins

C. The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, conjunctiva of the eye is incorrect. The soles of the feet can be yellow if they are calloused, making soles of the feet incorrect; the shins would be an area of darker pigment, so shins is incorrect. **In test review, they did mention specifically under eyelid, so read over.

The water seal is the most important element of the drainage system because: A. It indicates patency of the tubing by tidaling with inspiration and expiration B. It allows air to enter the pleural space but prevent air from exiting the pleural space through the chest tube C. It allows air to exit the pleural space but prevent air from entering the pleural space through the chest tube D. It allows air to move freely in and out of the pleural space through the chest tube

C. The water seal acts as a one-way valve: it allows air to exit through the system while preventing air from re-entering the pleural space, which could lead to accumulation of a pneumothorax. Losing the water seal would cause the same problem as having the creech tubing and thoracic catheter become disconnected and the thoracic catheter end open to the air.

A newly admitted client is diagnosed with Hodgkin's disease undergoes an excisional cervical lymph node biopsy under local anesthesia. What does the nurse assess first after the procedure? A. Vital signs B. Incision site C. Airway D. Level of consciousness

C. Airway Assessing for an open airway is the priority. The procedure involves the neck, the anesthesia may have affected the swallowing reflex or the inflammation may have closed in on the airway leading to ineffective air exchange.

What causes decreased BP in neurogenic shock? A. Movement of fluid into the cells B. Movement of fluid into the vasculature C. Disrupted SNS communication D. Polyuria

C. Disrupted SNS communication **The spinal or head injury causes loss of nerve control. The impaired nerve impulse causes vessels to dilate, and not enough blood to fill. **Two most common symptoms: hypotension and bradycardia

Which of the following would the nurse identify as the priority nursing diagnosis during a toddler's vaso-occlusive sickle cell crisis? A Ineffective coping related to the presence of a life-threatening disease B Decreased cardiac output related to abnormal hemoglobin formation C Pain related to tissue anoxia D Excess fluid volume related to infection

C. Pain For the child in a sickle cell crisis, pain is the priority nursing diagnosis because the sickled cells clump and obstruct the blood vessels, leading to occlusion and subsequent tissue ischemia. Although ineffective coping may be important, it is not the priority. Decreased cardiac output is not a problem with this type of vaso occlusive crisis. Typically, a sickle cell crisis can be precipitated by a fluid volume deficit or dehydration.

What is the preferred treatment for an anaphalactic shock? A. Epinephrine B. Placing the patient in a sitting position and administer oxygen C. Preventing the reaction from occurring through patient teaching D. Placing a bag of ice on the area, administer antihistamines and corticosteroids.

C. Preventing the reaction from occurring through patient teaching But if it does happen - epi first

The nurse following a client after a gastric resection observes carefully for evidence of nutritional deficiency anemia related to malabsorption including which of the following? 1.Bone pain 2.Dark yellow or bronze skin 3.Numbness and tingling of extremities 4. Steatorrhea

Correct Answer: Numbness and tingling of extremities Rationale: The client who has had a gastric resection is at risk for anemia because intrinsic factor may decrease, leading to vitamin B12 deficiency anemia with associated neurologic deficits such as numbness and tingling of extremities. The other symptoms are not related to nutritional deficiency anemia.

A patient is brought to the emergency department with hypotension, tachycardia, reduced capillary refill, and oliguria. During the assessment, the nurse determines the patient is experiencing cardiogenic shock because of which additional finding? 1. Jugular vein distention 2. Dry mucous membranes 3. Poor skin turgor 4. Thirst

Correct Answer: 1 Rationale 1: Jugular vein distention is a manifestation of cardiogenic shock. Rationale 2: The mucous membranes are not dry in cardiogenic shock. Rationale 3: The skin turgor is not poor in cardiogenic shock. Rationale 4: Thirst is not a manifestation of cardiogenic shock. Cardiogenic shock signs and symptoms: Rapid breathing, Severe shortness of breath, Sudden, rapid heartbeat (tachycardia), Loss of consciousness, Weak pulse, Sweating Pale skin, Cold hands or feet, Urinating less than normal or not at all

The nurse, caring for a patient recovering from an acute myocardial infarction, is planning interventions to reduce the risk of which type of shock? 1. Cardiogenic 2. Hypovolemic 3. Distributive 4. Obstructive

Correct Answer: 1 Rationale 1: One etiology of cardiogenic shock is a myocardial infarction. Rationale 2: Acute myocardial infarction does not cause hypovolemic shock. Rationale 3: Acute myocardial infarction does not cause distributive shock. Rationale 4: Acute myocardial infarction does not cause obstructive shock.

The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? a. Vitamin K b. Cobalamin c. Heparin sodium d. Protamine sulfate

Correct Answer: A Coumadin is a Vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin (Coumadin).

The female client recently diagnosed with Hodgkin's lymphoma asks the nurse about her prognosis. Which is the nurse's best response? 1.Survival for Hodgkin's disease is relatively good with standard therapy. 2.Survival depends on becoming involved in an investigational therapy program. 3.Survival is poor, with more than 50% of clients dying within six (6) months. 4.Survival is fine for primary Hodgkin's, but secondary cancers occur within a year

Correct Answer: 1. 1.Up to 90% of clients responds well to standard treatment with chemotherapy and radiation therapy, and those that relapse usually respond to a change of chemotherapy medications. Survival depends on the individual client and the stage of disease at diagnosis. 2.Investigational therapy regimens would not be recommended for clients initially diagnosed with Hodgkin's because of the expected prognosis with standard therapy. 3.Clients usually achieve a significantly longer survival rate than six (6) months. Many clients survive to develop long-term secondary complications. 4.Secondary cancers can occur as long as 20 years after a remission of the Hodgkin's disease has occurred."

A patient is demonstrating pulmonary edema, hypotension, and delayed capillary refill. The nurse suspects the patient is experiencing which type of shock? 1. Hypovolemic 2. Cardiogenic 3. Anaphylactic 4. Obstructive

Correct Answer: 2 Rationale 1: Pulmonary edema would not be present in hypovolemic shock. Rationale 2: In cardiogenic shock, there is a low cardiac output, hypotension, and pulmonary edema. Rationale 3: Pulmonary edema would not be present in anaphylactic shock. Rationale 4: Pulmonary edema would not be present in obstructive shock

A child with lymphoma is receiving extensive radiotherapy. Which of the following is the most common side effect of this treatment? A. malaise B. seizures C. neuropathy D. lymphadenopathy

Correct Answer: A 1. Malaise is the most common side effect of radiotherapy. For children, the fatigue may be especially distressing because it means they cannot keep up with their peers. 2. Seizures are unlikely because irradiation would not usually involve the cranial area for treatment of lymphoma. 3. Neuropathy is a side effect of certain chemotherapeutic agents. 4. Lymphadenopathy is one of the findings of lymphoma

The patient has CVI and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what these patients always have ordered. What assessment by the nurse would cause the application of compression stockings to harm the patient? a Rest pain b High blood pressure c Elevated blood sugar d Dry, itchy, flaky skin

Correct Answer: A Rationale: Rest pain occurs as peripheral artery disease (PAD) progresses and involves multiple arterial segments. Compression stockings should not be used on patients with PAD. Elevated blood glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension may or may not indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The RN should be the one to obtain the order and instruct the UAP to apply compression stockings if they are ordered.

Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? a A 70-year-old male, with high cholesterol and hypertension b A 40-year-old female with obesity and metabolic syndrome c A 60-year-old male with renal insufficiency who is physically inactive d A 65-year-old female with hyperhomocysteinemia and substance abuse

Correct Answer: A The most common etiology of descending abdominal aortic aneurysm (AAA) is atherosclerosis. Male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol

A bone marrow transplant is being considered for treatment of a patient with acute leukemia that has not responded to chemotherapy. In discussing the treatment with the patient, the nurse explains that a. hospitalization will be required for several weeks after the hematopoietic stem cell transplant (HSCT). b. the transplant of the donated cells is painful because of the nerves in the tissue lining the bone. c. donor bone marrow cells are transplanted immediately after an infusion of chemotherapy. d. the transplant procedure takes place in a sterile operating room to minimize the risk for infection

Correct Answer: A The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCT while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line, so the transplant is not painful, nor is an operating room required. The HSCT takes place 1 or 2 days after chemotherapy to prevent damage to the transplanted cells by the chemotherapy drug

A 68-year-old woman is diagnosed with thrombocytopenia due to acute lymphocytic leukemia. She is admitted to the hospital for treatment. The nurse should assign the patient: A. To a private room so she will not infect other patients and healthcare workers B. To a private room so she will not be infected by other patients and healthcare workers C. To a semiprivate room so she will have stimulation during her hospitalization D. To a semiprivate room so she will have the opportunity to express her feelings about her illness"

Correct Answer: B A. To a private room so she will not infect other patients and health care workers — poses little or no threat B. To a private room so she will not be infected by other patients and health care workers — CORRECT: protects patient from exogenous bacteria, risk for developing infection from others due to depressed WBC count, alters ability to fight infection C. To a semiprivate room so she will have stimulation during her hospitalization — should be placed in a room alone D. To a semiprivate room so she will have the opportunity to express her feelings about her illness — ensure that patient is provided with opportunities to express feelings about illness

A 67-year-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? a Patient complains of chest pain with strenuous activity. b Patient says muscle leg pain occurs with continued exercise. c Patient has numbness and tingling of all his toes and both feet. d Patient states the feet become red if he puts them in a dependent position.

Correct Answer: B Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain with exertion. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor.

A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the physician immediately to save the patient's limb? a Paralysis b Paresthesia c Crampiness d Referred pain

Correct Answer: B Rationale: The physician must be notified immediately if any of the six Ps of acute arterial ischemia occur to prevent ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being a very late sign indicating the death of nerves to the extremity. Crampy leg sensation is more common with varicose veins. The pain is not referred.

A 62-year-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker and has a history of gout. What should the nurse focus her teaching on to prevent complications for this patient? a Gender b Smoking c Ethnicity d Co-morbidities

Correct Answer: B Rationale: Smoking is the most significant factor for this patient. PAD is a marker of advanced systemic atherosclerosis. Therefore tobacco cessation is essential to reduce PAD progression, CVD events, and mortality. Diabetes mellitus and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD.

The patient had aortic aneurysm repair. What priority nursing action will the nurse use to maintain graft patency? a Assess output for renal dysfunction. b Use IV fluids to maintain adequate BP. c Use oral antihypertensives to maintain cardiac output. d Maintain a low BP to prevent pressure on surgical site

Correct Answer: B Rationale: The priority is to maintain an adequate BP (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it.

The nurse is caring for a patient suffering from anorexia secondary to chemotherapy. Which of the following strategies would be most appropriate for the nurse to use to increase the patient's nutritional intake? A. Increase intake of liquids at mealtime to stimulate the appetite. B. Serve three large meals per day plus snacks between each meal. C. Avoid the use of liquid protein supplements to encourage eating at mealtime. D. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods

Correct Answer: D The nurse can increase the nutritional density of foods by adding items high in protein and/or calories (such as peanut butter, skim milk powder, cheese, honey, or brown sugar) to the foods that a patient will eat. Other Rationales: Increasing liquids at meals can cause a patient to feel full faster, leading to eating fewer calories. Eating three large meals isn't possible for a patient on chemotherapy due to the decreased taste sensation. Liquid protein supplements should when needed but they lead to less eating during mealtimes due to feeling of satiation."

In planning care and patient teaching for the patient with venous leg ulcers, the nurse recognizes that the most important intervention in healing and control of this condition is a. sclerotherapy. b. using moist environment dressings. c. taking horse chestnut seed extract daily. d. applying elastic compression stockings.

Correct answer: d Rationale: Compression is essential for treating chronic venous insufficiency (CVI), healing venous ulcers, and preventing ulcer recurrence. Use of custom-fitted elastic compression stockings is one option for compression therapy.

What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for PAD patients (select all that apply)? a Ramipril (Altace) b Cilostazol (Pletal) c Simvastatin (Zocor) d Clopidogrel (Plavix) e Warfarin (Coumadin) f Aspirin (acetylsalicylic acid)

Correct Answers: a, c, d, f Angiotensin-converting enzyme inhibitors (e.g., ramipril [Altace]) are used to control hypertension. Statins (e.g., simvastatin [Zocor]) are used for lipid management. Aspirin is used as an antiplatelet agent. Cilostazol (Pletal) is used for intermittent claudication, but it does not reduce CVD morbidity and mortality risks. Clopidogrel may be used if the patient cannot tolerate aspirin. Anticoagulants (e.g., warfarin [Coumadin]) are not recommended to prevent CVD events in PAD patients.

A diagnosis of Hodgkin's disease is suspected in a 12 year old child seen in a clinic. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test results confirm the diagnosis of Hodgkin's disease? 1. Elevated vanillylmandelic acid urinary levels. 2. The presence of blast cells in the bone marrow. 3. The presence of Epstein-Barr virus in the blood. 4. The presence of Reed-Sternberg cells in the lymph nodes

Correct answer: #4 Hodgkin's disease is a malignancy of the lymph nodes. The presence of giant, multinucleated cells (Reed-sternberg cells) is the classic characteristic of this disease. The presence of blast cells in the bone marrow indicates leukemia. Epstein Barr virus is associated with infectious mononucleosis. Elevated levels of vanillylmandelic acid in the urine may be found in children with neuroblastoma

Multiple drugs are often used in combinations to treat leukemia and lymphoma because: a. there are fewer toxic and side effects b. the chance that one drug will be effective is increased c. the drugs are more effective without causing side effects d. the drugs work by different mechanisms to maximize killing of malignant cells

Correct answer: D Combination therapy is the mainstay of treatment for leukemia. The three purposes for using multiple drugs are to (1) decrease drug resistance, (2) minimize the drug toxicity to the patient by using multiple drugs with varying toxicities, and (3) interrupt cell growth at multiple points in the cell cycle

The nurse is caring for a 59-year-old woman who had surgery 1 day ago for removal of a suspected malignant abdominal mass. The patient is awaiting the pathology report. She is tearful and says that she is scared to die. The most effective nursing intervention at this point is to use this opportunity to: a. Motivate change in unhealthy lifestyles. b. Educate her about the seven warning signs of cancer. c. Instruct her about healthy stress relief and coping practices. d. Allow her to communicate about the meaning of this experience.

Correct answer: D Rationale: While the patient is waiting for diagnostic study results, the nurse should be available to actively listen to the patient's concerns and should be skilled in techniques that can engage the patient and the family members or significant others in a discussion about their cancer-related fears.

A key aspect of teaching for the patient on anticoagulant therapy includes which instructions? a. Monitor for and report any signs of bleeding. b. Do not take acetaminophen (Tylenol) for a headache. c. Decrease your dietary intake of foods containing vitamin K. d. Arrange to have blood drawn routinely to check drug levels.

Correct answer: a Rationale: Patients taking anticoagulants should be taught to monitor and report any signs of bleeding, which can be a serious complication. Other important patient teaching includes maintenance of a consistent intake of foods containing vitamin K, avoidance of supplements that contain vitamin K, and routine coagulation laboratory studies if a patient is taking warfarin.

The first priority of collaborative care of a patient with a suspected acute aortic dissection is to a. reduce anxiety. b. control blood pressure. c. monitor for chest pain. d. increase myocardial contractility.

Correct answer: b Rationale: The initial goals of therapy for acute aortic dissection without complications are blood pressure (BP) control and pain management. BP control reduces stress on the aortic wall by reducing systolic BP and myocardial contractility.

Rest pain is a manifestation of PAD that occurs due to a chronic a. vasospasm of small cutaneous arteries in the feet. b. increase in retrograde venous blood flow in the legs. c. decrease in arterial blood flow to the nerves of the feet. d. decrease in arterial blood flow to the leg muscles during exercise.

Correct answer: c Rationale: Rest pain most often occurs in the forefoot or toes and is aggravated by limb elevation. Rest pain occurs when blood flow is insufficient to meet basic metabolic requirements of the distal tissues. Rest pain occurs more often at night because cardiac output tends to drop during sleep and the limbs are at the level of the heart. Patients often try to achieve partial pain relief by dangling the leg over the side of the bed or sleeping in a chair to allow gravity to maximize blood flow.

A patient with infective endocarditis develops sudden left leg pain with pallor, paresthesia, and a loss of peripheral pulses. The nurse's initial action should be to a. elevate the leg to promote venous return. b. start anticoagulant therapy with IV heparin. c. notify the physician of the change in peripheral perfusion. d. place the bed in reverse Trendelenburg to promote perfusion.

Correct answer: c Rationale: The patient has potentially developed acute arterial ischemia (sudden interruption in the arterial blood supply to the extremity), caused by an embolism from a cardiac thrombus that occurred as a complication of infective endocarditis. Clinical manifestations of acute arterial ischemia include any or all of the six Ps : pain, pallor, paralysis, pulselessness, paresthesia, and poikilothermia. Without immediate intervention, ischemia may progress quickly to tissue necrosis and gangrene within a few hours. If the nurse detects these signs, the physician should be notified immediately

Priority nursing measures after an abdominal aortic aneurysm repair include a. assessment of cranial nerves and mental status. b. administration of IV heparin and monitoring of aPTT. c. administration of IV fluids and monitoring of kidney function. d. elevation of the legs and application of elastic compression stockings

Correct answer: c Rationale: Postoperative priorities include administration of IV fluids and maintenance of renal perfusion. An adequate blood pressure is important for maintaining graft patency, and administration of IV fluids and blood components (as indicated) is essential for adequate blood flow. The nurse should evaluate renal function by measuring hourly urine output and monitoring daily blood urea nitrogen (BUN) and serum creatinine levels. Irreversible renal failure may occur after aortic surgery, particularly in individuals at high risk.

The recommended treatment for an initial VTE in an otherwise healthy person with no significant co-morbidities would include a. IV argatroban (Acova) as an inpatient. b. IV unfractionated heparin as an inpatient. c. subcutaneous unfractionated heparin as an outpatient. d. subcutaneous low-molecular-weight heparin as an outpatient.

Correct answer: d Rationale: Patients with confirmed VTE should receive initial treatment with low-molecular-weight heparin (LMWH), unfractionated heparin (UH), fondaparinux, or rivaroxaban, followed by warfarin for 3 months to maintain the international normalized ratio (INR) between 2.0 and 3.0 for 24 hours. Patients with multiple comorbid conditions, complex medical issues, or a very large VTE usually are hospitalized for treatment and typically receive intravenous UH. LMWH only for 3 months is another option for patients with acute VTE. Depending on the clinical presentation, patients often can be managed safely and effectively as outpatients.

Which clinical manifestations are seen in patients with either Buerger's disease or Raynaud's phenomenon (select all that apply)? a. Intermittent fevers b. Sensitivity to cold temperatures c. Gangrenous ulcers on fingertips d. Color changes of fingers and toes e. Episodes of superficial vein thrombosis

Correct answers: b, c, d Rationale: Both Buerger's disease and Raynaud's phenomenon have the following clinical manifestations in common: cold sensitivity, ischemic and gangrenous ulcers on fingertips, and color changes of the distal extremity (fingers or toes).

The nurse is assessing a client diagnosed with acute myeloid leukemia. Which assessment data support this diagnosis? 1.) Fever and infections. 2.) Nausea and vomiting. 3.) Excessive energy and high platelet counts. 4.) Cervical lymph node enlargement and positive acid-fast bacillus

Correct: 1. 1. Fever and infection are hallmark symptoms of leukemia. They occur because the bone marrow is unable to produce WBCs of the number and maturity needed to fight infection (CORRECT). 2. Nausea and vomiting are symptoms related to the treatment of cancer but not to the diagnosis of leukemia (omit #2). 3. The clients are frequently fatigued and have low platelet counts. The platelet count is low as a result of the inability of the bone marrow to produce the needed cells (omit #3). 4. Cervical lymph node enlargement is associated with Hodgkin's lymphoma, and positive acid-fast bacillus is diagnostic for tuberculosis (omit #4).

Which of the following laboratory values could indicate that a child has leukemia? 1. WBCs 32,000/mm3 2. Platelets 300,000/mm3 3. Hemoglobin 15g/dL 4. Blood pH of 7.35

Correct: 1. 1. YES! - A normal WBC count is approximately 4.5 mm3 - 11.0 mm3. In leukemia a high WBC count is diagnostic and is usually confirmed by a blood smear. 2-4. None of these indicate leukemia

A child with leukemia is complaining of nausea. A nurse suspects that the nausea is related to the chemotherapy regimen. The nurse, concerned about the child's nutritional status, most appropriately would offer which of the following during this episode of nausea? 1. Cool, clear liquids 2. Low protein foods 3. Low-calorie foods 4. The child's favorite food

Correct: 1. With nausea, cool and clear liquids are better tolerated. Do not offer foods when the child is nauseated so he doesn't associate if with being sick. Support nutrition with oral supplements and foods high in proteins and calories

The client asks the nurse to explain what it means that his Hodgkin's disease is diagnosed at stage 1A. Which of the following describes the involvement of the disease? 1. Involvement of a single lymph node. 2. Involvement of two or more lymph nodes on the same side of the diaphragm. 3. Involvement of lymph node regions on both sides of the diaphragm. 4. Diffuse disease of one or more extralymphatic organs

Correct: 1. In the staging process, the designations A and B signify, respectively, that symptoms were or were not present when Hodgkin's disease was found. The Roman numerals I through IV indicate the extent and location of involvement of the disease. Stage I indicates involvement of a single lymph node; stage II, two or more lymph nodes on the same side of the diaphragm; stage III, lymph node regions on both sides of the diaphragm; and stage IV, diffuse disease of one or more extralymphatic organs.

The client diagnosed with leukemia has central nervous system involvement. Whichinstructions should the nurse teach? 1.Sleep with the head of the bed elevated to prevent increased intracranial pressure. 2.Take an analgesic medication for pain only when the pain becomes severe. 3.Explain that radiation therapy to the head may result in permanent hair loss. 4.Discuss end-of-life decisions prior to cognitive deterioration

Correct: 3 1.Sleeping with the head of the bed elevated might relieve some intracranial pressure, but it will not prevent intracranial pressure from occurring. 2.Analgesic medications for clients with cancer are given on a scheduled basis with a fast-acting analgesic administered PRN for break-through pain. 3.Radiation therapy to the head and scalp area is the treatment of choice for central nervous system involvement of any cancer. If the radiation therapy destroys the hair follicle, the hair will not grow back. 4.Cognitive deterioration does not usually occur"

A 4 yo is admitted for abdominal pain. She has been pale and excessively tired and is bruising easily. On physical exam, lymphadenopathy and hepatosplenomaegaly are noted. Diagnostic studies are being performed on the child because acute lymphocytic leukemia is suspected. Which diagnostic study would confirm this diagnosis "1. Platelet count 2. LUmbar puncture 3. bone marrow biopsy 4. wbc count

Correct: 3. 3 leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. The confirmatory test is microscopic exam of bone marrow obtained by bone marrow aspirate and biopsy. a lumbar puncture may be done to look for blast cells in the scfluid that indicate CNS disease. The wbc count may be normal, high or low in leukemia an altered platelet count occurs as a result of the disease but also may occur as a result of chemotherapy and does not confirm the diagnosis

The nurse is caring for a client diagnosed with acute myeloid leukemia. Which assess-ment data warrant immediate intervention? 1.T 99, P 102, R 22, and BP 132/68. 2.Hyperplasia of the gums. 3.Weakness and fatigue. 4.Pain in the left upper quadrant.

Correct: 4 1.These vital signs are not alarming. The vitalsigns are slightly elevated and indicate moni-toring at intervals, but they do not indicate animmediate need. 2.Hyperplasia of the gums is a symptom of myeloid leukemia, but it is not an emergency. 3.Weakness and fatigue are symptoms of thedisease and are expected. 4.Pain is expected, but it is a priority, andpain control measures should be imple-mented

Which test is considered diagnostic for Hodgkin's lymphoma? 1. A magnetic resonance image (MRI) of the chest. 2. A computed tomography (CT) scan of the cervical area. 3. An erythrocyte sedimentation rate (ESR). 4. A biopsy of the cervical lymph nodes

Correct: 4. 1. An MRI of the chest area will determine numerous disease entities, but it cannot determine the specific morphology of Reed-Sternberg cells, which are diagnostic for Hodgkin's disease. 2. A CT scan will show tumor masses in the area, but it is not capable of pathological diagnosis. 3. ESR laboratory tests are sometimes usedto monitor the progress of the treatmentof Hodgkin's disease, but ESR levels canbe elevated in several disease processes. 4. Cancers of all types are definitively diagnosed through biopsy procedures.The pathologist must identify ReedSternberg cells for a diagnosis ofHodgkin's disease (correct)

After a client with a potential diagnosis of leukemia is admitted to the hospital, the nurse should assess for which of the following? (Select all that apply.) A. Reports of fatigue and weakness B. An elevation in the leukocytes especially neutrophils C. Signs of bruising easily D. Recent weight gain

Correct: A, C ANSWER: Reports of fatigue and weakness Signs of bruising easily Rationale: General manifestations of leukemia result from anemia, infection, and bleeding. The client would complain of fatigue and weakness and show signs of bruising. Leukemic cells replace normal hematopoietic elements preventing the formation of mature leukocytes. Neutrophil count would be decreased. Because of an increased metabolism, weight loss may occur.

Which medication is contraindicated for a client diagnosed with leukemia? 1. Bactrim, a sulfa antibiotic 2. Morphine, a narcotic analgesic 3. Epogen, a biologic response modifier 4. Gleevec, a genetic blocking agent"

Correct: C 1. Because of the ineffective or nonexistent WBCs characteristic of leukemia, the body cannot fight infections, and antibiotics are given to treat infections. 2. Leukemic infiltrations into the organs or the CNS cause pain. Morphine is the drug of choice for most clients with cancer. 3. Epogen is a biologic response modifier that stimulates the bone marrow to produce RBCs. The bone marrow is the area of malignancy in leukemia. Stimulating the bone marrow would be generally ineffective for the desired results and would have the potential to stimulate malignant growth. 4. Gleevec is a drug that specifically works in leukemic cells to block the expression of the BCR-ABL protein, preventing the cells from growing and dividing.

Nursing considerations related to the administration of chemotherapeutic drugs include which of the following? A. Anaphylaxis cannot occur, since the drugs are considered toxic to normal cells. B. Infiltration will not occur unless superficial veins are used for the intravenous infusion. C. Many chemotherapeutic agents are vesicants that can cause severe cellular damage if drug infiltrates. D. Good hand washing is essential when handling chemotherapeutic drugs, but gloves are not necessary

Correct: C 3. Chemotherapeutic agents can be extremely damaging to cells. Nurses experienced with the administration of vesicant drugs should be responsible for giving these drugs and be prepared to treat extravasations if necessary. 1. Anaphylaxis is a possibility with some chemotherapeutic and immunologic agents. 2. Infiltration and extravasations are always a risk, especially with peripheral veins. 4. Gloves are worn to protect the nurse when handling the drugs, and the hands should be thoroughly washed afterward.

A client, diagnosed with chronic lymphocytic leukemia, is admitted to the hospital for treatment of hemolytic anemia. Which of the following measures, if incorporated into the nursing care plan, would best address the patient's needs? 1. Encourage activities with other patients in the day room. 2. Isolate him from visitors and patients to avoid infection. 3. Provide a diet high in Vitamin C 4. Provide a quiet environment to promote adequate rest

Correct: D. 1. does not meet need for rest 2. no info given about WBC or reverse isolation, on reverse isolation if neutrophil count is less than 500/mm3 3. needed for wound healing and resistance to infection, not best choice 4. primary problem activity intolerance due to fatigue. Correct

The client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? a) fatigue b) weakness c) weight gain d) enlarged lymph nodes

D - Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not related significantly to the disease."

A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is: A. Loss of sensation in the lower extremities B. Back pain that lessens when standing C. Decreased urinary output D. Pulsations in the periumbilical area

D. The client with an abdominal aortic aneurysm frequently complains of pulsations or "feeling my heart beat" in the abdomen. Answers A and C are incorrect because they occur with rupture of the aneurysm. Answer B is incorrect because back pain is not affected by changes in position.

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 The 70-year-old's history and clinical manifestations suggest possible aortic dissection. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery

What is systolic blood pressure? A) Pressure in the vessels when the heart rests between beats B) The amount of blood in the left ventricle prior to contraction C) The pressure the heart has to overcome to pump blood to the rest of the body D) Pressure in the blood vessels when the heart beats

D) Pressure in the blood vessels when the heart beats **amount of pressure or force generated by the left ventricle to distribute blood into the aorta

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? (Select all that apply.) 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, E, F Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion.

The client asks the nurse, "They say I have cancer. How can they tell if I have Hodgkin'sdisease from a biopsy?" The nurse's answer is based on which scientific rationale? A.Biopsies are nuclear medicine scans that can detect cancer. B.A biopsy is a laboratory test that detects cancer cells. C.It determines which kind of cancer the client has. D.The HCP takes a small piece out of the tumor and looks at the cells

D-COrrect: A biopsy is the removal of cells from a mass and examination of the tissue under a microscope to determine if the cells are cancerous. Reed-Sternberg cells are diag-nostic for Hodgkin's disease. If these cells are not found in the biopsy, the HCP can rebiopsy to make sure the specimen provided the needed sample or, depending on involvement of the tissue, diagnose a non-Hodgkin's lymphoma"

New bubbling is observed in the water seal chamber after a patient with a pleural chest tube returns from a test. The nurse clamps the chest tube momentarily with a tubing clamp at the dressing site. When this is done, bubbling in the water seal stops. The next appropriate nursing action is to: A. Continue to monitor the water seal chamber for bubbling every hour for the next four hours B. Do nothing. This bubbling is normal in patients with pleural chest tubes C. Call the physician immediately and do not leave the patient's bedside because of the risk of respiratory failure D. Remove the chest tube dressing to see if one or more eyelets of the chest tube have been pulled out of the chest

D.

Which of the following statements is true regarding patient movement while requiring chest drainage? (assume a physician order or protocol exists) A. Patients may go only from bed to a chair while the chest tube is connected to a chest drain B. If patient must leave nursing unit, suction tubing should be clamped shut while chest drain is disconnected from suction C. If a patient is ambulatory, the chest tube should be clamped shut while the chest drain is disconnected from suction D. Patients may walk around once the nurse disconnects the drain from suction as long as the drain remains below the chest

D.

An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae? A. The abdomen B. The thorax C. The earlobes D. The soles of the feet

D. Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petechiae. The abdomen, thorax , and earlobes are incorrect because the skin might be too dark to make an assessment.

A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client? A. Side-lying with knees flexed B. Knee-chest C. High Fowler's with knees flexed D. Semi-Fowler's with legs extended on the bed

D. Placing the client in semi-Fowler's position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client. Placing the client in semi-Fowler's position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client.

A client with leukemia has neutropenia. Which of the following functions must be frequently assessed? A Blood pressure B Bowel sounds C Heart sounds D Breath sounds

D. Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required. Although assessing blood pressure, bowel sounds, and heart sounds is important, it won't help detect pneumonia.

A client who has been receiving heparin therapy also is started on warfarin sodium (coumadin). The client asks the nurse why both medications are being administered. In formulating a response, the nurse incorporates the understanding that warfarin sodium: A Stimulates the breakdown of specific clotting factors by the liver, and it takes 2-3 days for this is exhibit an anticoagulant effect. B Inhibits synthesis of specific clotting factors in the liver, and it takes 3 to 4 days for this medication to exert an anticoagulation effect. C Stimulates production of the body's own thrombolytic substances, but it takes 2-4 days for it to begin. D Has the same mechanism action of heparin, and the crossover time is needed for the serum level of warfarin sodium to be therapeutic.

D. Question 9 Explanation: Warfarin sodium works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited.

You have developed the nursing diagnosis Risk for Impaired Tissue Integrity related to effects of radiation for a client with Hodgkin's lymphoma who is receiving radiation to the groin area. Which nursing activity is best delegated to a nursing assistant caring for the client? A. Check the skin for signs of redness or peeling. B. Apply alcohol-free lotion to the area after cleaning. C. Explain good skin care to the client and family. D. Clean the skin over daily with a mild soap.

D. Skin care is included in nursing assistant education and job description. Assessment and client teaching are more complex tasks that should be delegated to registered nurses. Use of lotions to the irradiated area is usually avoided during radiation therapy. Focus: Delegatio

A patient arrives in the emergency department with symptoms of myocardial infarction, progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with cardiogenic shock? A Hypertension. B Bradycardia. C Bounding pulse. D Confusion.

D. Cardiogenic shock severely impairs the pumping function of the heart muscle, causing diminished blood flow to the organs of the body. This results in diminished brain function and confusion, as well as hypotension, tachycardia, and weak pulse. Cardiogenic shock is a serious complication of myocardial infarction with a high mortality rate.

Chemotherapy is one of the therapeutic modalities for cancer. This treatment is contraindicated to which of the following conditions? A Recent surgery B Pregnancy C Bone marrow depression D All of the above

D. Chemotherapy is contraindicated in cases of infection (chemotherapeutic agents are immunosuppressive), recent surgery (chemotherapeutic agent may retard the healing process), impaired renal and hepatic function (drugs are nephrotoxic and hepatotoxic), recent radiation therapy (immunosuppressive treatment), pregnancy (drugs can cause congenital defects) and bone marrow depression (chemo. Agents may aggravate the condition).

Ms. Sy undergoes surgery and the abdominal aortic aneurysm is resected and replaced with a graft. When she arrives in the RR she is still in shock. The nurse's priority should be : A. Placing her in a trendeleburg position B. Putting several warm blankets on her C. Monitoring her hourly urine output D. Assessing her VS especially her RR

D. Shock is characterized by reduced tissue and organ perfusion and eventual organ dysfunction and failure. Checking on the VS especially the RR, which detects need for oxygenation, is a priority to help detect its progress and provide for prompt management before the occurrence of complications.

A client with heart failure and peripheral vascular disease has 4+ edema in his left ankle that extends to mid-calf. He is currently sitting on the side of his bed with his feet in a dependent position. Which goal would be the priority at this time? a. Resume normal respirations b. Reduce cardiac stress c. Prevent injury to lower extremity d. Decrease venous congestion

D. Venous congestion due to altered blood flow is the likely cause of this client's edema. The goal should be to decrease venous congestion by elevating the affected limb. No indication is given that this client is in respiratory distress or has abnormal cardiac stress at this time. The nurse should prevent injury to the lower extremity, but this is not the priority.

For a client experiencing symptoms of claudication, care plan activities should avoid promoting which of the following situations? a. Oxygen supply exceeds muscle demand b. Oxygen is absent c. Oxygen supply and muscle demand are equivalent d. Oxygen supply is inadequate for muscle demand

D. Clients who experience claudication complain of aching, cramping, and weakness. These signs indicate that oxygen supply is inadequate for muscle demand. Activities that aggravate these symptoms should be avoided.

A nurse understands they key symptom areas of PVD when the nurse includes: Tissue death, skin appearance and temperature, pulse changes, and: A. Increase of BP B. Vericose Veins C. Increased WBC D. Pain

D. Pain

The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment? A. Palpate the spleen B. Take the blood pressure C. Examine the feet for petechiae D. Examine the tongue

D. tongue will be smooth, red, and "beefy" in B12 anemia

A teenager arrives by private car. He is alert and ambulatory, but this shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that that they were goofing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration? A "There was a lot of blood and we used three bandages." B "He pulled the stick out, just now, because it was hurting him." C "The stick was really dirty and covered with mud." D "He's a diabetic, so he needs attention right away."

Question 20 Explanation: B An impaled object may be providing a tamponade effect, and removal can precipitate sudden hemodynamic decompensation. Additional history including a more definitive description of the blood loss, depth of penetration, and medical history should be obtained. Other information, such as the dirt on the stick or history of diabetes, is important in the overall treatment plan, but can be addressed later.

Notes from instructors regarding test questions after exam review: 1. A client receiving chemotherapy - all options were normal and expected except temp 100.9. 2. Compartment syndrome - loosen dressing first, then prepare for surgery. But PRIORITY = loosen dressing. 3. Newly diagnosed HTN - they ARE allowed to have alcohol in moderation. You can't tell them they can never drink again. 4. Sickle cell disease when you can palpate the spleen - nurses DO NOT obtain consent - we witness the consent, we monitor, and call the doctor. 5. A client in accident with tracheal shift - we fix the problem - Needle decompression needed. 6. Client with external fixator - we clean pin sites. 7. Sickle cell, RN just gave morphine. Do not underestimate the power of distraction in kids. Child life specialist were discussed in lecture. 8. Mucositis - eat every 2-3 hrs, SMALL meals 9. Delegation - why would the UAP not be able to take VS and report a temp? Not sure what happened here. Review

Notes from instructors regarding corresponding drug quiz: 1. Midazolam (AM) is a bendo, used for ANXIETY. You must know this drug for the Nclex. 2. Headaches and diarrhea NOT SEVERE side effects of gentamicin. They are expected. Only nephrotoxicity and ototoxicity are considered SEVERE. 3. ACE-I and Lasix are often given together. They are two different classes of antihypertensives. You can give one type of each class, just not two of the same class.

Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the: A Contralateral side in a simple pneumothorax B Affected side in a hemothorax C Affected side in a tension pneumothorax D Contralateral side in hemothorax

Question 10 Explanation: D The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax, accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation, the trachea will not shift. Tracheal deviation toward the contralateral side in simple pneumothorax is seen when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.

A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection? A Hematocrit B Partial thromboplastin time C Hemoglobin concentration D Prothrombin time

Question 14 Explanation: A Epogen is a recombinant DNA form of erythropoietin, which stimulates the production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit causes an elevation in blood pressure; therefore, the blood pressure is a vital sign that should be checked. The PTT, hemoglobin level, and PT are not monitored for this drug.

A patient sustains an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to the LPN/LVN? A Gently cleanse the amputated digits with Betadine solution. B Place the amputated digits directly into ice slurry. C Wrap the amputated digits in sterile gauze moistened with saline. D Store the amputated digits in a solution of sterile normal saline.

Question 14 Explanation: C The only correct intervention is C. the digits should be gently cleansed with normal saline, wrapped in sterile gauze moistened with saline, and placed in a plastic bag or container. The container is then placed on ice.

The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? A Whole grains B Green leafy vegetables C Meats and dairy products D Broccoli and Brussels sprouts

Question 2 Explanation: C Good sources of vitamin B12 include meats and dairy products. Whole grains are a good source of thiamine. Green leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin C).

You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-to-date immunizations. The date of the patient's last tetanus shot is unknown. Which of the following is the priority nursing diagnosis? A Risk for Infection related to organisms specific to cat bites B Impaired Skin Integrity related to puncture wounds C Ineffective Health Maintenance related to immunization status D Risk for Impaired Mobility related to potential tendon damage

Question 24 Explanation: A Cat's mouths contain a virulent organism, Pasteurella multocida, that can lead to septic arthritis or bacteremia. There is also a risk for tendon damage due to deep puncture wounds. These wounds are usually not sutured. A tetanus shot can be given before discharge.

A client with iron deficiency anemia is scheduled for discharge. Which instruction about prescribed ferrous gluconate therapy should the nurse include in the teaching plan? A "Take the medication with an antacid." B "Take the medication with a glass of milk." C "Take the medication with cereal." D "Take the medication on an empty stomach."

Question 26 Explanation: Preferably, ferrous gluconate should be taken on an empty stomach. Ferrous gluconate should not be taken with antacids, milk, or whole-grain cereals because these foods reduce iron absorption. **Take with orange join to increase absorption. If nausea occurs, have them take with food high in acidity to prevent nausea and increase absorption

In a multiple-trauma victim, which assessment finding signals the most serious and life-threatening condition? A A deviated trachea B Gross deformity in a lower extremity C Decreased bowel sounds D Hematuria

Question 27 Explanation: A A deviated trachea is a symptoms of tension pneumothorax. All of the other symptoms need to be addressed, but are of lesser priority.

A patient in a one-car rollover presents with multiple injuries. Prioritize the interventions that must be initiated for this patient. a. Secure/start two large-bore IVs with normal saline b. Use the chin lift or jaw thrust method to open the airway. c. Assess for spontaneous respirations d. Give supplemental oxygen per mask. e. Obtain a full set of vital signs. f. Remove patient's clothing. g. Insert a Foley catheter if not contraindicated. A C B D A E G F B C B D A E F G C A D F G E C B D A D F G C E B

Question 28 Explanation: B For a multiple trauma victim, many interventions will occur simultaneously as team members assist in the resuscitation. Methods to open the airway such as the chin lift or jaw thrust can be used simultaneously while assessing for spontaneous respirations. However, airway and oxygenation are priority. Starting IVs for fluid resuscitation is part of supporting circulation. (EMS will usually establish at least one IV in the field.) Nursing assistants can be directed to take vitals and remove clothing. Foley catheter is necessary to closely monitor output.

The nurse explains to the parents of a 1-year-old child admitted to the hospital in a sickle cell crisis that the local tissue damage the child has on admission is caused by which of the following? A Autoimmune reaction complicated by hypoxia B Lack of oxygen in the red blood cells C Obstruction to circulation D Elevated serum bilirubin concentration

Question 28 Explanation: C Characteristic sickle cells tend to cause "log jams" in capillaries. This results in poor circulation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell disease is an abnormality in the structure of RBCs. The erythrocytes are sickle-shaped, rough in texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction. Elevated serum bilirubin concentrations are associated with jaundice, not sickle cell disease.

The mothers asks the nurse why her child's hemoglobin was normal at birth but now the child has S hemoglobin. Which of the following responses by the nurse is most appropriate? A "The placenta bars passage of the hemoglobin S from the mother to the fetus." B "The red bone marrow does not begin to produce hemoglobin S until several months after birth." C "Antibodies transmitted from you to the fetus provide the newborn with temporary immunity." D "The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth."

Question 29 Explanation: D Sickle cell disease is an inherited disease that is present at birth. However, 60% to 80% of a newborns hemoglobin is fetal hemoglobin, which has a structure different from that of hemoglobin S or hemoglobin A. Sickle cell symptoms usually occur about 4 months after birth, when hemoglobin S begins to replace the fetal hemoglobin. The gene for sickle cell disease is transmitted at the time of conception, not passed through the placenta. Some hemoglobin S is produced by the fetus near term. The fetus produces all its own hemoglobin from the earliest production in the first trimester. Passive immunity conferred by maternal antibodies is not related to sickle cell disease, but this transmission of antibodies is important to protect the infant from various infections during early infancy.

The nurse has just admitted a 35-year-old female client who has a serum B12 concentration of 800 pg/ml. Which of the following laboratory findings would cue the nurse to focus the client history on specific drug or alcohol abuse? A Total bilirubin, 0.3 mg/dL B Serum creatinine, 0.5 mg/dL C Hemoglobin, 16 g/dL D Folate, 1.5 ng/mL

Question 3 Explanation: D The normal range of folic acid is 1.8 to 9 ng/mL, and the normal range of vitamin B12 is 200 to 900 pg/mL. A low folic acid level in the presence of a normal vitamin B12 level is indicative of a primary folic acid-deficiency anemia. Factors that affect the absorption of folic acid are drugs such as methotrexate, oral contraceptives, antiseizure drugs, and alcohol. The total bilirubin, serum creatinine, and hemoglobin values are within normal limits.

A mother asks the nurse if her child's iron deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following? A Little is known about iron-deficiency anemia and its relationship to infection in children B Children with iron deficiency anemia are more susceptible to infection than are other children C Children with iron-deficiency anemia are less susceptible to infection than are other children D Children with iron-deficient anemia are equally as susceptible to infection as are other children.

Question 31 Explanation: B Children with iron-deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.

Which of the following foods would the nurse encourage the mother to offer to her child with iron deficiency anemia? A Rice cereal, whole milk, and yellow vegetables B Potato, peas, and chicken C Macaroni, cheese, and ham D Pudding, green vegetables, and rice

Question 33 Explanation: B Potato, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice by itself also is not a good source of iron.

A child suspected of having sickle cell disease is seen in a clinic, and laboratory studies are performed. A nurse checks the lab results, knowing that which of the following would be increased in this disease? A Platelet count B Hematocrit level C Reticulocyte count D Hemoglobin level

Question 37 Explanation: C A diagnosis is established based on a complete blood count, examination for sickled red blood cells in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin and hematocrit levels and a decreased platelet count, and increased reticulocyte count, and the presence of nucleated red blood cells. Increased reticulocyte counts occur in children with sickle cell disease because the life span of their sickled red blood cells is shortened.

A clinic nurse instructs the mother of a child with sickle cell disease about the precipitating factors related to pain crisis. Which of the following, if identified by the mother as a precipitating factor, indicates the need for further instructions? A Infection B Trauma C Fluid overload D Stress

Question 38 Explanation: C Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1 ½ to 2 times the daily requirement to prevent dehydration.

Laboratory studies are performed for a child suspected of having iron deficiency anemia. The nurse reviews the laboratory results, knowing that which of the following results would indicate this type of anemia? A An elevated hemoglobin level B A decreased reticulocyte count C An elevated RBC count D Red blood cells that are microcytic and hypochromic

Question 39 Explanation: D The results of a CBC in children with iron deficiency anemia will show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

A vegetarian client was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: A Adds dried fruit to cereal and baked goods B Cooks tomato-based foods in iron pots C Drinks coffee or tea with meals D Adds vitamin C to all meals

Question 7 Explanation: C Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed. **Animal products and green leafy veg for diet**if vegetarian add dried fruits and legumes

A client was admitted with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance? A "What activities were you able to do 6 months ago compared with the present?" B "How long have you had this problem?" C "Have you been able to keep up with all your usual activities?" D "Are you more tired now than you used to be?"

Question 8 Explanation: A It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the client's activity tolerance by asking the client to compare activities 6 months ago and at the present. Asking a client how long a problem has existed is a very open-ended question that allows for too much subjectivity for any definition of the client's activity tolerance. Also, the client may not even identify that a "problem" exists. Asking the client whether he is staying abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were being completed or the resulting condition of the client after the tasks were completed. Asking the client if he is more tired now than usual does not address his activity tolerance. Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual.

A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is: a. Normal because of the increased blood flow through the leg b. Slightly deteriorating and should be monitored for another hour c. Moderately impaired, and the surgeon should be called. d. Adequate from the arterial approach, but venous complications are arising.

a. An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Options 2, 3, and 4 are incorrect interpretations.

Which type of fluid is most appropriate for volume replacement for a patient with non-hemorrhagic hypovolemic shock? a.) Lactated Ringers (LR) b.) 10% Dextrose in Water (D 10 W) c.) One-half Normal Saline (1/2% NS) d.) Packed Red Blood Cells (PRBC)

a.) Lactated Ringers (LR)

A client has been diagnosed with sepsis. The nurse will most likely find which of the following when assessing this client: Select all that apply: a.) Rapid shallow respirations. b.) Severe hypotension. c.) Mental status changes. d.) Elevated temperature. e.) Lactic acidosis. f.) Oliguria.

a.) Rapid shallow respirations. d.) Elevated temperature. Sepsis is first stage - tachypnea, tachycardia, compensated BP, elevated temperature (or very decreased) . Stage two severe sepsis involves brain and kidneys, hypotension and bradycardia here.

A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia is a.) urine output of 0.5 ml/kg/hr. b.) decreased peripheral edema. c.) decreased CVP. d.) oxygen saturation 90% or more.

a.) urine output of 0.5 ml/kg/hr. Rationale: A urine output of 0.5 ml/kg/hr indicates adequate renal perfusion, which is a good indicator of cardiac output. The patient may continue to have peripheral edema because fluid infusions may be needed despite third-spacing of fluids in relative hypovolemia. Decreased central venous pressure (CVP) for a patient with relative hypovolemia indicates that additional fluid infusion is necessary. An oxygen saturation of 90% will not necessarily indicate that cardiac output has improved.

Which of the following complications are three main consequences of leukemia? A Bone deformities, spherocytosis, and infection. B Anemia, infection, and bleeding tendencies C Lymphocytopoiesis, growth delays, and hirsutism D Polycythemia, decreased clotting time, and infection

The three main consequences of leukemia are anemia, caused by decreased erythrocyte production; infection secondary to neutropenia; and bleeding tendencies, from decreased platelet production. Bone deformities don't occur with leukemia although bones may become painful because of the proliferation of cells in the bone marrow. Spherocytosis refers to erythrocytes taking on a spheroid shape and isn't a feature in leukemia. Mature cells aren't produced in adequate numbers. Hirsutism and growth delay can be a result of large doses of steroids but isn't common in leukemia. Anemia, not polycythemia, occurs. Clotting times would be prolonged.

A nursing diagnosis that is appropriate for patients with moderate to sever anemia of any etiology is a. impaired skin integrity related to edema and pruiortos b. disturbed body image related to changes in appearance and body function c. imbalanced nutrition less than body requirements related to lack of knowledge of adequate nutrition d. activity intolerance related to decreased hemoglobin and imbalance between o2 supply and demand

answer d: pts with anemia have decreased hemoglobin and symptoms of hypoxemia, leading to activity intolerance. impaired skin integrity and body image disturbance may be appropriate for patients with jaundice from hemolytic anemias, and altered nutrition is indicated whn iron, folic acid, or vitamin b intake is deficint

A client with anemia has a nursing diagnosis of activity intolerance. Which of the following interventions will the nurse plan for this client? 1.Promote active and passive range-of-motion activities. 2.Space activities and plan rest periods. 3.Teach the client to change position slowly to prevent dizziness. 4. Teach the client the basics of good nutrition.

answer: 2 - Space activities and plan rest periods. Rationale: The client with activity intolerance tires easily, so it is best for the nurse to plan care and activities around periods of rest. Teaching good nutrition will not help the client to be less tired. Promoting range of motion does not address the issue of fatigue, nor does teaching the client to change position slowly.

The nurse is admitting a 7-year-old client who is experiencing sickle cell crisis and plans care based on which of the following nursing diagnoses? 1. Risk for Bleeding 2. Ineffective Airway Clearance 3.Risk for Constipation 4. Delayed Growth and Development

answer: 4 Delayed Growth and Development Rationale: The child with sickle cell disease is often developmentally delayed due to the effects of physical disability, pain, and inpatient hospital stays. The nurse would plan activities that help maintain developmental levels the child has reached. The child in sickle cell crisis does not experience ineffective airway clearance, bleeding, or constipation as a result of sickle cell disease. The child may have an illness that could cause one of these symptoms, but they are not common to children with sickle cell disease.

A nurse is completing an integumentary assessment of a client who has anemia. which of the following is an expected finding a. absent turgor b. sppon shaped nails c. shiny, hairless legs, d. yellow mucous membranes

answer: b spoon shaped nails, pail nail beds and mucous membranes are all present iwithin these patients **Notes say nails will be brittle, ridged, and concave

A nurse in a clinic receives a phone call form a client seeking info about his new prescription for erythropoietin (epogen) which of the following inf o should be reviewed with the client. a. the client needs an erythrocyte sedimentation rate test weekly (esr) b. the client should have his hemoglobin checked twice a week c. o2 saturation levels should be monitored d. folic acid production will increase.

answer: hemoglobin/ hematocrit will be measured twice a week bp is monitored for an increase, erythropoietin promotes increased production of rbc, it is evaluated by changes in hematocrit

The nurse caring for a patient in shock notifies the health care provider of the patient's deteriorating status when the patient's ABG results include: a.) pH 7.48, PaCO2 33 mm Hg. b.) pH 7.33, PaCO2 30 mm Hg. c.) pH 7.41, PaCO2 50 mm Hg. d.) pH 7.38, PaCO2 45 mm Hg.

b.) pH 7.33, PaCO2 30 mm Hg. Rationale: The patient's low pH in spite of a respiratory alkalosis indicates that the patient has severe metabolic acidosis and is experiencing the progressive stage of shock; rapid changes in therapy are needed. The values in the answer beginning "pH 7.48" suggest a mild respiratory alkalosis (consistent with compensated shock). The values in the answer beginning "pH 7.41" suggest compensated respiratory acidosis. The values in the answer beginning "pH 7.38" are normal.

The patient at highest risk for venous thromboembolism (VTE) is a.a 62-year-old man with spider veins who is having arthroscopic knee surgery. b.a 32-year-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe. c.a 26-year-old woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during her labor. d.an active 72-year-old man at home recovering from transurethral resection of the prostate for benign prostatic hyperplasia.

b.a 32-year-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe. Three important factors (called Virchow's triad) in the etiology of venous thrombosis are (1) venous stasis, (2) damage of the endothelium (inner lining of the vein), and (3) hypercoagulability of the blood. Patients at risk for venous thrombosis usually have predisposing conditions for these three disorders (see Table 38-8). The 32-year-old woman has the highest risk: long trips without adequate exercise (venous stasis), tobacco use, and use of oral contraceptives. Note: The likelihood of hypercoagulability of blood is increased in women older than 35 years who use tobacco.

When compensatory mechanisms for hypovolemic shock are activated, the nurse would expect which two patient findings to normalize? a.) Intensity of peripheral pulses and body temperature. b.) Peripheral pulses and heart rate (HR). c.) Metabolic alkalosis and oxygen saturation. d.) Cardiac output (CO) and blood pressure (BP).

d.) Cardiac output (CO) and blood pressure (BP).