Adult Exam 2

The nurse is providing teaching to a client taking bumetanide (Bumex). Which statement made by the client indicates an understanding of the teaching?

"I should take this medication early so I don't pee all night."

A client with atrial fibrillation is prescribed apixaban to reduce blood clot risk. Which client statement indicates teaching is successful?

"I'm glad that frequent blood monitoring will not be needed."

s/s of diastolic HF

- normal ventricle sign - Thick ventricle walls and/or thick septum - Normal contractile function - Normal EF - Pulmonary edema due to high ventricular pressure - S4 w/ HTN - BP often high - BNP elevated

S/S of right sided heart failure

-Jugular vein distention -Anorexia -N/V -Abdominal distention -Ascites -Hepatomegaly -Dependent edema, peripheral edema -Weight gain -Signs of left-sided heart failure -Tachycardia -Fatigue -Nocturia -Decreased pulse ox readings

Treatment for hypertensive emergency?

-admit patient to the ICU for IV meds and management of end-organ dysfunction-for most patients, aim to lower the bp by 10-15% over the first hour-IV meds and doses used to treat include:-nicardipine: initial infusion rate 5 mg/hr, increasing by 2.5 mg/hr evrey 5 min to a max of 15 mg/hr-sodium nitroprusside: 0.3-0.5 mcg/kg/min, increase by 0.5 mcg/kg/minute every few minutes as needed to a max dose of 10 mcg/kg/min-labetalol: 10-20 mg IV followed by bolus doses of 20-80 mg at 10 min intervals until target BP is reached to a max 300 mg cumulative dose-esmolol: initial loading dose 500 mcg/kg/min over 1 min, then 50-100 mcg/kg/min to a max dose 300 mcg/kg/min

Cardiac assessment with hypertensive crisis?

-asses for murmurs and gallops-asses for signs of heart failure, which is second most common sign of end-organ damage-we assess for murmurs at the top of the aorta, and where valves open and close (murmur comes from a malfunction in the valve)

Assessment for hypertensive crisis (HEENT)?

-head, eyes, ears, nose, throat-epitaxis (nosebleed)-funduscopic exam findings may include:-advanced retinopathy with arteriolar changes-hemorrhages-exudates-papilledema

Aflutter treatment

1. Carotid massage (performed by MD) 2. Oxygen 3. Amiodarone or Diltiazem 4. Cardioversion 5. Ablation therapy

A nurse discusses resumption of sexual activity with a client who is recovering from a myocardial infarction. Which information should the nurse share with the client?1Choose only familiar sexual positions.2Select familiar settings for sexual activity.3Return to regular sexual activity in four to six weeks.4Depending upon your preference, take a hot or cold shower after intercourse.

2.An unfamiliar environment increases stress, which increases cardiac workload. It is advantageous to experiment with positions and find one that is relaxing and permits unrestricted breathing. It is generally safe to resume sexual activity 7 to 10 days after an uncomplicated MI. However, some physicians believe that the client should decide when ready to resume sex. Hot or cold showers should be avoided just before and after intercourse.

The nurse teaches a student nurse about diagnostic studies used for acute coronary syndrome. Which statement made by the student nurse indicates effective learning?1"A pathogenic Q wave is seen in patients with unstable angina."2"Serum cardiac markers are released from necrotic heart muscle."3"A nitroprusside stress echocardiogram is used for patients with acute pericarditis."4"Coronary angiography is the only way to confirm the diagnosis of unstable angina."

2Serum cardiac markers such as myoglobin, creatine kinase, cardiac-specific troponin I (cTnI), and cardiac-specific troponin T (cTnT) are released in patients with myocardial infarction (MI) into the blood from necrotic heart muscle. These markers are important to diagnose MI. A patient with a pathologic Q wave and ST-elevated MI has prolonged coronary occlusion, because the MI evolves with time. Pharmacologic stress echocardiogram testing with dobutamine, dipyridamole, or adenosine simulates the effects of exercise and is performed on patients who are unable to exercise or have abnormal, nondiagnostic baseline echocardiograms. A coronary angiography is used for patients with stable or high-risk unstable angina.Text Reference - p. 749

A patient who is being discharged from the hospital after acute coronary syndrome will be participating in cardiac rehabilitation. Which information will the nurse provide about the early recovery phase of rehabilitation?1. Activity level depends on severity of angina or myocardial infarction (MI).2. Therapeutic lifestyle changes should become lifelong habits.3. Activity level is increased gradually with supervision and with electrocardiogram (ECG) monitoring.4. The focus will be on management of chest pain, anxiety, dysrhythmias, and other complications.

3. Activity level is increased gradually with supervision and with electrocardiogram (ECG) monitoring. In the early recovery phase after the patient is dismissed from the hospital, the activity level is increased gradually under supervision and with ECG monitoring. In the first phase of recovery, activity is dependent on the severity of the angina or MI. The late recovery phase includes therapeutic lifestyle changes that become lifelong habits. In the first phase of recovery attention is focused on the management of chest pain, anxiety, dysrhythmias, and other complications. STUDY TIP: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although you may have been able to enjoy regular sessions at the health club or at an exercise class several times a week, you now may have to cut down on that time without giving up a set schedule for an exercise routine. Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes for an exam. Listening to lecture recordings while doing floor exercises is another option. At least a couple of times a week, however, the exercise routine should be done without the mental connection to school; time for the mind to unwind is necessary, too. P. 726

A nurse is discussing discharge instructions with a client who had a coronary artery bypass graft (CABG). The client states, "My spouse is afraid to have sex with me. When will it be safe to have sex again?" Which is the most appropriate response by the nurse?1"You should wait at least 6 weeks to allow enough time for your chest incision to heal."2"You will need to talk that over with your surgeon before you leave."3"You can resume sexual activity when you feel you have recovered enough and when your chest no longer hurts."4"You can resume sexual activity as soon as you can climb one flight of stairs without fatigue or discomfort."

4"You can resume sexual activity as soon as you can climb one flight of stairs without fatigue or discomfort."The response "As soon as you can climb one flight of stairs without fatigue or discomfort" addresses the client's request for information. The energy required for sexual intercourse is equivalent to that of climbing one flight of stairs. Each client is different and may require longer or shorter than 6 weeks. The response "You will need to talk that over with your surgeon before you leave" avoids the client's question and cuts off communication. The nurse has a responsibility to teach. The answer "When you feel you have recovered enough and when your chest no longer hurts" is too vague and may be dangerous because the client has no basis to make a safe decision.

A patient asks the nurse about resuming sexual activity after acute coronary syndrome (ACS). What should the nurse include in the patient's teaching plan?1. Take a hot shower just before intercourse to provide relaxation.2. Limit the time, including foreplay, to 30 minutes to prevent overexertion.3. Wait an hour after ingesting a large meal before engaging in sexual activity.4. Taking a prophylactic nitrate may decrease chest pain during sexual activity.

4. Taking a prophylactic nitrate may decrease chest pain during sexual activity.(Taking a prophylactic nitrate may decrease chest pain during sexual activity. Hot or cold showers should be avoided just before or after intercourse. Consumption of food and alcohol should be reduced before intercourse is anticipated (e.g., waiting 3-4 hours after ingesting a large meal before engaging in sexual activity). There is no established time limit. Foreplay is desirable because it allows a gradual increase in heart rate before orgasm.)

The nurse is formulating a teaching plan according to evidence-based breast cancer screening guidelines for a 50-year-old woman with low risk factors. Which diagnostic methods should be included in the plan? (Select all that apply.

A. Annual mammogramD. Breast self-awarenessE. Clinical breast examination

Which client should the medical unit nurse assess first after receiving the shift report?A: the 84-yr-old client diagnosed w/ pneumonia who is afebrile but getting restlessB: the 25-yr-old client diagnosed w/ influenza who is febrile & has a headacheC: the 56-yr-old client daignosed w/ left-sided hemothorax w/ tidaling in the water-seal compatmnet of the pleurvacD: the 38-yr-old client diagnosed w/ a sinus infection who has green drainage from the nose

A; elderly clients diagnosed w/ pneumonia may not present w/ the "normal" symptoms, such as fever. The client's increased restlessness may indicate a decrease in O2 to the brain. This client should be seen first. B; the client w/ influenza would be expected to have an elevated temperature & a headache; therefore, this client would not need to be assessed first. C; tidaling in the water-seal compartment is expected; therefore the nurse would not need to assess this client first. D; sinus drainage is to be expected in a client diagnosed w/ a sinus infection.

the nurse is caring for clients on a vascular disorder unit. Which labatory data warrant immediate intervention by the nurse?A: the PTT of 98 seconds for a client diagnoses w/ DVTB: the hemoglobin 11.4 for a client diagnosed w/ Raynaud's phenomenonC: the WBC could of 11,000 for a client w/ a stasis venous disorderD: the triglyceride level of 312 mmol/L in a client diagnosed w/ HTN

A; therapeutic levels for PTT should be 1.5-2X the normal value, which is 39 seconds; therefore, this client is at risk for bleeding. the prolonged PTT indicates the client is recieving heparin. The nurse should stop the infusion & follow the facility protocol. B; the hemoglobin is within normal range& the client w/ Raynaud's disease does not have a problem w/ bleeding. C; The WBC count is elevated (norm is 5,000-10,000) but it would be elevated in a client who has an infection such as venous stasis ulcer. D; The triglycerides are high but it will take weeks to months of a heart healthy diet, exercise, & possibly meds to lower this level.

1. While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicatesa. decreased fluid volume.b. jugular vein atherosclerosis.c. increased right atrial pressure.d. incompetent jugular vein valves.

ANS: CThe jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.

38. After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first?a. A 39-yr-old patient with pericarditis who is complaining of sharp, stabbing chest painb. A 56-yr-old patient with variant angina who is scheduled to receive nifedipine (Procardia)c. A 65-yr-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about today's planned discharged. A 59-yr-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI)

ANS: DAfter PCI, the patient is at risk for hemorrhage from the arterial access site. The nurse should assess the patient's blood pressure, pulses, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority.

2. The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective?a. Weight loss of 2 pounds in 24 hoursb. Hourly urine output greater than 60 mLc. Reduction in patient complaints of chest paind. Reduced dyspnea with the head of bed at 30 degrees

ANS: DBecause the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occurred, but are not as specific to evaluating this patient's response.

Principles of ALARA

As Low As Reasonably Achievable (time, distance, shielding)

bradycardia drug

Atropine

The nurse has just received the shift report. Which client should the nurse assess first?A: the client w/ Guillain-Barre syndrome who has ascending paralysis to the kneesB: the client w/ a C-6 spinal injury who has autonomic dysreflexiaC: the client w/ parkinson's who is experiencing "pill rolling"D: the client w/ Huntington's disease who has writhing, twisting movements of the face

B; the client w/ a C-6 SCI is expected to have autonomic dysreflexia but it is an emergency situation; therefore, the nurse should assess this client first. A; the nurse would expect the client w/ Guillian-Barre syndrome to have ascending paralysis. C; "pill rolling" a hand tremor wherein a thumb & forefinger appear to move in a rotary fashion as if rolling a pill, is an expected clinical manifestation of Parkinson's. D; the client w/ Huntington's disease has chorea, which includes abnormal & excessive involuntary movements

The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first?A: the client w/ acute glomerulonephritis who has oliguira & periorbital edemaB: the client w/ benign prostatic hypertrophy who has blood oozing from the IV siteC: the client w/ renal calculi who is complaining of flank pain rated as a 5 on a scale of 1-10D: the client w/ nephrotic syndrome who has proteinuria & hypoalbuminemia

B; the nurse would not expect the client w/ BPH to have oozing blood from the intravenous site. This may indicate disseminated intravascular coagulation (DIC), which is a potentially life-threatening complication & requires immediate intervention. A; the nurse would expect the client w/ acute glomerulonephritis to have oliguira & periorbital edema. Acute glomerulonephritis is a d/o of glomeruli or small vessels in the kidney. C; the nurse would expect the client w/ renal calculi to have pain but a level 5 pain indicates the pain is under control. The nurse would expect the client w/ nephrotic syndrome to have proteinuria & hypoalbuminemia. Nephrotic syndrome is a non-specified d/o in which the kidneys are damaged, causing them to leak large amounts of protein into the urine.

How will the proper microbial medication be determined for a patient with acute pericarditis?

Based on the results of a blood culture, & whether the infective organism is viral, fungal, or bacterial

Low grade fever in cancer patient with low WBC is a _________ _______________. And what should you do for this?

Blood cultures before antibiotics. Antibiotics started within one hour

What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure?A. Urine outputB. Lung soundsC. Blood pressureD. Respiratory rate

C. Blood pressureAlthough all identified assessments are appropriate for a patient receiving IV nesiritide, the priority assessment would be monitoring for hypotension, the main adverse effect of nesiritide.

The nurse is working in an orthopedic unit. Which client should the nurse assess first?A: the client who is 2 weeks postoperative open reduction & external fixation (ORIF) of the right hip who is complaining of pain when ambulatingB: the client who is 10 days post op for left total knee replacement (TKR) who is refusing to use the continuous passive motion (CPM) machineC: the client who is 1 week post op for L3-L4 laminectomy who is complaining of numbness & tingling of the feetD: the client who is being admitted to the rehabilitation unit from the orthopedic surgical unit after a motor vehicle accident (MVA)

C; numbness & tingling of the legs are signs of possible neurovascular compromise. This client should be assessed first. A; the client having pain when ambulating after an ORIF of the hip is expected; this client would not need to be assessed first. B; the client should be ambulating & moving the left leg while in bed & would not need to be in the CPM machine 10 days postoperatively. D; the client being transferred should be assessed but would be considered stable; therefore, this client would not be assessed before a client would not be assessed before, this client would not be assessed before a client experiencing possible neurovascular compromise.

the nurse is caring for clients on a medical unit. Which task should the nurse implement first?A: change the abdominal surgical dressing for a client who has ambulated in the hallB: discuss the correct method of placing Montgomery straps on the client w/ the UAPC: assess the male client who called the desk to say he is nauseated & just vomitedD: place a call to the extended care facility to give the report on a discharged client

C; this client has experienced a physiological problem & the nurse must assess the client & the emesis to decide on possible interventions. A; this client should be seen in a timely manned, but not before the client who is vomiting. B; this can take some time & should not be hastily completed bc the nurse must know the task is being done correctly before delegating it to a UAP. D; this nurse could call the extended care facility after assessing the client who has vomited & after dressing the client's abdomen.

The nurse received the a.m. shift report on the following clients. Which client should the nurse assess first?A: the client w/ a right total knee replacement who wants to be removed from the continuous passive motion (CPM) machine.B: the client diagnosed w/ chronic low back pain who is crying & upset about being discharged homeC: the client who is 1 week postoperative for right total hip replacement (THR) who has a temperature of 100.4F (38)D: the client who has full-thickeness burns who needs to be medicated before being taken to whirlpool

D; the client must be medicated w/ a narcotic meds prior to begin taken to whirlpool., which is a physiological need. This client should be assessed first. A; the client needs assistance being removed from the CPM machine but it is not priority over a client who needs pain meds prior to a painful procedure. B; this is a psychosocial need & should be addressed but is not priority over a physiological need. C; this temp is elevated and the client should be seen but the nurse should medicate the client going to the whirlpool first then assess this client. Pain is priority over an elevated temp.

The unlicensed assistive personnel tells the nurse the client has a bp of 78/46 and a pulse of 116 using a vital signs maching. Which intervention should the nurse implement first?A: notify the HCP immediatelyB: have the UAP recheck the client's vitals manuallyC: place the client in Trendelenburg positionD: assess the client's cardiovascular status

D;The nurse should immediately go to the client's room to assess the client. A; the nurse should first assess the client to determine that status prior to notifying the HCP. B; the UAP has notified the nurse of a potentially serious situation, the nurse must assess first before taking any action. C; the nurse might place the client in Trendelenburg position once cardiovascular shock is determined

What is the purpose of NSAIDs & corticosteroids in the management of acute pericarditis?

Given for relief of pain & reduction of inflammation

sinus tachycardia

HR above 100 regular pr and qrs

ST elevation means what?

Infarction Infarction means tissue death that's reversible

What is JVD and what does it indicate?

Jugular vein distention is the bulging of the major veins in your neck. It's a key symptom of heart failure and other heart and circulatory problems. It's not a painful symptom, but it can happen with conditions that can be life-threatening.

S/S of left sided heart failure

L=Lungs -Pulmonary congestion -dyspnea -cough -blood-tinged frothy sputum -restlessness -tachycardia -S-3 -Orthopnea -nocturnal dyspnea

A patient reports dizziness, fatigue, and decreased exercise tolerance.Based on the reported symptoms, the nurse anticipates that the healthcare provider will diagnose the patient as having which classification of heart failure?SystolicRight-sidedDiastolicLeft-sided

Left-sidedFatigue, dizziness, and decreased exercise tolerance indicate left-sided heart failure. Diastolic, systolic, and right-sided heart failure present with different signs and symptoms.

The nurse teaches the client which guidelines regarding lifestyle modifications for hypertension?Reduce smoking to no more than four cigarettes per dayLimit aerobic physical activity to 15 minutes, three times per weekStop alcohol intakeMaintain adequate dietary intake of fruits and vegetables

Maintain adequate dietary intake of fruits and vegetables

first degree av block treatment

No treatment Monitor patients for more changes in heart rhythm

A nurse is reviewing the laboratory results of a client receiving chemotherapy for cancer. The nurse reports which abnormal result to the health care provider?

Platelet count, 40,000 cells/mm3

A patient with acute decompensated heart failure (ADHF) is admitted to the unit. About which orders should the nurse ask for clarification?

Regular diet-Normal saline IV bolus-Vital signs every 4 hours

Hypernatremia

S (Skin flushed) A (agitation) L (low grade fever ) T (thirst)

In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage?Serum uric acid of 3.8 mg/dLSerum creatinine of 2.6 mg/dLSerum potassium of 3.5 mEq/LBlood urea nitrogen of 15 mg/dL

Serum creatinine of 2.6 mg/dL

A client receiving IV fluid therapy suddenly becomes anxious and exhibits an elevated blood pressure, a bounding pulse, and shortness of breath. Which nursing action(s) would be most appropriate to assist this client? Select all that apply.Slow the IV rate.Contact the physician.Lower the client's head.Provide oxygen to the client.Restart the IV.

Slow the IV rate.Contact the physician.Provide oxygen to the client.

Pericarditis patient has a lot of chest pain. How is it treated?

Treat them with NSAIDS

What is the purpose of antimicrobials in acute pericarditis?

Treatment of causative infection

"The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider?A. White blood cell (WBC) count of 2700/µLB. Hematocrit of 30%C. Hemoglobin of 10 g/LD. Platelets of 95,000/µL"

a

A B C D

airway breathing circulation disability (neuro(change in LOC))

symptomatic bradycardia treatment

atropine and then pacemaker atropine effectiveness determined by elevated heart rate

sinus tachycardia drug

beta blockers calcium channel blockers

What to teach clients on coumadin?

bleeding precautions

You are providing discharge teaching to a patient being discharged home after hospitalization with pericarditis. The physician has ordered the patient to take Colchicine. Which of the following statements indicates the patient did NOT understand the education you provided?a) "I can take this medication with or without food."b) "I will notify the doctor immediately if I start experiencing nausea, vomiting, or stomach pain while taking this medication."c) "I like to take all my medications in the morning with grapefruit juice."d) "This medication is also used to treat patients with gout."

c) "I like to take all my medications in the morning with grapefruit juice."- The answer is C. Patients should not take Colchicine with grapefruit juice because it increases the amount of Colchicine the body absorbs (causing an increased chance of Colchicine toxicity). This medication can be taken WITH or WITHOUT food.

You are providing care to a patient experiencing chest pain when coughing or breathing in. The patient has pericarditis. The physician has ordered the patient to take Ibuprofen for treatment. How will you administer this medication? a) Strictly without food b) with a full glass of juice c) with a full glass of water d) with or without food

c) with a full glass of water- The answer is C. Ibuprofen should be taken with a full glass of water to prevent GI problems, such as ulcers or bleeding.

reasons for sinus tachycardia

exercise fever pain hypovolemia hemorrhage anxiety hypothyroidism

3 pacemaker complications

failure to capture failure to sense and failure to pace

hyperkalemia

heart palpitations, shortness of breath, chest pain, nausea, vomiting

a fib

irregularly irregular

undergo a left lobectomy to lung cancer.

its ok to feel afraid. lets talk about what you are afraid of

first degree av block

long PR interval normal p wave normal qrs

pacemaker teaching

minimize shoulder movement intially, assess hiccup, make sure grounded connection - permanent: carry ID card, first 2 weeks (wear sling, avoid raising arm above shoulder), no heavy lifting for 2 mo. - dont place alarm, magnet, stereo speaker, generators, garage opener on top of pacemaker -inform dentist

Normal Sinus rhytm

no treatment pr interval qrs interval: rate: 60-100

types of oncologic emergencies

obstructive metabolic infiltrative

s/s of systolic HF

orthopnea, nocturnal dyspnea, JVD, edema

how do you know first degree av block?

prolonger pr interval greater than 5 boxes,

Afib treatment

put on anticoagulants Warfarin Heparin Amiodarone

HYpocalcemia

risk for bleeding and cardiac dysrhythmias

bradycardia

slow heart rate (less than 60 bpm)

Hyponatremia

tachycardia and weak and thready pulses

treatment for sinus tachycardia

treat the underlying cause

What types of medications may be used in the management of acute pericarditis?

• NSAIDs• Corticosteroids• Antimicrobials

Which teaching point will the nurse include when providing discharge instructions to the patient with a new permanent pacemaker?

"Avoid lifting heavy objects for as long as your physician prescribes"

The nurse caring for a patient who requires a temporary transvenous pacemaker. Which statement indicates that the patient understands the nurse's teaching?

"I may experience uncomfortable muscle contractions"

The nurse is caring for a post-MI patient who has been started on daily simvastatin (Zocor) and a low-fat diet. Which statement best indicates that the nurse's teaching has been successful?

"I should call my doctor if I experience unexplained muscle pain"

The nurse is teaching the patient with an arrhythmia. Which statement indicates that the patient requires further teaching?

"I've switched from 5 cups of coffee to 5 cups of tea"

Which client statement indicates a good understanding of the nutritional modifications needed to manage hypertension?"A glass of red wine each day will lower my blood pressure.""I should eliminate caffeine from my diet to lower my blood pressure.""If I include less fat in my diet, I'll lower my blood pressure.""Limiting my salt intake to 2 grams per day will improve my blood pressure."

"Limiting my salt intake to 2 grams per day will improve my blood pressure."To lower blood pressure, a client should limit daily salt intake to 2 g or less. Alcohol intake is associated with a higher incidence of hypertension, poor compliance with treatment, and refractory hypertension. Moderate caffeine and fat intake don't significantly affect blood pressure

The statement indicates that the nurse's teaching about the purpose of an implanted cardioverted-defibrillator (ICD) has been successful?

"The ICD will detect bad rhythms and shock my heart into normal rhythm"

The nurse is performing health education-related lifestyle modifications for a patient who has been newly diagnosed with hypertension. As a component of these modifications, the DASH (Dietary Approaches to Stop Hypertension) eating plan has been recommended to the patient. Which of the nurse's recommendations is most congruent with this eating plan?"Try to buy and consume as many organic and natural foods as you can.""Try to replace the complex carbohydrates in your diet with protein-rich foods.""Try to reduce the overall amount of fat that is in your diet.""If you eat four of five small meals each day, you'll find that you're able to reduce your calorie intake."

"Try to reduce the overall amount of fat that is in your diet."The DASH eating plan emphasizes fruits, vegetables, fiber, potassium, and low-fat dairy products, and a reduction in animal protein, fat, and saturated fat. Organic foods and small, frequent meals are not components of the DASH eating plan.

The nurse performs patient teaching about minimally invasive direct coronary artery bypass (MIDCAB). Which statement indicates that the patient needs further instruction?

"it frightens me to think that my heart will be stopped for a long time during surgery"

The nurse is caring for a post-MI patient. The patient questions the reason for a stool softener and denies constipation. Which statement indicates that the patient accurately understands the nurse's teaching?

"stool softeners help me keep from straining during bowel movements, which can lower my heart rate"

Important for the nurse to ask what questions related to hypertensive crisis?

-history of present illness:-ask about neurologic symptoms such as:-headache-n/v-visual disturbances-sudden onset of severe headache suggests subarachnoid hemorrhage-rapid onset of radiating pain in chest and/or back may suggest aortic dissection-ask about dyspnea, orthopnea, cough, or fatigue, which may suggest cardiac decompensation

Treatment for hypertensive urgency?

-treat patients without evidence of end-organ damage with 1 of the following orally administered meds:-nicardipine (calcium channel blocker) 20-40 mg oral q8 hrs-captopril (ace inhibitor) 25 mg oral q8-12 hrs-labetalol (beta blockers) initial dose 200 mg oral, then additional 200-400 mg dose after 6-12 hrs prn-normalize bp gradually over 24-48 hrs, as rapid bp decreases may result in dangerously reduced organ perfusion-before discharge from the ed, observe the patient for several hrs

A client asks whether a benign tumor is cancerous. What is the best response by the nurse?1. "No, these rarely require drug treatment."2. "No, but if surgically removed, it will grow back."3. "Yes, this word is often used interchangeably with tumor."4. "Yes, these grow rapidly and can become resistant to treatment."

1. "No, these rarely require drug treatment."

The nurse is distinguishing differences between malignant and benign tumors. Which tumors would the nurse include in the list of benign tumors? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected.1. Adenoma2. Lipoma3. Carcinoma4. Sarcoma5. Melanoma

1. Adenoma2. Lipoma

The nurse is considering the risk factors for a clients development of primary hypertension. Which of the following would be considered nonmodifiable risk factors for the client? (Select all that apply.)1. Age2. Stress3. Gender4. Ethnicity5. Regular exercise6. Limits fat and salt in diet

1. Age3. Gender4. Ethnicity

Which of the following should the nurse tell a client when instructing on ways to reduce the risk factors for hypertension? (Select all that apply.)1. Smoking2. Diet3. Exercise4. Family history5. Race6. Stress

1. Smoking2. Diet3. Exercise6. Stress

The nurse is teaching a client diagnosed with hypertension about the DASH diet. How many servings of meat, fish, and poultry should the client consume per day?2 or fewer2 or 34 or 57 or 8

2 or fewerTwo or fewer servings of lean meat, fish, and poultry are recommended in the DASH diet. The diet also recommends two or three servings of low-fat or fat-free dairy foods, four or five servings of fruits and vegetables, and seven or eight servings of grains and grain products.

The nurse is explaining the DASH diet to a client diagnosed with hypertension. The client inquires about how many servings of fruit per day can be consumed on the diet. What is the nurse's best response?4 or 5 servings per day7 or 8 servings per day2 or 3 servings per day2 or fewer servings per day

4 or 5 servings per dayThe client can consume 4 or 5 servings of fruit per day on the DASH diet. The servings for grains and grain product is 7 or 8. Two or 3 servings of low-fat or fat-free dairy foods can be consumed per day. Meat, fish, and poultry servings are 2 or fewer per day.

A client tells the nurse that they are confused by the terms benign and malignant tumors. Which best describes these terms?1. Benign tumors grow rapidly and metastasize.2. Malignant tumors grow slowly and do not require treatment.3. Benign tumors need to be surgically removed and require antineoplastic therapy.4. Malignant tumors are called cancer and become resistant to treatment.

4. Malignant tumors are called cancer and become resistant to treatment.

47) The nurse coming on duty receives the report from the nurse going off duty. Which of the following clients should the on-duty nurse assess first?1. The 58-year-old client who was admitted 2 days ago with heart failure, BP of 126/76, and a respiratory rate of 21 breaths a minute.2. The 88-year-old client with end-stage right-sided heart failure, BP of 78/50, and a DNR order.3. The 62-year-old client who was admitted one day ago with thrombophlebitis and receiving IV heparin.4. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving IV diltiazem (Cardizem).

4. The client with A-fib has the greatest potential to become unstable and is on IV medication that requires close monitoring. After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion, and then go to the 58-year-old client admitted 2-days ago with heart failure (her s/s are resolving and don't require immediate attention). The lowest priority is the 89-year-old with end stage right-sided heart failure, who requires time consuming supportive measures.

The client receiving internal radiation therapy. The nurse should:A. Remember to give the badge to the next shift nurseB. Maintain 30 mins close contact with patientC. Wear gloves , mask and gown when entering client's roomD. Instruct relatives not to visit client during entire duration of therapy

A

A nurse is providing teaching to a client with cancer who is receiving external radiation therapy. Which of the following statements by the client indicates an understanding of the teaching?A. "I need to protect the area from sunlight"B. "I'm going to apply a heating pad to the area after each treatment."C "I'll massage the area once per day."D. "I'll wash off the markings after each therapy treatment."

A.To prevent skin irritation and subsequent breakdown, the nurse should instruct the client to protect areas of skin from sunlight that receive radiation

A nurse in the post anesthesia care unit is caring for a client who is postop following a thoracotomy and lobectomy. Which of the following postop assessments should the nurse give highest priority to?

ABGs

A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)?a. Cook food thoroughly before eating.b. Choose low fiber, low residue foods.c. Avoid public transportation such as buses.d. Use rectal suppositories if needed for constipation.e. Talk to the oncologist before having any dental work done.

ANS: A, C, EEating only cooked food and avoiding public transportation will decrease infection risk. A high-fiber diet is recommended for neutropenic patients to decrease constipation. Because bacteria may enter the circulation during dental work or oral surgery, the patient may need to postpone dental work or take antibiotics.

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/dLb. Blood potassium level of 3.0 mEq/Lc. Early morning BP reading of 164/96 mm Hgd. Orthostatic systolic BP decrease of 12 mm Hg

ANS: BHypokalemia 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.

The nurse is preparing a client for a biopsy of a lump in the right breast and the client asks the nurse about the difference between a benign tumour and a malignant tumour. Which of the following responses by the nurse is correct? a. "Benign tumours do not cause damage to other tissues." b. "Benign tumours are likely to recur in the same location." c. "Malignant tumours may spread to other tissues or organs." d. "Malignant cells reproduce more rapidly than normal cells."

ANS: CThe major difference between benign and malignant tumours is that malignant tumours invade adjacent tissues and spread to distant tissues and benign tumours never metastasize. The other statements are inaccurate. Both types of tumours may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumours do not usually recur.

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

AThe elevated creatinine indicates renal damage caused by the hypertension. The other laboratory results are normal.

A client who is immunosuppressed is being admitted to the hospital on neutropenic precautions. Which nursing interventions should be implemented to protect the client from infection? Select all that apply.1. Restrict all visitors.2. Admit the client to a private room.3. Place a mask on the client if the client leaves the room.4. Use strict aseptic technique for all invasive procedures.5. Place a "See the Nurse Before Entering" sign on the door to the room.6. Remove a vase with fresh flowers in the room that was left by a previous client.

Answer: 2, 3, 4, 5, 6Rationale: The client should wear a mask for protection from exposure to microorganisms whenever he or she leaves the room. The client who is on neutropenic precautions is immunosuppressed and therefore is admitted to a private room on the nursing unit. The use of strict aseptic technique is necessary with all invasive procedures to prevent infection. A sign indicating "See the Nurse Before Entering" should be placed on the door to the client's room, so the nurse can ensure that neutropenic precautions are implemented by anyone entering the room. Sources of standing water and fresh flowers should be removed to decrease the microorganism count. Not all visitors must be restricted; however, visitors need to be restricted to healthy adults and must perform strict hand-washing procedures and don a mask before entering the client's room.

The charge nurse on the cardiac unit is planning assignments for the day. Which of the following is the most appropriate assignment for the float nurse that has been reassigned from labor and delivery?A. A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prior to discharge.B. A suspected myocardial infarction patient on telemetry, just admitted from the Emergency Department and scheduled for an angiogram.C. A patient with unstable angina being closely monitored for pain and medication titration.D. A post-operative valve replacement patient who was recently admitted to the unit because all surgical beds were filled.

Answer: AThe charge nurse planning assignments must consider the skills of the staff and the needs of the patients. The labor and delivery nurse who is not experienced with the needs of cardiac patients should be assigned to those with the least acute needs. The patient who is one-week post-operative and nearing discharge is likely to require routine care. A new patient admitted with suspected MI and scheduled for angiography would require continuous assessment as well as coordination of care that is best carried out by experienced staff. The unstable patient requires staff that can immediately identify symptoms and respond appropriately. A post-operative patient also requires close monitoring and cardiac experience.

For a female client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care:A. Administering aspirin if the temperature exceeds 102B. Inspecting the skin for petechiae once every shiftC. Providing for frequent rest periodsD. Placing client in strict isolation

B

The nurse is caring for clients on an oncology unit. Which neutropenia precautions should be implemented?A. Hold all venipuncture sites for 5 minutesB. Safe food handlingC. Place all clients in reverse isolationD. Have clients use a soft bristle toothbrush

B

When teaching a patient about dietary management of stage 1 hypertension, which instruction is most appropriate?A Restrict all caffeine.B Restrict sodium intake.C Increase protein intake.D Use calcium supplements.

B Restrict sodium intake.The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Caffeine and protein intake do not affect hypertension. Calcium supplements are not recommended to lower BP.

When providing dietary instruction to a patient with hypertension, the nurse would advise the patient to restrict intake of which meat?A Broiled fishB Roasted duckC Roasted turkeyD Baked chicken breast

B Roasted duckRoasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall CVD risk. The other meats are lower in fat and are therefore acceptable in the diet.

The nurse is providing teaching to a client who has somatitis due to chemotherapy and radiation therapy. Which of the following statements by the client indicates a need for further teaching?A. I will use a soft toothbrush or foam swab for oral careB. I will use lemon and glycerin swabs after mealsC. I will remove my dentures except while eatingD. I will rinse my mouth frequently with hydrogen peroxide solution

B.The nurse should instruct the client who has stomatitis to aoid the use of lemon-glycerin swabs because they cause drying and irritation to the mucous membranes

The nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first?A: the client diagnosed w/ arterial occlusive disease who has intermittent claudicationB: the client on strict bed rest who is complaining of calf pain & has reddened calfC: the client who complains of low back pain when lying supine in the bedD: the client who is upset bc the food didn't taste good & is cold all the time

B; the client w/ calf pain could be experiencing DVT, a complication of immobility, which may be fatal if a pulmonary embolus occurs; therefore, this client should be assessed first. Client A; intermittent claudication is a symptom of arterial occlusive disease, so does not need to be assessed first. Client C; the client should be assessed but not prior to the client w/ a suspected DVT. Client D; the nurse should address the client's concern, but it's not priority over a physiological problem.

A patient with Hodgkin's lymphoma is undergoing external radiation therapy on an outpatient basis. After 2 weeks of treatment, the patient tells the nurse, "I am so tired I can hardly get out of bed in the morning." An appropriate intervention for the nurse to plan with the patient is to:A. Exercise vigorously when fatigue is not as noticeableB. Consult with a psychiatrist for treatment of depressionC. Establish a time to take a short walk every dayD. Maintain bed rest until treatment is completed

C

Skin reactions are common in radiation therapy. Nursing responsibilities on promoting skin integrity should be promoted apart from:A. Avoiding use of ointments, powders, and lotion to the areaB. Using soft cotton fabrics for clothingC. Washing the area with a mild soap and water and patting it dry not rubbing itD. Avoid direct sunshine or cold

C

The nurse teaches a 28-year-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which statement by the patient requires an intervention by the nurse?A "I will avoid adding salt to my food during or after cooking."B "If I lose weight, I might not need to continue taking medications."C "I can lower my blood pressure by switching to smokeless tobacco."D "Diet changes can be as effective as taking blood pressure medications."

C "I can lower my blood pressure by switching to smokeless tobacco."Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (such as the DASH diet) lowers blood pressure, and these decreases compare with those achieved with blood pressure-lowering medication.

When teaching how lisinopril (Zestril) will help lower the patient's blood pressure, which mechanism of action should the nurse use to explain it?A Blocks β-adrenergic effects.B Relaxes arterial and venous smooth muscle.C Inhibits conversion of angiotensin I to angiotensin II.D Reduces sympathetic outflow from central nervous system.

C Inhibits conversion of angiotensin I to angiotensin II.Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that inhibits the conversion of angiotensin I to angiotensin II, which reduces angiotensin II-mediated vasoconstriction and sodium and water retention. Beta blockers result in vasodilation and decreased heart rate. Direct vasodilators relax arterial and venous smooth muscle. Central acting α-adrenergic antagonists reduce sympathetic outflow from the CNS to produce vasodilation and decreased SVR and BP.

The nurse is teaching a women's group about prevention of hypertension. What information should be included in the teaching for all the women (select all that apply)?A Lose weight.B Limit nuts and seeds.C Limit sodium and fat intake.D Increase fruits and vegetables.E Exercise 30 minutes most days.

C Limit sodium and fat intake.D Increase fruits and vegetables.E Exercise 30 minutes most days.Primary prevention of hypertension is to make lifestyle modifications that prevent or delay the increase in BP. Along with exercise for 30 minutes on most days, the DASH eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP. Nuts and seeds and dried beans are used for protein intake. Weight loss may or may not be necessary for the individual.

A charge nurse is observing a newly licensed nurse provide care for a client who is receiving internal radiation therapy for the treatment of cervical cancer. For which of the following actions by the newly licensed nurse should the charge nurse intervene?A. Leave soiled linens in a container in the client's room.B. Instructing visitors to remain 3ft away from the client.C. Borrowing a dosimeter film badge from another nurse before entering the client's room.D. Removing an extra IV pole from the client's room to be used by another client.

C.A nurse should never borrow a dosimeter film badge from another staff member. Nurses who are caring for the client should each have a personal badge and wear it while in the client's room. The badge measures the radiation exposure that the nurse is receiving, and each film badge will indicate the nurse's cumulative radiation exposure.

What is the priority nursing action when a patient is transferred from the postanesthesia care unit (PACU) to the surgical unit after a lobectomy?1 Assess the patient's pain.2 Take the patient's vital signs.3 Check the rate of the intravenous (IV) infusion.4 Check the health care provider's postoperative prescriptions.

Correct2The highest priority action by the nurse is to assess the physiologic stability of the patient. This is in part accomplished by taking the patient's vital signs. Assessing the patient's pain, checking the prescriptions, and checking the rate of IV infusion can take place in a rapid sequence after taking the vital signs.

A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to the patient:A. Remove food debris from the teeth and oral mucosa with a stiff toothbrushB. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teethC. Gargle and rinse the mouth several times a day with an antiseptic mouthwashD. Rinse the mouth before and after each meal and at bedtime with a saline solution

D

Radiation protection is very important to implement when performing nursing procedures. When the nurse is not performing any nursing procedures what distance should be maintained from the client?A. 1 feetB. 2 feetC. 2.5 feetD. 3 feet

D

A 44-year-old man is diagnosed with hypertension and receives a prescription for benazepril (Lotensin). After the nurse teaches him about the medication, which statement by the patient indicates his correct understanding?A "If I take this medication, I will not need to follow a special diet."B "It is normal to have some swelling in my face while taking this medication."C "I will need to eat foods such as bananas and potatoes that are high in potassium."D "If I develop a dry cough while taking this medication, I should notify my doctor."

D "If I develop a dry cough while taking this medication, I should notify my doctor."Benazepril is an angiotensin-converting enzyme inhibitor. The medication inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indicate angioedema and should be reported immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modifications to lower blood pressure such as a reduced-sodium diet.

In reviewing medication instructions with a patient being discharged on antihypertensive medications, which statement would be most appropriate for the nurse to make when discussing guanethidine (Ismelin)?A "A fast heart rate is a side effect to watch for while taking guanethidine."B "Stop the drug and notify your doctor if you experience any nausea or vomiting."C "Because this drug may affect the lungs in large doses, it may also help your breathing."D "Make position changes slowly, especially when rising from lying down to a standing position."

D "Make position changes slowly, especially when rising from lying down to a standing position."Guanethidine is a peripheral-acting α-adrenergic antagonist and can cause marked orthostatic hypotension. For this reason, the patient should be instructed to rise slowly, especially when moving from a recumbent to a standing position. Support stockings may also be helpful. Tachycardia or lung effects are not evident with guanethidine.

A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which statement is the most therapeutic?a. The nurse stands at the patient's bedside and states, "Iunderstand how you feel. My mother said the same thingwhen she was ill."b. The nurse places a hand on the patient's arm and states, "You feel so alone."c. The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day."d. The nurse holds the patient's hand and asks, "What makes you feel so alone?"

D-The nurse holds the patient's hand and asks, "What makes you feel so alone?"The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely.

A nurse is providing teaching to a client who has cancer and is undergoing external radiation treatment. Which of the following statements by the client indicates an understanding of the teaching?A. I should use petroleum based lotions on the areas being radiated.B. I will dry the areas being radiated by rubbing in a circular pattern.C. I will apply sunscreen to the areas being radiated when spending time in the sun.D. I should use my hand, instead of a washcloth, to wash the areas being radiated.

D.Washing the areas being radiated with the hand is gentler than using a washcloth

A patient with a history of chronic hypertension is being evaluated in the emergency department for a blood pressure of 200/140 mm Hg. Which patient assessment question is the priority?Is the patient pregnant?Does the patient need to urinate?Does the patient have a headache or confusion?Is the patient taking antiseizure medications as prescribed?

Does the patient have a headache or confusion?The nurse's priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensive encephalopathy from increased cerebral capillary permeability leading to cerebral edema. In addition, headache or confusion could represent signs and symptoms of a hemorrhagic stroke.

A client with newly diagnosed hypertension asks how to decrease the risk for related cardiovascular problems. What risk factor is modifiable by the client?AgeImpaired renal functionFamily historyDyslipidemia

DyslipidemiaAge, family history, and impaired renal function are risk factors for cardiovascular disease related to hypertension that the client cannot change. Obesity, inactivity, and dyslipidemia are risk factors that the client can improve through diet, exercise, and other healthy lifestyle changes.

A patient with suspected heart failure is being assessed by the nurse.Which set of clinical manifestations indicate that the patient is presenting with left-sided failure?Edema of the feet and legs, anorexia, and nauseaRight upper quadrant pain, weakness, nausea, and vomitingFatigue, dizziness, shortness of breath, and coughDistended veins of the neck and edema of lower limbs

Fatigue, dizziness, shortness of breath, and coughCommon clinical manifestations of left-sided heart failure include fatigue, dizziness, shortness of breath, and cough. A patient presenting with symptoms such as anorexia, nausea, right upper quadrant pain, edema of the legs and feet, and distended veins of the neck is showing manifestations consistent with right-sided heart failure.

A 40-year-old woman was admitted to the oncology unit for severe dehydration from nausea and vomiting associated with chemotherapy 10 days ago. She has had two adjuvant treatments for breast cancer with doxorubicin (Adriamycin) and cyclophosphamide (Cytoxan). She has a Groshong port that was inserted 2 months ago for chemotherapy administration.The health care provider's orders include- Strict I&O every 12 hours- May use port for blooddraws and IV fluids- Call for vomiting or temp of100º F or greater- D5½NS at 125 mL/hr- Ondansetron (Zofran) 8 mgIV every 8 hours- Clear liquid diet andprogress as tolerated- CBC, Ca level, and basicmetabolic panel in AM- Bed rest with bathroomprivileges- Knee-high supportstockingsWhat does the nurse understand to be the rationale for each of the provider's orders?

I&O: Because the patient was admitted with dehydration, it is very important to monitor intake and output (I&O).Using port for blood draws/IV fluids: When the patient has nausea and vomiting, you often see a decrease in electrolytes from the excessive fluid volume loss.Call for vomiting or ≥100° F temperature: Any temperature elevation may be a sign of infection and should be reported immediately.D5½NS: This is to replace fluids.Ondansetron: This medication is to prevent nausea and vomiting caused by cancer chemotherapy.Clear liquid diet: This is to replace fluids and to provide some nutrition with decreased risk of nausea and vomiting.CBC, Ca, BMP: When the patient has nausea and vomiting, you often see a decrease in electrolytes from the excessive fluid volume loss.Bed rest, bathroom privileges: Because the patient is weak and dehydrated, these restrictions are for safety. Having bathroom privileges is often less stressful than using a bedpan.Knee-high stockings: There is a concern for DVT with prolonged bedrest, so support hose is ordered for the patient to increase venous return and prevent pooling of the blood.

A 67-yr-old woman with hypertension is admitted to the emergency department with a blood pressure of 234/148 mm Hg and was started on nitroprusside (Nitropress). After 1 hour of treatment, the mean arterial blood pressure (MAP) is 55 mm Hg. Which nursing action is a priority?Start an infusion of 0.9% normal saline at 100 mL/hr.Maintain the current administration rate of the nitroprusside.Request insertion of an arterial line for accurate blood pressure monitoring.Stop the nitroprusside infusion and assess the patient for potential complications.

Stop the nitroprusside infusion and assess the patient for potential complications.

The nurse receives report on the medical/surgical unit. Which of the following clients should the nurse see FIRST?1. A client with an IV of normal saline infusing at 125 ml per hour complaining of slight swelling at the IV insertion site.2. A client 3 days post right knee replacement complaining of right calf pain with movement.3. A client with a respiratory rate of 24 and an oxygen saturation of 94% on room air.4. A client 12 hours after a hysterectomy complaining of nausea.

Strategy: Determine the most unstable client.(1) assess site for client's comfort and to prevent complications associated with IV infusion, probable DVT takes priority(2) CORRECT—assessment for possible DVT should be performed and reported to the physician immediately(3) respiratory status is stable at present(4) administer antiemetics; client with calf pain takes priority

The nurse is seeing patients in the medical/surgical unit. Which of the following patients should the nurse see FIRST?1. A patient diagnosed with heart failure who has received 800 ml of IV fluids in 2 hours.2. A patient diagnosed with lung cancer with a blood calcium level of 10.5 mg/dL.3. A patient diagnosed with hypertension requiring the 9 A.M. dose of captopril (Capoten).4. A patient postoperative after a laminectomy who requires supervision when ambulating.

Strategy: Determine the most unstable patient.(1) CORRECT— assess for circulatory overload(2) normal range is 8.5 to 10.5 mg/dL(3) can give 30 min before or after prescribed time; ACE inhibitor(4) nothing to indicate patient is unstable

The nurse learns that patients from a motor vehicle accident are being transferred to the emergency department (ED). The nurse performs triage in the ED. Which of the following patients should the nurse see FIRST?1. A patient with ecchymosis and lacerations to the facial area.2. A patient complaining of shortness of breath and pressure in the chest.3. A patient with blood pressure of 90/60 and apical pulse of 120 bpm.4. A patient complaining of dizziness and nervousness.

Strategy: Determine the most unstable patient.(1) does not require immediate attention(2) potential problems; not the most unstable(3) CORRECT— vital signs indicate shock; most unstable patient(4) most stable patient of the four; use Maslow hierarchy of needs theory to prioritize; physiological needs take priority; use ABCs

A sibling of a client recently diagnosed with colon cancer questions the nurse in regard to the carcinoembryonic antigen (CEA) blood test. Appropriate info from the nurse should include, "The CEA test is...?A. most helpful in monitoring in the progress of the disease in clients already being treated for colon cancerB. an effective screening test and is indicated due to your family history of colon cancerC. recommended by the American Cancer Association to be performed yearly starting at age 50D. used to confirm diagnosis if a client has symptoms consistent with colon or rectal cancer

a

The nurse is teaching a 47-year-old woman about recommended screening practices for breast cancer. Which statement by the client indicates understanding of the nurse's instructions?A "My mother and grandmother had breast cancer, so I am at risk."B "I get a mammogram every 2 years since I turned 30."C "A clinical breast examination is performed every month since I turned 40."D "A computed tomography (CT) scan will be done every year after I turn 50."

a

The prostate-specific antigen (PSA) test is used in screening for prostate cancer. Which statement is true regarding this test?A. The PSA test can be used to monitor the disease after prostate cancer treatment.B. PSA levels less than 7.5 ng/mL may be considered normal.C. Elevated PSA levels are diagnostic for prostate cancer.D. Younger men, particularly African Americans, often have a higher normal PSA.

a

The nurse at the clinic is interviewing a 61-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)? a. Pap testing b. Tobacco use c. Sunscreen use d. Mammography e. Colorectal screening

a.Pap testingc.Sunscreen used.Mammographye.Colorectal screening

A client's spouse asks the nurse why must prostate screening be emphasized to the African-American population. What is the nurse's best response?A. "Metastasis of prostate cancer is higher."B. "Prostate cancer occurs at an earlier age."C. "Prostate-specific antigen (PSA) is not sensitive to prostate disease."D. "Clinical presentation is different."

b

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

b

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

b

The nurse determines that the patient has stage 2 hypertension when the patient's average blood pressure is (select all that apply):a. 155/88 mm Hgb. 172/92 mm Hgc. 160/110 mm Hgd. 172/106 mm Hg

b c d

The primary health care provider has ordered neutropenic precautions for a patient with neutropenia. What restrictions may be included in protective isolation precautions?a. Low sodium dietb. Restrictions on fresh fruits and vegetablesc. Restricted fluidsd. Visitors forbidden

b. Restrictions on fresh fruits and vegetables

HYpercalcemia

bones, blood, beats swollen and slow with moans groans and stones

The human papilloma virus (HPV) test may be collected at the same time as the Papanicolaou (Pap) test for screening. Which finding indicates the highest risk for development of cervical cancer?A. Normal Pap results and no HPV infectionB. Abnormal Pap results and no HPV infectionC. Abnormal Pap results and positive HPV testD. Normal Pap results and positive HPV results

c

Which of the following is a health promotion activity for the early detection and treatment of​ cervix/uterine cancer?A. Begin DRE at age 50 yearsB. Conduct breast​ self-examinations monthly starting at age 20 yearsC. Begin screenings 3 years after first having vaginal intercourse but no later than age 21 yearsD. Begin yearly mammograms at age 40 years

c

With which male client will the nurse conduct prostate screening and education?A. Young adult with a history of urinary tract infections.B. Client who has sustained an injury to the external genitalia.C. Adult who is older than 50 years.D. Sexually active client

c

The nurse instructs a young adult about testicular cancer. What is the most important preventive intervention for testicular cancer?A. Annual prostate screening.B. Circumcision.C. Daily exercise.D. Monthly testicular self-examination.

d

The nurse presents a cancer prevention program to teens. Which instruction will have the greatest impact in cancer prevention?A Avoid asbestos.B Wear sunscreen.C Get the human papilloma virus (HPV) vaccine.D Do not smoke cigarettes.

d

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

d

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

d

Potassium effects on heart

heart rhythm

Calcium effects on ECG

hyper= shorten st segment hypo=prolonged st segment

Potassium effects of ECG

hyperkalemia= peaked t wave, flattened p wave, prolonged pr interval, st depression, and prolonged qrs duration hypokalemia= peaked p wave, prolonged pr interval, prominent u wave, shallow t wave, and st depression

Magnesium effects on heart

hypermagnesia= heart beats slowly hypomagnesia- heart beats quicker

Magnesium effects on ECG

hypermagnesia= prolongation of pr interval, increased duration of qrs complex, prolonged qt interval, delayed intraventricular conduction, and increased height of the t wave hypomagnesia= low t wave

undergo surgery for benign prostatic hypertrophy. the client states " i don't know what i will do if they discover i have cancer

im hearing that you are concerned that you could have cancer

A client who was recently diagnosed with prehypertension is to meet with a dietitian and return for a follow-up with the cardiologist in 6 months. What would this client's treatment likely include?nonpharmacological interventionspharmacological interventionsprocedural interventionsobservation only

nonpharmacological interventions

The nurse is caring for a male patient with angina who has a new prescription for sublingual nitroglycerin. What information is most important for the nurse to include in the teaching plan?

store nitroglycerin tablets in a cool, dark location

client who has cancer/ the client wants to try nontraditional treatments instead of the chemo

tell me more about your concerns

hypokalemia

weak muscles and abnormal heart rhythms

assisting with a group therapy session for clients who are newly dx with cancer.

what do you mean when you say you cannot ever return to work

a nurse caring for a client who has invasive breast cancer and is starting chemo tells the nurse that she is worried about the adverse effects of the treatment

what is it about the adverse affects that concern you