Care 2 Exam 1 Practice Questions

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. 2. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. 4. The client with chronic renal failure who has an elevated creatinine level.

1. The client diagnosed with myocardial infarction who has an audible S3 heart sound.

The nurse is providing discharge instructions to a client recovering from mechanical valve replacement. Which statement indicates that teaching has been effective? 1) "I may have to have the valve replaced every year." 2) "I will take an enteric-coated aspirin every morning." 3) "I should take antibiotics before any invasive procedure." 4) "I will use a hard-bristle toothbrush when I brush my teeth."

3) "I should take antibiotics before any invasive procedure." Prophylactic antibiotics before invasive procedures help prevent an infection that can lead to endocarditis. The client understands the discharge teaching. In most cases, a mechanical valve will last a lifetime. Aspirin interferes with clotting and may potentiate the effects of the anticoagulant therapy, which the client with a mechanical valve will be prescribed. The client will be receiving anticoagulant therapy and should use a soft-bristle toothbrush to help prevent gum trauma and bleeding.

The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching? 1. "Do you have a daily bowel movement?" 2. "Do you get yearly chest x-rays?" 3. "Are you sexually active?" 4. "Have you had any weight change?"

3. "Are you sexually active?" It is a risk factor for angina in an older pt w/CAD

10. The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting. 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain with inspiration and a nonproductive cough.

3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62.

The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication? 1. The client's apical pulse is 64. 2. The client's calcium level is elevated. 3. The client's telemetry shows occasional PVCs. 4. The client's blood pressure is 90/62.

4. The client's blood pressure is 90/62. The pts BP is low and a CCB could cause the BP to bottom out.

The nurse is conducting a health education group for retired clients with COPD to help them improve their respiratory effort and gas exchange. The nurse should place the most emphasis on which of the following? A. Cluster activities to conserve energy B. Do not shovel snow C. Eat frequent, large meals to promote healing D. Sleep in supine position to improve air movement

Answer: B extreme temps and vigorous activities will tax respiratory system, should pace activities with rest in between, eat small frequent meals to prevent bloat and more pressure on diaphragm, should elevate HOB

The nurse is caring for a patient with a right pleural effusion that needs to be treated. Which of the following items should the nurse have available for immediate use by the physician? A. ABG kit B. Intubation Kit C. Paracentesis tray D. Thoracentesis tray

D. thoracentesis is the procedure that drains fluid in pleural space

A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often at rest in the absence of precipitating factors. How would the nurse best describe this type of anginal pain? A. Stable angina B. Variant angina C. Unstable angina D. Nonanaginal pain

Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction.

27. The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? 1. Perform passive range-of-motion exercises. 2. Assess the client's neurovascular status. 3. Keep the client in high Fowler's position. 4. Assess the gag reflex prior to feeding the client.

2. Assess the client's neurovascular status. Nurse needs to make sure that blood is circulating to the right leg, so the pt should be assessed for pulses, paresthesia, paralysis, coldness, + pallor.

Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? 1. Assess the client's radial pulse. 2. Assess the client's serum potassium level. 3. Assess the client's glucometer reading. 4. Assess the client's pulse oximeter reading.

2. Assess the client's serum potassium level.

Unlicensed assistive personnel (UAP) report that a client is having trouble breathing. Which intervention should the nurse implement first? 1) Elevate the head of the bed 2) Notify the respiratory therapist 3) Check the pulse oximetry reading 4) Administer oxygen via nasal cannula

1) Elevate the head of the bed The first intervention should be to elevate the client's head of the bed to help expand the lungs. The nurse can notify the respiratory therapist, but the first intervention is to take care of the client. The nurse can check the client's peripheral oxygenation level, but the first intervention is to help the client breathe easier. The nurse should administer oxygen if prescribed but not before elevating the client's head of the bed.

5. The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? 1. An elevated B-type natriuretic peptide (BNP). 2. An elevated creatine kinase (CK-MB). 3. A positive D-dimer. 4. A positive ventilation/perfusion (V/Q) scan.

1. An elevated B-type natriuretic peptide (BNP).

The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement? 1. Notify the health-care provider immediately. 2. Elevate the head of the client's bed. 3. Document this as a normal and expected finding. 4. Administer morphine intravenously.

1. Notify the health-care provider immediately. An S3 indicates left ventricular heart failure and should be reported to the HCP. It is a potential life-threatening complication of an MI.

The nurse is teaching a client recently diagnosed with essential hypertension. Which statement indicates that additional teaching is required? 1) "I should take my medication even if I am feeling good." 2) "I should perform isometric exercises three times a week." 3) "I should eat a low-salt, low-fat, and low-cholesterol diet." 4) "I will get my blood pressure checked three times a week."

2) "I should perform isometric exercises three times a week." Isometric exercises (such as weight lifting) should be discouraged, because performing them can raise the systolic blood pressure. This indicates the client needs more teaching. Essential hypertension is known as the "silent killer," because the client may be asymptomatic.

During a postoperative assessment, the nurse notes that a client has decreased breath sounds in both lung bases. What action would be the most effective at this time? 1) Assist to a side-lying position 2) Coach in the use of the incentive spirometer 3) Encourage to move lower extremities in bed 4) Keep the head of the bed at a 30-degree angle

2) Coach in the use of the incentive spirometer The use of the incentive spirometer will help aerate the lower lung bases. A side-lying position will not improve bilateral lower lung functioning. Moving the lower extremities in bed will help prevent venous stasis. The head of the bed should be elevated higher to help aerate the lower lung lobes.

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Midepigastric pain and pyrosis. 2. Diaphoresis and cool clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema.

2. Diaphoresis and cool clammy skin. Diaphoresis (sweating) is a systemic reaction to an MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this in turn, leads to cool, clammy skin

The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. 2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. 3. Determine if the client has gained weight and instruct the client to keep the legs elevated. 4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.

2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice.

The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? 1. Put a nitroglycerin tablet under the tongue. 2. Stop the activity immediately and rest. 3. Document when and what activity caused angina. 4. Notify the health-care provider immediately.

2. Stop the activity immediately and rest. Stopping the activity decreases the heart's need for O2 and may help decrease the angina.

7. The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include? 1. Instruct the client to take a cough suppressant if a cough develops. 2. Teach the client how to prevent orthostatic hypotension. 3. Encourage the client to eat bananas to increase potassium level. 4. Explain the importance of taking the medication with food.

2. Teach the client how to prevent orthostatic hypotension.

The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication? 1. The client has a BP of 110/70. 2. The client has an apical pulse of 56. 3. The client is complaining of a headache. 4. The client's potassium level is 4.5 mEq/L.

2. The client has an apical pulse of 56.

A client is being treated for an acute exacerbation of congestive heart failure (CHF). Which manifestations should the nurse expect when assessing this client? 1) Nonproductive cough 2) Uses one pillow to sleep 3) Audible S3 heart sounds 4) Capillary refill time less than 3 seconds

3) Audible S3 heart sounds The client with CHF would have third heart sounds, tachycardia, dependent edema, fatigue, lung congestion, and change in mental status. The client with CHF usually has pink frothy sputum and crackles that do not clear with coughing. The client with CHF would report sleeping on more than one pillow, if not sleeping in an upright position, and labored breathing. A capillary refill time of less than 3 seconds is within normal limits and would not indicate CHF.

A client with arterial occlusive disease is scheduled for a femoral-popliteal bypass in the morning. Which interventions should the nurse implement? Select all that apply. 1) Determine if pain at rest is present 2) Keep legs elevated on two pillows 3) Ensure the consent form has been signed 4) Assess the lower extremities for paresthesia 5) Encourage to keep the legs in a dependent position

3, 4, 5 The nurse should ensure the client has signed the surgical consent form. Resting pain occurs in clients with arterial occlusive disease and indicates very little oxygen is getting to the lower extremities. The dependent position (hanging off the bed) will increase blood supply to the lower extremities and decrease leg pain. The nurse should determine if the client has any numbness or tingling. Elevating the legs increases pain to the lower extremities, because this decreases oxygen supply to the already hypoxic lower extremity muscles.

The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client? 1. Social worker. 2. Physical therapy. 3. Cardiac rehabilitation. 4. Occupational therapy.

3. Cardiac rehabilitation.

The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement? 1. Perform isometric exercises daily. 2. Walk for 15 minutes three (3) times a week. 3. Do not walk outside if it is less than 40 ̊F. 4. Wear open-toed shoes when ambulating.

3. Do not walk outside if it is less than 40 ̊F. When it is cold outside, vasconstriction occurs and this will decrease O2 to the heart muscle.

The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Obtain a STAT electrocardiogram. 3. Have the client sit down immediately. 4. Assess the client's vital signs.

3. Have the client sit down immediately. Stopping all activity will decrease the need of the myocardium for O2 and may decrease the chest pain.

The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? 1. The client is keeping the affected extremity straight. 2. The pressure dressing to the right femoral area is intact. 3. The client is complaining of numbness in the right foot. 4. The client's right pedal pulse is 3+ and bounding.

3. The client is complaining of numbness in the right foot. Any neurovascular assessment data that are abnormal require intervention by the nurse; **numbness may indicate decreased blood supply to the right food**.

The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain.

3. The 75-year-old client scheduled for a cardiac catheterization. A new grad nurse should be able to complete a preprocedure checklist and get this pt to the cath lab.

Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction? 1. Creatine kinase (CK-MB). 2. Lactate dehydrogenase (LDH). 3. Troponin. 4. White blood cells (WBCs).

3. Troponin. Troponin is the enzyme that elevates w/in 1-2hrs of an MI.

25. The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching? 1. "I should keep the tablets in the dark-colored bottle they came in." 2. "If the tablets do not burn under my tongue, they are not effective." 3. "I should keep the bottle with me in my pocket at all times." 4. "If my chest pain is not gone with one tablet, I will go to the ER."

4. "If my chest pain is not gone with one tablet, I will go to the ER." Pt should take 1 tab every 5 mins (3 max) and, if not relief occurs after the 3rd tab, call 911

A client with an elevated temperature, fatigue, and labored breathing is admitted with a diagnosis of pneumonia. Which of the following nursing interventions should be started to assist with airway clearance? Select all that apply. A. Encourage client to turn side-to-side frequently B. Encourage deep breathing and coughing exercises C. Encourage the use of incentive spirometry D. Place the client in the supine position E. Provide adequate hydration

A, B, C, E

A nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply. A. Emotional stress B. Atrial fibrillation C. Nutritional anemia D. Peptic ulcer disease E. Recent upper respiratory infection

A, B, C, E Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia.

Which are expected S/S of COPD? Select all that apply. A. Barrel chest B. Clubbed fingers C. Decreased respiratory rate D. Dyspnea on exertion E. Fever F. Shortened expiratory phase

A, B, D, F

The nurse is preparing teaching for a client with peripheral arterial disease. What should the nurse include in these instructions? Select all that apply. 1) Encourage to walk daily for at least 30 minutes 2) Remind to apply moisturizing cream to both feet 3) Encourage to buy new shoes in the late afternoon 4) Demonstrate the correct way to apply elastic support hose 5) Instruct to inspect both feet daily for any type of irritation

1, 2, 3, 5 Walking promotes the development of collateral circulation to ischemic tissue and slows the process of atherosclerosis. Moisturizing prevents drying of the feet. New shoes should be purchased in the afternoon when the feet are the largest. The feet must be checked daily to ensure early treatment to any impaired skin integrity. Elastic support hose reduce the circulation to the legs and should be avoided.

Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. 1. Encourage a low-fat, low-cholesterol diet. 2. Instruct client to walk 30 minutes a day. 3. Decrease the salt intake to two (2) g a day. 4. Refer to counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet.

1, 2, 4, 5 1. Will help decrease the build up of atherosclerosis in the arteries 2. Will increase collateral circulation around the athersclerosis/build-up 3. Salt should be restricted in a pt w/hypertension, not CAD. 4. Helps prevent excess stress on heart muscle. 5. Will help remove cholesterol via GI system.

A client is diagnosed with angina. Which should the nurse include when teaching the client about this disorder? Select all that apply. 1) Explain the importance of stopping all tobacco products 2) Discuss the need to decrease the amount of salt in the diet 3) Recommend performing isotonic exercises three times a week 4) Direct to call 911 if the first nitroglycerin (NTG) does not relieve the chest pain 5) Instruct to keep sublingual NTG in a dark container

1, 3, 5 Smoking is the one risk factor that must be stopped totally; there is no compromise. Isotonic exercises, such as walking and swimming, help develop collateral circulation and decrease anxiety; they also help clients to lose weight. Sublingual NTG loses efficacy if exposed to sunlight. **Salt is decreased in clients with hypertension or congestive heart failure. Sodium restriction is not indicated in a client with angina.** The client should take three NTG every 5 minutes and call 911 if the third NTG does not relieve the chest pain.

The client with coronary artery disease asks the nurse, "Why do I get chest pain?" Which statement would be the most appropriate response by the nurse? 1. "Chest pain is caused by decreased oxygen to the heart muscle." 2. "There is ischemia to the myocardium as a result of hypoxemia." 3. "The heart muscle is unable to pump effectively to perfuse the body." 4. "Chest pain occurs when the lungs cannot adequately oxygenate the blood."

1. "Chest pain is caused by decreased oxygen to the heart muscle." When the coronary arteries cannot supply adequate O2 to the heart muscle, there is chest pain. Choice 3 explains CHF, not way chest pain occurs.

The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response? 1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal." 2. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias." 3. "Your doctor has ordered bedrest. Therefore, you must stay in the bed." 4. "Just because your chest doesn't hurt anymore doesn't mean you are out ofdanger."

1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal."

A client with severe lower leg pain is diagnosed with a deep vein thrombosis (DVT) of the right leg. Which action should the nurse make first? 1) Monitor aPTT levels 2) Prepare heparin for infusion 3) Assess for abnormal bleeding 4) Perform range-of-motion (ROM) exercises to the left leg.

2) Prepare heparin for infusion The client will be placed on heparin therapy to help prevent further clot formation. This is the first intervention. The nurse will monitor activated partial thromboplastin time (aPTT) levels to ensure that the heparin drip is maintaining the client in therapeutic range, but the heparin must be initiated first. The client will not have bleeding at this time; however, after heparin therapy is instituted, the nurse should assess for bleeding. The nurse should have the client perform active ROM on the left leg so this leg will not develop a DVT, but it is not the first intervention.

The nurse is unable to palpate a pedal pulse on the right foot of a client with arterial occlusive disease; however, the client is able to move the right foot and denies tingling. Which intervention should the nurse implement first? 1) Notify the health-care provider immediately 2) Use a Doppler device to assess for the pedal pulse 3) Ask the client to ambulate and then reassess for the pulse 4) Place the right leg on two pillows and assess for the pulse

2) Use a Doppler device to assess for the pedal pulse An absent pulse is not uncommon in a client diagnosed with arterial occlusive disease. To identify the location of the pulse, the nurse should use a Doppler device to amplify the sound. Because the client can move the right leg and denies tingling, the health-care provider does not need to be notified. **An absent pedal pulse is not uncommon in a client with arterial occlusive disease.** Ambulating will not help assess the client's pedal pulse. Elevating the feet will further decrease the blood supply to the right foot and will not help in assessing the pedal pulse.

3. The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply. 1. Notify health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from the dinner table. 4. Encourage client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime.

2, 3

Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? 1. "I will not eat more than six (6) eggs a week." 2. "I should bake or grill any meats I eat." 3. "I will drink eight (8) ounces of whole milk a day." 4. "I should not eat any type of pork products."

2. "I should bake or grill any meats I eat." AHA recommends a *low-fat*, *low-cholesterol* diet for pts w/CAD. The pt should avoid any fried foods, especially meats, and bake/broil/grill and meat.

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer morphine intramuscularly. 2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. 4. Place the client in a supine position. 5. Administer nitroglycerin subcutaneously

2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula.

The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? 1. Medicate the client with intravenous morphine. 2. Assess the client's chest dressing and vital signs. 3. Encourage the client to turn from side to side. 4. Check the client's telemetry monitor.

2. Assess the client's chest dressing and vital signs.

A client is admitted to the medical department due to pneumonia associated with influenza. Which of the following interventions promotes airway patency? Select all that apply. A. Apply chest physiotherapy B. Decrease fluid intake C. Frequent turning D. Avoid stress

A, C

The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse plan, based on the health care provider's prescriptions? Select all that apply. A. Elevation of the right leg B. Ambulation in the hall every 4 hours C. Application of moist heat to the right leg D. Administration of acetaminophen (Tylenol) E. Monitoring for signs of pulmonary embolism

A, C, D, E Standard management of the client with deep vein thrombosis includes possible bed rest for 5 to 7 days or as prescribed; limb elevation; relief of discomfort with warm, moist heat and analgesics as needed; anticoagulant therapy; and monitoring for signs of pulmonary embolism. Ambulation is contraindicated because it increases the likelihood of dislodgement of the tail of the thrombus, which could travel to the lungs as a pulmonary embolism.

The nurse is caring for a patient with asthma and is instructing the patient on the proper use of a spacer device. Which statement by the patient indicates the need for further instruction. A. "I can use the medication half as often." B. "It will reduce the risk of a yeast infection." C. " The spacer disperses the medication deeply." D. "The spacer makes it easier for me to coordinate my breathing with the inhaler

A. "I can use the medication half as often."

The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? A. "I will eat enough daily fiber to prevent straining at stool." B. "I will try to exercise vigorously to strengthen my heart muscle." C. "I will drink 3000 to 3500 mL of fluid daily to promote good kidney function." D. "Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels."

A. "I will eat enough daily fiber to prevent straining at stool." Standard home care instructions for a client with this problem include, among others, lifestyle changes such as decreased alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid and electrolyte balance. Consuming 3000 to 3500 mL of fluid and exercising vigorously will increase the cardiac workload.

The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse should immediately ask the client which question? A. "Where is the pain located?" B. "Are you having any nausea?" C. "Are you allergic to any medications?" D. "Do you have your nitroglycerin with you?"

A. "Where is the pain located?" If a client complains of chest pain, the initial assessment question would be to ask the client about the pain intensity, location, duration, and quality. Although options 2, 3, and 4 all may be components of the assessment, none of these questions would be the initial assessment question with this client.

A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure? A. Chest pain B. Urge to cough C. Warm, flushed feeling D. Pressure at the insertion site

A. Chest pain The client is taught to report chest pain or any unusual sensations immediately. The client also is told that he or she may be asked to cough or breathe deeply from time to time during the procedure. The client is informed that a warm, flushed feeling may accompany dye injection and is normal. Because a local anesthetic is used, the client is expected to feel pressure at the insertion site.

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? A. Listening to lung sounds B. Monitoring for organomegaly C. Assessing for jugular vein distention D. Assessing for peripheral and sacral edema

A. Listening to lung sounds The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function.

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider will most likely prescribe which option? A. Maintain bed rest. B. Maintain the affected leg in a dependent position. C. Administer an opioid analgesic every 4 hours around the clock. D. Apply cool packs to the affected leg for 20 minutes every 4 hours.

A. Maintain bed rest. Standard management for the client with DVT includes bed rest; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Ambulation is contraindicated because such activity can cause the thrombus to dislodge and travel to the lungs. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen (Tylenol).

A client who has had a myocardial infarction asks the nurse why she should not bear down or strain to ensure having a bowel movement. The nurse's response incorporates the information that bearing down or straining would trigger which physical response? A. Vagus nerve stimulation, causing a decrease in heart rate and cardiac contractility B. Vagus nerve stimulation, causing an increase in heart rate and cardiac contractility C. Sympathetic nerve stimulation, causing an increase in heart rate and cardiac contractility D. Sympathetic nerve stimulation, causing a decrease in heart rate and cardiac contractility

A. Vagus nerve stimulation, causing a decrease in heart rate and cardiac contractility Bearing down as if straining to have a bowel movement can stimulate a vagal reflex. Stimulation of the vagus nerve causes a decrease in heart rate and cardiac contractility. Stimulation of the sympathetic nervous system has the opposite effect. These two branches of the autonomic nervous system oppose each other to maintain homeostasis.

A 52-year-old patient on the surgical floor has a BP of 128/72, a heart rate of 125 bpm, a respiratory rate of 32 breaths/min, and a temperature of 99.1 Fahrenheit. The patient complains of severe shortness of breath. Which should the nurse assess first? A. Lung sounds B. Heart sounds C. Peripheral circulation D. Pupil reactivity

Answer: A a change in breath sounds will give nurse more info regarding pt's situation.

The health care provider prescribes bedrest for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply . A. Place in Fowler's position for eating. B. Encourage coughing with deep breathing. C. Encourage increased oral intake of water daily. D. Place thigh-length elastic stockings on the client. E. Place sequential compression boots on the client. F. Encourage the intake of dark green, leafy vegetables

B, C, D The client with DVT may require bedrest to prevent embolization of the thrombus resulting from skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus autodigestion, fluids for hemodilution and to decrease blood viscosity, and elastic stockings to reduce peripheral edema and promote venous return. While the client is on bedrest, the nurse prevents complications of immobility by encouraging coughing and deep breathing. Venous return is important to maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower extremities by avoiding hip flexion, which occurs with Fowler's position. The nurse avoids providing foods rich in vitamin K, such as dark green, leafy vegetables, because this vitamin can interfere with anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not include use of sequential compression boots for an existing thrombus. They are used only to prevent DVT, because they mimic skeletal muscle action and can disrupt an existing thrombus, leading

A patient with COPD is receiving discharge instructions from the nurse. The nurse should include which of the following to be avoided by the patient. Select all that apply. A. Children B. Cigarette smoke C. Cleaning products D. Cold air E. Exercise F. Influenza vaccine G. Stairs

B, C, D fumes, cold air, etc. can irritate the respiratory tract; exercise should not be avoided unless causing intense strain vaccinations prevent exacerbations people do not need to be avoided unless they have a resp. infection

A nurse is caring for a client who underwent thoracic surgery. Which of the following should the nurse assess for manifestations of tension pneumothorax? Select all that apply. A. Auscultate breath sounds for crackles B. Check for tracheal deviation to unaffected side C. Monitor BP, heart rate, and respirations D. Monitor for fever, hemoptysis, and signs of right sided heart failure E. Monitor for progressive cyanosis, extreme restlessness, agitation, and severe dyspnea

B, C, E

A client who underwent a pneumonectomy has the nursing diagnosis of ineffective airway clearance related to increased secretions and decreased coughing effectiveness due to pain. Which of the following interventions can help the client achieve effective airway clearance? Select all that apply. A. Avoid traction on chest tubes while changing client position B. Help the client cough and deep breath every 1-2 hours during the first 24-48 hours postop C. Offer sips of water frequently D. Place patient on opposite site of pneumonectomy E. Place client in semi- or high-fowler's position F. Schedule deep breathing sessions when pain medications are maximally effective

B, C, E, F There is no chest tube bc lung was removed.

The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? A. "I'll need to become a vegetarian." B. "I should use polyunsaturated oils in my diet." C. "I need to substitute eggs and whole milk for meat." D. "I should eliminate all cholesterol and fat from my diet."

B. "I should use polyunsaturated oils in my diet." The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian.

The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? A. Keep the legs aligned with the heart. B. Elevate the legs higher than the heart. C. Clean the skin with alcohol every hour. D. Position the client onto the side every shift.

B. Elevate the legs higher than the heart. In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the return of venous blood to the heart. Alcohol is very irritating and drying to tissues and should not be used in areas of skin breakdown. Option 4 specifies infrequent care intervals, so it is not the priority intervention.

A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse should next assess the client for which finding? A. Bilateral edema B. Increased calf circumference C. Diminished distal peripheral pulses D. Coolness and pallor of the affected limb

B. Increased calf circumference The client with thrombophlebitis, also known as deep vein thrombosis, exhibits redness or warmth of the affected leg, tenderness at the site, possibly dilated veins (if superficial), low-grade fever, edema distal to the obstruction, and increased calf circumference in the affected extremity. Peripheral pulses are unchanged from baseline because this is a venous, not an arterial, problem. Often, thrombophlebitis develops silently; that is, the client does not present with any signs and symptoms unless pulmonary embolism occurs as a complication.

The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? A. Use nail polish to protect the nail beds from injury. B. Stop smoking because it causes cutaneous vasospasm. C. Wear gloves for all activities involving use of both hands. D. Always wear warm clothing even in warm climates to prevent vasoconstriction.

B. Stop smoking because it causes cutaneous vasospasm. Raynaud's disease is peripheral vascular disease characterized by abnormal vasoconstriction in the extremities. Smoking cessation is one of the most important lifestyle changes that the client must make. The nurse should emphasize the effects of tobacco on the blood vessels and the principles involved in stopping smoking. The nurse needs to provide information to the client about smoking cessation programs available in the community. Options 1 and 4 are incorrect. It is not necessary to wear gloves for all activities.

A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? A. Sleep with the head of bed flat. B. Weigh himself or herself on a daily basis. C. Increase the dose of the diuretic if peripheral edema is noted. D. Withhold prescribed digoxin (Lanoxin) if slight respiratory distress occurs.

B. Weigh himself or herself on a daily basis. The client can best determine fluid status at home by weighing himself or herself on a daily basis. Increases of 2 to 3 lb in a short period are reported to the HCP. The client should sleep with the head of the bed elevated. During recumbent sleep, fluid (which has seeped into the interstitium with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head of the bed flat is therefore avoided. The client does not modify medication dosages without consulting the HCP.

The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem? A. Anxiety related to the need to make lifestyle changes B. Boredom resulting from having already learned the material C. An attempt to ignore or deny the need to make lifestyle changes D. Lack of understanding of the material provided at the teaching session and embarrassment about asking questions

C. An attempt to ignore or deny the need to make lifestyle changes Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to interpret the client's behavior as boredom or as either understanding or not understanding the material provided at the teaching session.

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? A. Stage 1 ulcer B. Vascular ulcer C. Arterial ulcer D. Venous stasis ulcer

C. Arterial ulcer Arterial ulcers have a pale deep base and are surrounded by tissue that is cool w/ changes such as dry skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A stage 1 ulcer indicates a reddened area with an intact skin surface. A venous stasis ulcer (vascular) has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of venous congestion.

The nurse is assessing a patient with a barrel chest. The nurse explains to the patient that this is caused by which disease? A. Asthma B. Bronchitis C. Emphysema D. Pneumonia

C. Emphysema

A client is diagnosed with an ST-segment elevation myocardial infarction (STEMI) and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which action is a priority nursing intervention? A. Monitor for kidney failure. B. Monitor psychosocial status. C. Monitor for signs of bleeding. D. Have heparin sodium available.

C. Monitor for signs of bleeding. Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin may be administered after thrombolytic therapy, but the question is not asking about follow-up medications.

The nurse is caring for a patient with pleuritis (pleurisy). When the nurse auscultates the patient's lungs, a friction rub is heard. This is the result of: A. Antibiotic therapy B. Decreased inflammation C. Serositis D. Patient clearing secretions

C. Serositis inflammation of the parietal pleura that causes pleuritic pain and can be caused by infection Serositis - itis = inflammation

A nurse is auscultating a 56 year old adult client's apical heart rate before giving digoxin (Lanoxin) and notes that the heart rate is 48 beats/minute. Which action should the nurse take? A. Withhold the digoxin, and reevaluate the heart rate in 4 hours. B. Administer half the prescribed dose to avoid a further decrease in heart rate. C. Withhold the digoxin; assess for signs of decreased cardiac output and digoxin toxicity. D. Administer the digoxin. The heart rate would be considered normal because of the client's age

C. Withhold the digoxin; assess for signs of decreased cardiac output and digoxin toxicity. The normal heart rate is 60 to 100 beats/min in an adult. If the nurse notes a heart rate that is less than 60 beats/min, the nurse would not administer the digoxin and would further evaluate the client for signs and symptoms of digoxin toxicity. When clients are bradycardic, they may have symptoms of decreased cardiac output so this would also be assessed.

The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? A. "I need to be sure not to go barefoot around the house." B. "If I cut my toenails, I need to be sure that I cut them straight across." C. "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." D. "I need to be sure that I elevate my leg above my heart level for at least an hour every day."

D. "I need to be sure that I elevate my leg above my heart level for at least an hour every day." Foot care instructions for the client with peripheral arterial disease are the same as those for a client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program or if venous stasis is also present. The client statements in options 1, 2, and 3 are correct statements.

A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed? A. "I'm not supposed to eat cold cuts." B. "I can have most fresh fruits and vegetables." C. "I'm going to weigh myself daily to be sure I don't gain too much fluid." D. "I'm going to have a ham and cheese sandwich and potato chips for lunch."

D. "I'm going to have a ham and cheese sandwich and potato chips for lunch." When a client has HF, the goal is to reduce fluid accumulation. One way that this is accomplished is through sodium reduction. Ham (and most cold cuts), cheese, and potato chips are high in sodium. Daily weighing is an appropriate intervention to help the client monitor fluid overload. Most fresh fruits and vegetables are low in sodium.

The ambulatory care nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. What should the nurse plan to teach the client about this type of angina? A. It is most effectively managed by β-blocking agents. B. It has the same risk factors as stable and unstable angina. C. It can be controlled with a low-sodium, high-potassium diet. D. Generally it is treated with calcium-channel-blocking agents

D. Generally it is treated with calcium-channel-blocking agents Prinzmetal's angina results from spasm of the coronary vessels and is treated with calcium-channel blockers. β-Blockers are contraindicated because they may actually worsen the spasm. The risk factors are unknown, and this type of angina is relatively unresponsive to nitrates. Diet therapy is not specifically indicated.

A patient is receiving a heparin infusion for the management of a PE. The nurse observes bright red urine in the patient's catheter bag. What should be done first? A. Administer protamine sulfate B. Check the patient's activated partial thromboplastin time (aPTT) C. Decrease the infusion rate D. Notify the physician

D. Protamine Sulfate (antidote for heparin) should not be given unless confirmed FIRST by the physician

The nurse is suctioning a patient's Endotracheal tube and observes sinus bradycardia on the patient's EKG monitor. What should the nurse do next? A. Administer atropine B. Continue suctioning until all mucus is removed C. Elevate the patient's HOB D. Stop suctioning and administer oxygen

D. Stop suctioning and administer oxygen

A patient was recently diagnosed with emphysema. Which of the following interventions should the nurse implement when caring for this patient? A. Keep patient prone B. Keep patient supine C. Reduce patient's fluid intake to less than 2,000 mL/day D. Teach patient tripod position

D. Teach patient tripod position