Hesi Review

Which test is used to diagnose sleep apnea? Sonography Polysomnography Echocardiography Plethysmography

Polysomnography

Which principle of time management is the nurse following when listing activities according to goals for the client's condition? 1 Goal setting 2 Time analysis 3 Priority setting 4 Interruption control

Priority setting

Which specific drug classification would the nurse explain includes captopril? Diuretic Sedative Hypnotic Antihypertensive

Antihypertensive Captopril is an antihypertensive; it inhibits conversion of angiotensin I to angiotensin II. Diuretics promote fluid excretion. Sedatives reduce muscle tension and anxiety. Hypnotics promote sleep.

Which statement by the nurse regarding respiratory changes in the immobile client requires correction? 1 "Mucus accumulates independent regions of the airways." 2 "There is increased cough productivity in immobile clients." 3 "Hypostatic pneumonia may develop in clients with immobility." 4 "Distribution of mucus in the bronchi increases when the client is in the supine position

2 "There is increased cough productivity in immobile clients."

While taking a client's temporal artery temperature, the nurse places the probe flush against the client's forehead. What is the rationale behind this intervention? 1 To maintain standard precautions 2 To scan continuously for the highest temperature 3 To prevent the nurse from measuring ambient temperature 4 To decrease the chance of moisture interfering with the measurement

3 To prevent the nurse from measuring ambient temperature

Which is the nurse's best response to a client considering sclerotherapy who asks the nurse to explain the cause of varicose veins? 1 "Abnormal configurations of the veins" 2 "Incompetent valves of superficial veins" 3 "Decreased pressure within the deep veins" 4 "Atherosclerotic plaque formation in the veins

2 "Incompetent valves of superficial veins"

For which side effect will the nurse monitor in a client who is prescribed metoprolol? 1 Hirsutism 2 Bradycardia 3 Restlessness 4 Hypertension

2 Bradycardia Rationale: Beta-blockers block stimulation of beta 1 (myocardial) adrenergic receptors, which decreases the heart rate and blood pressure. The client should be monitored for bradycardia, which can progress to heart failure or cardiac arrest. Excessive growth of hair or the presence of hair in unusual places does not occur with this medication; however, absence or loss of hair (alopecia) may occur. A side effect of this medication is fatigue, not restlessness. This medication may produce hypotension, not hypertension.

Which information would the nurse include when teaching a client with hypertension about metoprolol? 1 Consume alcoholic beverages in moderation. 2 Do not abruptly discontinue the medication. 3 Increase the medication dosage if chest pain occurs. 4 Report a heart rate of less than 70 beats/min.

2 Do not abruptly discontinue the medication. Rationale: Abrupt discontinuation of metoprolol may cause rebound hypertension and an acute myocardial infarction. Alcohol is contraindicated for clients taking beta-adrenergic blockers such as metoprolol. Clients should never increase medications without medical direction. The pulse rate can go lower than 70 beats/min as long as the client feels well and is not dizzy

Which medication would be used to liquefy mucus for a client with a harsh, dry cough due to bronchitis? 1 Antitussive agent 2 Expectorant agent 3 Anti Inflammatory agent 4 Immunomodulator agent

2 Expectorant agent Rationale: Expectorant agents are often prescribed for clients with nonproductive coughs to help liquefy mucus because they stimulate the secretion of natural lubricant fluids from serous glands. Antitussive agents act by suppressing the cough center in the brain. Antiinflammatory agents reduce inflammation. Immunomodulator agents are prescribed for clients who have been diagnosed with subtypes of asthma and usually are used in combination with other drugs to reduce the frequency of asthma exacerbations

Which describes how coarse rhonchi sound in a client with chronic obstructive pulmonary disease (COPD)? 1 Snorting sounds during the inspiratory phase 2 Moist rumbling sounds that clear after coughing 3 Musical sounds more that are pronounced during expiration 4 Crackling inspiratory sounds that are unchanged with deep breath

2 Moist rumbling sounds that clear after coughing Rationale: Coarse rhonchi, particularly on expiration, indicate partial airway obstruction because of bronchiolar alterations associated with COPD. Snorting sounds are made in the nose. Wheezes are musical sounds usually heard during expiration; they are caused by rapid vibration of bronchial walls. Crackling sounds heard on inspiration that are unchanged by coughing are known as fine crackles; they result when air passes through alveoli that are partially filled with fluid.

The nurse recognizes that if both prospective parents carry sickle cell traits, the child has which chance of developing the disease? 25% 50% 75% 100%

25 Sickle cell is an autosomal recessive genetic disorder. If both individuals have sickle cell traits, there is a 25% chance they will produce a child with the disease. Other options, such as 50%, 75%, and 100%, are not plausible.

Which blood type can be used by the client with type A-negative blood? 1 O positive 2 AB positive 3 A negative or O negative 4 A negative or AB negative

3 A negative or O negative Rationale: Both A-negative and O-negative blood are compatible with the client's blood. A-negative blood is the same as the client's blood type and preferred; in an emergency, type O-negative blood also may be given. Although type O blood may be used, it must be Rh negative; Rh-positive blood is incompatible with the client's blood and will cause hemolysis. Type AB positive blood is incompatible with the client's blood and will cause hemolysis. Type A-negative blood is compatible with the client's blood, but type AB-negative blood is incompatible and will cause

How would the nurse position a client with epistaxis? 1 Supine 2 Side-lying 3 Upright leaning forward 4 Sitting with the head tipped backward

3 Upright leaning forward Rationale: A client with a nosebleed should be positioned upright leaning forward to prevent aspiration and decrease blood flow to the nose. The supine position increases the possibility of aspiration or swallowing blood. The side-lying position will increase blood flow to the nose more than sitting upright and may increase aspiration risk. Having the head tipped backward increases the possibility of aspiration or swallowing blood

How would the nurse document a client who was intubated 3 days ago and has developed pneumonia? 1 Nosocomial pneumonia 2 Hospital-acquired pneumonia 3 Ventilator-associated pneumonia 4 Health care-associated pneumonia

3 Ventilator-associated pneumonia Rationale Ventilator-associated pneumonia happens 48 to 72 hours after undergoing an endotracheal intubation. Therefore, the nurse would document this finding as ventilator-associated pneumonia. Nosocomial and health care-associated pneumonia are synonymous and occur after being in a health care facility. Health care-associated pneumonia is the term used when symptoms occur 48 hours after admission.

Which nursing activity is an example of primary prevention? Select all that apply. One, some, or all responses may be correct. 1. Preventing disabilities 2 Correcting dietary deficiencies 3 Establishing goals for rehabilitation 4 Assisting with immunization programs 5 Facilitating a program about smoking cessation

4 Assisting with immunization programs 5 Facilitating a program about smoking cessation

Which test would the nurse explain will be used for the initial screening for AIDS? 1 CD4 T-cell count 2 Western blot test 3 Polymerase chain reaction test 4 Enzyme-linked immunosorbent assay (ELISA)

4 Enzyme-linked immunosorbent assay (ELISA)

Which part of the upper respiratory system is involved in equalizing the pressure within the middle ear while swallowing? 1 Glottis 2 Paranasal sinus 3 Palatine tonsils 4 Eustachian tubes

4 Eustachian tubes Rationale: The Eustachian tubes connect the nasopharynx to the middle ears; these tubes open during swallowing to equalize pressure within the middle ear. The glottis is the opening between true vocal cords. The paranasal sinuses are air-filled cavities within the bones that surround the nasal passages. Palatine tonsils are a part of the immune system and are located on the sides of the oropharynx. These tonsils protect against invading organism

Which laboratory report is most important for the nurse to monitor when considering the effects of chemotherapy in a client with cancer of the tonsils and enlarged lymph glands in the neck? 1 Platelets 2 Hemoglobin level 3 Red blood cell count 4 White blood cell count

4 White blood cell count Rationale Antineoplastic drugs depress bone marrow resulting in leukopenia. The client must be protected from infection, which may cause death. Platelets may decrease rapidly, but complications may be limited by infusions of platelets. The hemoglobin level diminishes, but a transfusion with packed red blood cells (RBCs) will alleviate the anemia. RBCs diminish slowly and may be replaced with a transfusion of packed RBCs

Which value is within the normal range of values for arterial pH? 7.44 7.26 7.56 7.66

7.44

Why is O negative blood called a "universal donor"? 1 It does not have any of the antigens that can cause a reaction. 2 The donor can donate blood more frequently than other people. 3 More people have this blood type, so it is more universally available. 4 It is more frequently administered when compared with other blood types.

1 It does not have any of the antigens that can cause a reaction. Rationale: Type O Rh negative red blood cells will not cause an antigen-antibody reaction in people with O, A, B, AB, Rh-positive, or Rh-negative blood; therefore, this type of blood can be

Which is the most common characteristic of anginal pain? 1 It is relieved by rest. 2 It is precipitated by light activity 3 It is described as sharp or knife-like. 4 It is unaffected by the administration of vasodilators.

1 It is relieved by rest. Rationale: Anginal pain commonly is relieved by immediate rest because rest decreases the cardiac workload. Angina usually is precipitated by exertion, emotion, or a heavy meal. Anginal pain usually is described as tightness, indigestion, or heaviness. Nitroglycerin dilates coronary arteries, which increases oxygen to the myocardium, decreasing pain.

Which information is essential for the nurse to include in the education plan for a client prescribed warfarin? 1 Periodic blood testing is necessary. 2 Dietary restrictions will not be necessary. 3 Physical activities should be limited. 4 If you miss a dose of the medication, you can double the next dose.

1 Periodic blood testing is necessary. Rationale: Testing is essential to determine dosing; a therapeutic prothrombin time (PT) ranges from 1.3 to 1.5 times greater than the control and is equal to an international normalized ratio (INR) of 2 to 3 times control. Foods high in vitamin K may affect the medication if eaten in larger than usual amounts. Activities usually are not restricted. The client should contact the health care provider if a dose is missed, not double the next dose

Which characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? 1 Pink 2 Clear 3 Green 4 Yellow

1 Pink Rationale: With a pulmonary embolus there is partial or complete occlusion of pulmonary blood flow; when infarcted areas or areas of atelectasis produce alveolar damage, red blood cells move into the alveoli, resulting in hemoptysis that can be pink in color. Clear sputum is associated with a viral infection. Green and yellow sputum are associated with a bacterial infection.

Which action about documenting and transcribing prescriptions indicates a need for further teaching? 1 Processing the stat prescription last to avoid confusion 2 Reading through all prescriptions before transcribing them 3 Checking computer entry prescriptions with the intended order 4 Reading back the verbal prescriptions and then documenting the details

1 Processing the stat prescription last to avoid confusion

Which information would the nurse consider when examining value clarification in the resolution of ethical dilemmas? 1 Tolerating differences of opinions 2 Reinforcing or challenging family values 3 Accepting strong values by individuals as facts 4 Relating values to facts when dealing with ethical issues

1 Tolerating differences of opinions

Which medication would the nurse expect to be prescribed to a female client who exhibits the genital lesions presented in the illustration? Zidovudine Ceftriaxone Metronidazole Acyclovir sodium

Acyclovir sodium

Which blood type would be preferred for a client with type B-negative blood? A positive B negative O negative AB positive

B negative B-negative blood is the same as the client's blood type and would be preferred; only in an emergency would be type O-negative blood be given. Irrespective of blood type, Rh-positive blood is incompatible with the client's blood and would cause hemolysis if it is transfused. Although O-negative blood can be used in an emergency, it is not the preferred blood type in an elective situation.

Which leukocyte is responsible for the allergic response? Basophils Monocytes Eosinophils Macrophages

Basophils

Which type of tracheostomy relates to one that has a small balloon encircling its tracheal end? Fenestrated Foam-cuffed Double cannula Cuffed tracheostomy

Cuffed tracheostomy A cuffed tracheostomy tube has a small balloon encircling its tracheal end that when inflated provides a seal and keeps air from leaking around the tube. A fenestrated tracheostomy tube has a small opening in the outer cannula that allows air to escape through the larynx. A foam-cuffed tracheostomy has a cuff filled with a spongelike material that is fully expanded at rest. A double cannula has an outer cannula that acts as a sleeve for the inner cannula, which can be removed for cleaning.

Which clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block? Syncope Headache Tachycardia Hemiparesis

Syncope

Which monitoring for side effects will the nurse conduct on a client diagnosed with a pulmonary embolism who received tissue plasminogen activator (t-Pa) to dissolve the clot? Auscultate breath sounds Observe for signs of bleeding Observe the skin and nailbeds Take the client's blood pressur

Observe for signs of bleeding

Which explanation of an electrocardiogram (ECG) would the nurse give the client that is suspected of having had a silent myocardial infarction 1. "This test will detect your heart sounds." 2. "This test will reflect any heart damage." 3. "This procedure helps us change your heart's rhythm." 4. "The ECG will tell us how much stress your heart can tolerate."

"This test will reflect any heart damage." Changes in an ECG will reflect the area of the heart that is damaged because of hypoxia. A stethoscope is used to detect heart sounds. Medical interventions, such as cardioversion or cardiac medications, not an ECG, can alter heart rhythm. An ECG will reflect heart rhythm, not change it. Identifying how much stress a heart can tolerate is accomplished through a stress test; this uses an ECG in conjunction with physical exercise.

Which measure would the nurse include when teaching about the Hospital National Patient Safety Goals? Select all that apply. One, some, or all responses may be correct. 1 Use at least two ways to identify a client. 2 Ensure alarms are heard and responded to on time. 3 Make sure that the correct surgery is done on the correct client. 4 Use proven guidelines to prevent infections that are difficult to treat. 5 Use proven guidelines to prevent infections of the urinary tract caused by catheters.

1 Use at least two ways to identify a client. 2 Ensure alarms are heard and responded to on time. 3 Make sure that the correct surgery is done on the correct client. 4 Use proven guidelines to prevent infections that are difficult to treat. 5 Use proven guidelines to prevent infections of the urinary tract caused by catheters.

Which statement by the nurse indicates a need for further teaching regarding the goals of palliative care? 1 "Enhancing quality of life and postponing death is the objective of palliative care." 2 "Providing relief from pain and other distressing symptoms is a primary goal of palliative care." 3 "A team approach is used in palliative care to address the needs of not only clients but also their families." 4 "Developing a support system to help families cope during the client's illness and their own bereavement is a focus of palliative care.

1 "Enhancing quality of life and postponing death is the objective of palliative care."

Which hormone is responsible for altered serum calcium concentrations? Select all that apply. One, some, or all responses may be correct. 1 Calcitonin 2 Thyroxine 3 Glucocorticoids 4 Growth hormone 5 Parathyroid hormone

1 Calcitonin 5 Parathyroid hormone Rationale: Produced by the thyroid gland, calcitonin decreases the serum calcium concentration if it increases above the normal level. Parathyroid hormones increase and stimulate bones to promote osteoclastic activity and release calcium into the blood in response to low serum calcium levels. Thyroxine increases the rate of protein synthesis in all types of tissues. Glucocorticoids regulate protein metabolism to maintain the organic matrix of bone. Growth hormone helps to increase bone length and determine the amount of bone matrix formed before puberty

Which observation would the nurse expect when caring for a client experiencing anginal pain? 1 Unchanged by rest 2 Precipitated by light activity 3 Described as a knife-like sharpness 4 Relieved by sublingual nitroglycerin

4 Relieved by sublingual nitroglycerin

Which intervention is most likely to decrease mortality in the septic client? Oxygen Antibiotics Vasopressors Intravenous fluids

Antibiotics

Which specific drug classification would the nurse include in client education for captopril? Diuretic Sedative Hypnotic Antihypertensive

Antihypertensive

Which body process associated with vitamin B12 is assessed with the Schilling test? Storage Digestion Production Absorption

Absorption With the Schilling test, radioactive vitamin B12 is administered, and its absorption and excretion are ascertained. Storage is not measured by this test. Digestion is not measured by this test. Vitamin B12 is not produced in the body. Pernicious anemia is caused by an inability to absorb vitamin B12 as a result of a lack of intrinsic factor in gastric juices.

Which condition is an example of humoral reaction? Sarcoidosis Anaphylaxis Contact dermatitis Tissue transplant rejection

Anaphylaxis

Which assessment finding is a key feature of right-sided heart failure? Select all that apply. One, some, or all responses may be correct. Collapsed neck veins Distended abdomen Dependent edema Urinating at night Cool extremities

Distended abdomen Dependent edema Urinating at night

Which medication does the nurse expect to be prescribed for a child with newly diagnosed cystic fibrosis? Select all that apply. One, some, or all responses may be correct. Steroids Antibiotics Antihistamines Pancreatic enzymes Fat-soluble vitamins

Pancreatic enzymes Fat-soluble vitamins Antibiotics

Which therapy would the nurse anticipate being prescribed for a client admitted to hospital for general paresis as a complication of syphilis? Penicillin therapy Major tranquilizers Behavior modification Electroconvulsive therapy

Penicillin therapy

Which wound healing phase produces an irregular, purplish, immature scar? Maturation Hemostasis Reconstruction Inflammatory phase

Reconstruction

Which result indicates a therapeutic outcome for a client taking ezetimibe? Increased blood pressure Normalization of serum glucose Decrease of lactic dehydrogenase (LDH) Reduction of low-density lipoproteins (LDLs)

Reduction of low-density lipoproteins (LDLs) Ezetimibe is a miscellaneous antilipidemic agent that reduces low-density lipoproteins (LDLs) by blocking absorption of cholesterol from the small intestine. Ezetimibe does not increase blood pressure. Ezetimibe is not used to normalize serum glucose levels. Ezetimibe may cause elevated liver enzymes such as lactic dehydrogenase (LDH), and routine liver testing should be done.

Which condition would a nurse discuss when teaching a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus? Asthma Anemia Rheumatic fever Reye syndrome

Rheumatic fever Streptococcal infection can cause rheumatic fever if not treated. This involves autoantibody production and may affect the valves of the heart. Asthma, anemia, and Reye syndrome are not caused by beta-hemolytic streptococcus

The parents of a school-age child with leukemia ask the nurse why irradiation of the spine and skull are necessary. Which response by the nurse is the most accurate? 1 "Radiation retards the growth of cells in the bone marrow of the cranium." 2 "This therapy decreases cerebral edema and prevents increased intracranial pressure." 3 "Leukemic cells may invade the nervous system, but the usual drugs are ineffective in the brain." 4 "Neoplastic drug therapy without radiation is effective in most cases, but this is a precautionary treatment."

1 "Radiation retards the growth of cells in the bone marrow of the cranium." 3 "Leukemic cells may invade the nervous system, but the usual drugs are ineffective in the brain." The protective blood-brain barrier initially screens leukemic cells from the central nervous system. However, in advanced stages leukemic infiltration occurs. Chemotherapeutic agents, also screened out by the blood-brain barrier, are ineffective. Radiation destroys, not just retards, malignant cells. Radiation does not decrease cerebral edema. Irradiation of the cranium is needed because chemotherapy does not pass the blood-brain barrier.

Which medication does the nurse expect to be prescribed for a child with newly diagnosed cystic fibrosis? Select all that apply. One, some, or all responses may be correct. 1 Steroids 2 Antibiotics 3 Antihistamines 4 Pancreatic enzymes 5 Fat-soluble vitamins

2 Antibiotics 4 Pancreatic enzymes 5 Fat-soluble vitamins Rationale: Antibiotics are prescribed to treat recurrent respiratory tract infections. Thick secretions obstruct the pancreatic ducts, and essential pancreatic enzymes are blocked from reaching the duodenum; therefore, pancreatic enzymes are administered with meals to aid digestion. Fat-soluble vitamins are necessary because of the decreased absorption of fat. Steroids are not indicated in the treatment of cystic fibrosis. Antihistamines are not used because of their drying effect on the already tenacious mucus.

Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with which autosomal recessive disorder? 1 Cerebral palsy 2 Cystic fibrosis 3 Muscular dystrophy 4 Multiple sclerosis The early symptom of cystic fibrosis is meconium ileus, which is impacted stool in the newborn. Thick mucous secretions, salty sweat, and difficulty gaining weight because of high caloric demands are characteristics of the condition. Cerebral palsy is a motor disorder caused by damage to the brain. Muscular dystrophy is a muscular disorder. Multiple sclerosis is a condition with progressive disintegration of the myelin sheath

2 Cystic fibrosis The early symptom of cystic fibrosis is meconium ileus, which is impacted stool in the newborn. Thick mucous secretions, salty sweat, and difficulty gaining weight because of high caloric demands are characteristics of the condition. Cerebral palsy is a motor disorder caused by damage to the brain. Muscular dystrophy is a muscular disorder. Multiple sclerosis is a condition with progressive disintegration of the myelin sheath

Which finding is consistent in a client with the diagnosis of atelectasis? 1 Bradypnea 2 Hypoventilation 3 Presence of crackles 4 Symmetrical chest wall

2 Hypoventilation Rationale: Hypoventilation may occur due to atelectasis resulting from blockage of bronchioles by secretions and the collapse of distal lung tissue. Tachypnea is seen in atelectasis, not bradypnea. Crackle sounds are heard with pneumonia, not atelectasis. An asymmetrical chest wall, not a symmetrical chest wall, is observed due to lung collapse.

Which type of pneumonia is likely in a client who developed the condition 3 days after admission to the hospital? 1 Aspiration pneumonia 2 Nosocomial pneumonia 3 Community-acquired pneumonia 4 Ventilator-associated pneumonia

2 Nosocomial pneumonia

Which condition unrelated to cardiac disease is the major cause of right ventricular failure? 1 Renal disease 2 Hypovolemic shock 3 Severe systemic infection 4 Chronic obstructive pulmonary disease (COPD)

4 Chronic obstructive pulmonary disease (COPD) Rationale: COPD causes destruction of capillary beds around the alveoli, interfering with blood flow to the lungs from the right side of the heart. As the heart continues to strain against this resistance, heart failure eventually results. Renal disease causes stress on the left side of the heart. Hypovolemic shock will not cause stress on the right side of the heart. Severe systemic infection probably will produce greater stress on the left side of the heart.

Which is the cause of dyspnea in a client with emphysema? 1 Spasm of the bronchi that traps the air 2 Increase in the vital capacity of the lungs 3 Too rapid expulsion of the air from the alveoli 4 Difficulty in expelling the air trapped in the alveoli

4 Difficulty in expelling the air trapped in the alveoli Rationale: Emphysema involves destructive changes in the alveolar walls, leading to dilation of the air sacs; there is subsequent air trapping and difficulty with expiration. Bronchospasm is characteristic of asthma, not emphysema. The vital capacity is decreased because of restriction of the diaphragm and thoracic movement. Expiration is slowed by pursed-lip breathing to keep the airways open so less air is trapped

Which statement is true about active immunity? 1 It is also called cell-mediated immunity. 2 It results when T cells are activated by an antigen. 3 Antivenom given after a snake bite is an example of active immunity. 4 It develops as the body defends itself from the presence of an active infection.

4 It develops as the body defends itself from the presence of an active infection. Rationale: Active immunity develops as the body defends itself from the presence of an active infection. Cellular immunity is also known as cell-mediated immunity. Cellular immunity results when T cells are activated by an antigen. Antivenom given after a snake bite is an example of passive immunity.

Which breath sound would the nurse auscultate on a client experiencing an acute exacerbation of asthma? 1 Rales 2 Ronchi 3 Crackles 4 Wheezes

4 Wheezes Rationale: A client experiencing an acute exacerbation of asthma will exhibit a high-pitched expiratory wheeze, as airways are narrowed. Rales, rhonchi, and crackles are sounds produced by different causes of airway obstruction, such as fluid or a foreign body

Which assessment would the nurse perform before administering digoxin to a client? Apical heart rate Radial pulse on the left side Radial pulse in both right and left arms Difference between apical and radial pulses

Apical heart rate

Which term describes the action of class IV antidysrhythmic agents? Beta blocker Sodium channel blocker Calcium channel blocker Potassium channel blockers

Calcium channel blocker

Which evidence of tuberculosis is provided by the radiograph? Cavities caused by caseation Sensitized T cells Presence of acid-fast bacilli Microscopic primary infection

Cavities caused by caseation

Which condition unrelated to cardiac disease is the major cause of right ventricular failure? Renal disease Hypovolemic shock Severe systemic infection Chronic obstructive pulmonary disease (COPD)

Chronic obstructive pulmonary disease (COPD)

The nurse knows that in a client with peripheral artery disease, walking that sometimes results in severe pain in the calf muscles is best documented using which medical term? Rest pain Intermittent claudication Phantom limb sensation Raynaud's phenomenon

Intermittent claudication

Which therapeutic effect would be expected if simvastatin administration is working for a client? International normalized ratio (INR) decreases Heart rate decreases Triglyceride level decreases Blood pressure decreases

Triglyceride level decreases

To assess for bleeding in a client with a recent gastrointestinal bleed, which would the nurse monitor the client for? 1 Lethargy 2 Tachycardia 3 Deep breathing 4 Abdominal pain

2 Tachycardia Rationale: Tachycardia is a cardiovascular compensatory mechanism as the effort to circulate the decreasing blood volume intensifies. Lethargy is not an initial response to blood loss. The client is more apt to be restless; lethargy may occur later. Breathing may be rapid, not deep, with blood loss. Abdominal pain is not a response to blood loss.

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. Hemophilia A is linked to a deficiency in which factor? Factor II Factor III Factor IX Factor VIII

Factor VIII Hemophilia type A, which is the most common type of hemophilia, is from a deficiency of Factor VIII. Factors II and III are distractors. Factor IX is associated with hemophilia type B.

client who has received sodium bicarbonate in large amounts is at risk for developing metabolic alkalosis. The nurse checks this client for which signs and symptoms characteristic of this disorder? 1. Disorientation and dyspnea 2. Drowsiness, headache, and tachypnea 3. Tachypnea, dizziness, and paresthesias 4. Decreased respiratory depth and rate and dysrhythmias

Decreased respiratory depth and rate and dysrhythmias

Which vitamin is an antioxidant that affects the structure of cell walls? A B1 C E

E Vitamin E is an antioxidant that hinders the oxidative breakdown of structural lipid membranes in body tissues, which is caused by free radicals in the cells. Vitamin A assists in the formation of visual purple needed for night vision. Vitamin C is used for formation of collagen, which is important for maintaining capillary strength, promoting wound healing, and resisting infection. Vitamin B1 is necessary for protein and fat metabolism and for functioning of the nervous system.

Which sexually transmitted infection is recognized by the symptom of a creamy yellow, bloody discharge from the penis? Chancroid Gonorrhea Candidiasis Trichomoniasis

Gonorrhea In men, the initial symptoms of gonorrhea include urethral pain and a creamy, yellow, sometimes bloody discharge. Chancroid causes genital ulcers; the lesions begin as macules, progress to pustules, and then rupture. Candidiasis, trichomoniasis, and bacterial vaginosis are vaginal infections that can be sexually transmitted, and the male partner is usually asymptomatic.

Which explanation of the purpose of the Valsalva maneuver would the nurse give to a client in atrial fibrillation? The vagus nerve is stimulated. The glottis closes momentarily. Thoracic pressure decreases. Respiratory pattern is interrupted.

The vagus nerve is stimulated. Inhaling and forcing the diaphragm and chest muscles against a closed glottis increases intrathoracic pressure, which affects the vagus nerve and slows the heart. Although the glottis closes, this does not interrupt the dysrhythmia. Thoracic pressure increases, not decreases, during the Valsalva maneuver. Although the respiratory pattern is interrupted briefly, this does not interrupt the dysrhythmia.

Which statement is true regarding the reconstruction phase of wound healing? Wound dehiscence mostly occurs in the reconstruction phase. The reconstruction phase begins on the second day and lasts for 2 to 3 days. Collagen formation increases rapidly between postoperative days 1 and 5. During the reconstruction phase, the wound takes the form of a light pink, matured scar.

Wound dehiscence mostly occurs in the reconstruction phase.

A client has an electrocardiogram (ECG), and hypokalemia is suspected. The nurse expects that the diagnosis will be confirmed by which diagnostic test? 1. Complete blood count 2. Electrolyte panel 3. X-ray film of long bones 4. Blood cultures

Electrolyte panel

Which is the minimum systolic pressure the nurse would expect when obtaining blood pressure in a client with untreated stage 1 hypertension? 1 110 to 119 mm Hg 2 120 to 129 mm Hg 3. 130 to 139 mm Hg 4. 140 to 159 mm Hg

140 to 159 mm Hg

Which hormone is responsible for altered serum calcium concentrations? Select all that apply. One, some, or all responses may be correct. 1 Calcitonin 2 Thyroxine 3 Glucocorticoids 4 Growth hormone 5 Parathyroid hormone

1 Calcitonin 5 Parathyroid hormone Rationale: Produced by the thyroid gland, calcitonin decreases the serum calcium concentration if it increases above the normal level. Parathyroid hormones increase and stimulate bones to promote osteoclastic activity and release calcium into the blood in response to low serum calcium levels. Thyroxine increases the rate of protein synthesis in all types of tissues. Glucocorticoids regulate protein metabolism to maintain the organic matrix of bone. Growth hormone helps to increase bone length and determine the amount of bone matrix formed before puberty.

Which client symptom may be associated with a cardiac output of 3 L per minute? 1 Fatigue 2 Polyuria 3 Hot skin 4 Weight loss

1 Fatigue Rationale: Normal cardiac output is in the range of 4 to 8 L per minute. A rate of 3 L per minute indicates decreased cardiac output, which is an indication of heart failure. Fatigue is a symptom associated with decreased cardiac output in a client with heart failure. Oliguria, not polyuria, occurs with heart failure. Cool, not hot, skin is a symptom of heart failure. Weight gain, not loss, is common with heart failure.

Which action would the nurse perform to prevent the spread of infection when caring for a client with Clostridioides difficile (C. difficile)? Select all that apply. One, some, or all responses may be correct. 1 Initiate contact isolation. 2 Wear a gown upon entry to the client's room. 3 Wear gloves for direct contact with the client. 4 Wear gloves when touching any object or surface in the client's room. 5 Wash hands with soap and water upon entering and leaving the client's room.

1 Initiate contact isolation. 2 Wear a gown upon entry to the client's room. 3 Wear gloves for direct contact with the client. 4 Wear gloves when touching any object or surface in the client's room. 5 Wash hands with soap and water upon entering and leaving the client's room. Rationale: Contact isolation is used with clients who have a C. difficile infection because the infection spreads through direct contact and the fecal-oral route. A gown and gloves are worn when entering the client's room and when touching any object and surface in the client's room. C. difficile produces a spore that is not destroyed by alcohol-based hand hygiene products, so soap and water must be used for hand cleansing, and bleach must be used for equipment.

Which is a clinical manifestation of respiratory acidosis? 1 Tetany 2 Tremors 3 Bradycardia 4 Hypertension

2 Tremors Rationale Tremors are a clinical manifestation of respiratory acidosis. Tetany is a clinical manifestation of respiratory alkalosis. Tachycardia, not bradycardia, is a clinical manifestation of respiratory acidosis. Hypotension, not hypertension, may manifest in respiratory acidosis

Which feature belongs to a transdisciplinary rehabilitation team? Select all that apply. One, some, or all responses may be correct. 1 Relies solely on communication for success 2 Collaborates to identify individual goals of different disciplines 3 Allows for the blurring of boundaries between different disciplines 4 Has discipline-specific goals and clear boundaries between disciplines 5 Uses crosstraining and flexibility to minimize the duplication of effort toward individual goal attainment

3 Allows for the blurring of boundaries between different disciplines 5 Uses crosstraining and flexibility to minimize the duplication of effort toward individual goal attainmen

The nurse is reinforcing instructions to a Native-American client regarding the procedure for collecting a urine sample. The nurse observes that the client continually stares at the floor during the instructional session. The nurse interprets this as being indicative of which behavior? Rudeness Disinterest Attentiveness Embarrassment

Attentiveness Many Native-American clients often stare at the floor when the nurse is talking. This culturally appropriate behavior indicates that the listener is paying close attention to the speaker. Rudeness, disinterest, and embarrassment are not correct interpretations of the client's behavior.

The nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply. Client with asthma Client with pancreatitis Malnourished client Client with diabetes mellitus Client with status epilepticus Client with severe prolonged diarrhea

Client with pancreatitis Malnourished client Client with diabetes mellitus Client with status epilepticus Client with severe prolonged diarrhea

The nurse determines that which clients are at high risk for metabolic acidosis? Select all that apply. Clients with asthma Clients with diabetes Clients with pneumonia Clients with kidney failure Clients with severe anxiety

Clients with kidney failure Clients with malnourishment Clients with asthma

Which function of leukocytes are involved in inflammation? Select all that apply. One, some, or all responses may be correct. Destruction of bacteria and cellular debris Selective attack and destruction of nonself cells Release of vasoactive amines during allergic reactions Secretion of immunoglobulins in response to a specific antigen Enhancement of immune activity through secretion of various factors, cytokines, and lymphokines

Destruction of bacteria and cellular debris Release of vasoactive amines during allergic reactions

The nurse concludes that the client on a 2-gram sodium diet needs further teaching when the client selects which foods? A soft-cooked egg, toast, jelly, and skim milk Baked chicken, boiled potatoes, broccoli, and coffee Fillet of sole, a baked potato, and a fresh fruit cup (berries and melons) Cottage cheese, crackers, and a relish dish (celery, olives, and sweet pickles)

Cottage cheese, crackers, and a relish dish (celery, olives, and sweet pickles) A meal consisting of cottage cheese, crackers, and a relish dish (celery, olives, and sweet pickles) has the highest sodium content. Meals consisting of a soft-cooked egg, toast, jelly, and skim milk; baked chicken, boiled potatoes, broccoli, and coffee; and fillet of sole, a baked potato, and a fresh fruit cup (berries and melons) are low in sodium.

3-year-old child is hospitalized because of persistent vomiting. Which conditions should the nurse expect this child to be high risk for? Select all that apply. Diarrhea Dehydration Metabolic acidosis Metabolic alkalosis

Dehydration Metabolic alkalosis

Which clinical finding would the nurse expect the client with the diagnosis of chronic heart failure to experience? 1. Dependent edema in the evening 2. Chest pain that decreases with rest 3. Palpitations in the chest when resting 4. Frequent coughing with yellow sputum

Dependent edema in the evening Decreased cardiac output causes fluid retention, which results in dependent edema; this is often noticed in the evening after the client has been standing or sitting for prolonged periods. Chest pain is indicative of cardiac ischemia. Palpitations are indicative of cardiac dysrhythmias. Coughing with yellow sputum is indicative of an infectious process in the respiratory tract; pink, frothy sputum is associated with pulmonary edema that can result from heart failure.

Which conclusion would the nurse make when assessing a client who has an area of induration that is 10 mm within 48 hours after having a Mantoux test? Contracted clinical tuberculosis Passive immunity to tuberculosis Exposure to the tubercle bacillus Resistance to the tubercle bacillus

Exposure to the tubercle bacillus Induration measuring 10 mm or more in diameter is interpreted as significant. It does not indicate that active tuberculosis is present. About 90% of individuals who have significant induration do not develop the disease. Exposure to the tubercle bacillus indicates exposure and infection can be past or present. Passive immunity occurs when the body plays no part in the preparation of the antibodies. A positive Mantoux indicates the presence of antibodies, not how they were formed. A resistance to the tubercle bacillus reaction indicates exposure not resistance.

The client receives a prescription for tap water enemas until clear. Which condition may occur if more than two enemas are given in one session? 1 Hypercalcemia 2 Hypocalcemia 3 Hyperkalemia 4 Hypokalemia

Hypokalemia Repeated tap water enemas deplete cells and extracellular fluid of potassium and sodium, resulting in hypokalemia, hyponatremia, and the potential for water intoxication. Repeated tap water enemas do not have a direct effect on hyper- or hypocalcemia. Potassium is depleted from cells and extracellular fluid, which does not result in hyperkalemia.

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse trying to enhance the client's respiratory status should avoid performing which actions? Select all that apply. Keeping the head of the bed elevated Monitoring the client's oxygen saturation level Increase the liter flow to 5 L per nasal cannula Assisting the client to turn, cough, and deep breathe Encouraging the client to breathe slowly and shallowly

Increase the liter flow to 5 L per nasal cannula Encouraging the client to breathe slowly and shallowly

Which statement is true about immunocompetence? 1 It is the immune system's ability to mobilize and use its antibodies. 2 It is the quality of being unaffected by a particular disease or condition. 3 It is the malfunction of the system caused by disruption of homeostasis. 4 It provides physical, mechanical, and chemical barriers to invading pathogens.

It is the immune system's ability to mobilize and use its antibodies. Rationale: Immunocompetence is the immune system's ability to mobilize and use its antibodies. Immunity is the quality of being unaffected by a particular disease or condition. Immunocompetence is the malfunction of the system caused by disruption of homeostasis. Other factors provide physical, mechanical, and chemical barriers to invading pathogens

The nurse is collecting data from a client with a suspected diagnosis of gastric ulcer. The client tells the nurse that oral antacids are taken frequently throughout the day. The nurse continues to collect data from the client, understanding that the client is at risk for which acid-base disturbance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis:

Metabolic alkalosis

Which is the priority nursing intervention when providing postprocedure care to a client who had a cardiac catheterization via a brachial artery in the first hour after the procedure? Monitor vital signs every 15 minutes. Maintain the client in the supine position. Keep the client's lower extremities in extension. Administer the prescribed oxygen at 4 L/min via nasal cannula.

Monitor vital signs every 15 minutes. A cardiac catheterization may cause cardiac irritability, and the nurse would monitor the client's vital signs every 15 minutes for 1 hour and then every 30 minutes for the next 2 hours until stable. The vital signs can then be monitored every 4 hours. When a brachial artery is used for catheter insertion, the low-Fowler position usually is recommended because it promotes respirations. Keeping the client's lower extremities in extension is not necessary as the brachial artery was used for the catheter insertion. Administering the prescribed oxygen at 4 L/min via nasal cannula may be done, but it is not the priority. The client's response to the procedure is the priority.

During the immune response, which factor leads to chronic inflammation and damage to the host tissue? Regulation of action Remembering the invader Responding to nonself invaders Recognition of the self from nonself

Regulation of action