Mastery Term #3

A client awaiting a heart transplant expresses concern about cyclosporine, the medication he will be taking to prevent organ rejection. The client asks for more information about cyclosporine. The nurse's correct response is which of the following?

"Cyclosporine greatly decreases the body's rejection of transplanted organs, but it also decreases the body's ability to resist infections."

A client is being evaluated for possible lung cancer. Which client statement most likely indicates lung cancer?

"My cough has changed from a dry cough to one with lots of sputum production."

A client recently had a myocardial infarction (MI) and asks the nurse if he will require a heart transplant. Based on the nurse's knowledge of indications for heart transplant, what is the best response?

"No. Heart transplant is indicated for cardiomyopathy, end-stage coronary artery disease, and end-stage heart failure."

A client has been admitted for a commissurotomy. The nurse knows that a commissurotomy repairs which of the following?

A valve

The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the sinoartrial (SA) node and then proceeds in which sequence?

AV node to bundle of His to Purkinje fibers

Hypertension is defined as "sustained elevations in systolic or diastolic blood pressures that exceed prehypertension levels." What are some of the consequences of hypertension that make it such a health menace in the United States?

All options are correct.

Which mechanisms are part of the body's defenses against infection?

All options are correct.

The nurse is reviewing the results of a client's diagnostic test indicating a positive strep culture. Which prescription medication does the nurse anticipate?

Amoxicillin

The nurse is providing discharge instructions to a client diagnosed with postoperative tonsillectomy and adenoidectomy. Which discharge instructions would the nurse include? Select all that apply.

Avoid carbonated fluids. Gradually increase fluids then add soft foods. Apply an ice collar to the neck area. Gargle with warm saline water.

The nurse is caring for an adult client with heart failure who is prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? Select all that apply.

Confusion Bradycardia

A client is diagnosed with rheumatic endocarditis. What bacterium is the nurse aware causes this inflammatory response?

Group A, beta-hemolytic streptococcus

A patient comes to the clinic and is diagnosed with tonsillitis and adenoiditis. What bacterial pathogen does the nurse know is commonly associated with tonsillitis and adenoiditis?

Group A, beta-hemolytic streptococcus

A female patient is being seen in the ER complaining of fatigue and shoulder blade discomfort. She is also short of breath. Based on these symptoms, what will the nurse suspect?

Myocardial infarction (MI)

A client receiving thyroid replacement therapy develops influenza and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication puts the client at risk for developing which life-threatening complication?

Myxedema coma

A child is brought to the clinic with a rash and is subsequently diagnosed with measles. The parent reports also having had measles as a young child. What type of immunity to measles develops after the initial infection?

Naturally acquired active immunity

The nurse is conducting a community program about prevention of respiratory illness. What illness does the nurse know is the most common cause of death from infectious diseases in the United States?

Pneumonia

After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent dysrhythmias?

Serum potassium level

The emergency department nurse is assessing a client following a motor vehicle accident. The nurse notes facial deformities with swelling and bleeding and a clear drainage coming from the nares. Which diagnostic test is completed to determine if the clear drainage is cerebrospinal fluid?

Test fluid with a Dextrostix

The nurse is caring for a client who is having a mitral valve replacement with a mechanical valve. What instructions should the nurse be sure the client understands prior to being discharged?

The client will require anticoagulation.

Which statements would be considered appropriate interventions for a client with an endotracheal tube? Select all that apply.

The cuff is deflated before the tube is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.

A patient taking corticosteroids for exacerbation of Crohn's disease comes to the clinic and informs the nurse that he wants to stop taking them because of the increase in acne and moon face. What can the nurse educate the patient regarding these symptoms?

The moon face and acne will resolve when the medication is tapered off.

The nurse is assessing a client who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, which statement by the client should prompt the nurse to refer the client for further assessment?

"Lately, I have this cough that just never seems to go away."

Which statement would indicate that the parents of child with cystic fibrosis understand the disorder?

"The mucus-secreting glands are abnormal."

A nurse and a nursing student are performing a physical assessment of a client with pericarditis. The client has an audible pericardial friction rub on auscultation. When leaving the room, the student asks the nurse what causes the sound. The nurse's best response is which of the following?

"The pericardial surfaces lose their lubricating fluid because of inflammation and rub against each other."

A parent of a child who has been having frequent bouts of tonsillitis brings the child back to the clinic for another sore throat. The parent asks the nurse, "What are tonsils good for anyway?" What is the best response by the nurse?

"These tissues filter bacteria from tissue fluid."

A monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin. Which response by the charge nurse is best?

"Warfarin prevents clot formation in the atria of clients with atrial fibrillation."

A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). The client's blood pressure is 104/68 mm Hg. The client's pulse rate is 76 beats/minute. The nurse detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take?

Contact the health care provider and report the findings.

A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client?

Continuous positive airway pressure (CPAP)

Which particular area(s) should be examined to assess peripheral edema?

Feet, ankles

The nurse knows the mortality rate is high in lung cancer clients due to which factor?

Few early symptoms

A middle-aged female client complains of anxiety, insomnia, weight loss, the inability to concentrate, and eyes feeling "gritty." Thyroid function tests reveal the following: thGoiteryroid-stimulating hormone (TSH) 0.02 U/ml, thyroxine 20 g/dl, and triiodothyronine 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these assessment findings, the nurse should suspect:

Graves' disease.

The heart has valves between the atrium and the ventricles. What valve separates the left atrium and ventricle?

Mitral

The critical care nurse is precepting a new nurse on the unit. Together they are caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?

Monitor the pressure in the cuff at least every 8 hours

Following thoracic surgery, what should the nurse include in the care plan for a client at risk for impaired gas exchange? Select all that apply.

Monitor vital signs frequently. Reinforce preoperative breathing exercises. Elevate head of bed 30 to 40 degrees as tolerated

A client with a history of diabetes insipidus seeks medical attention for an exacerbation of symptoms. Which laboratory finding indicates to the nurse that the client has been restricting fluids in an attempt to control the symptoms?

Sodium level of 150 mEq/L

A client is prescribed corticosteroid therapy. What would be priority information for the nurse to give the client who is prescribed long-term corticosteroid therapy?

The client is at an increased risk for developing infection.

A client has tested positive for tuberculosis (TB). While providing client teaching, which information should the nurse prioritize?

The importance of adhering closely to the prescribed medication regimen

The nurse is caring for a client with Addison disease who is scheduled for discharge. When teaching the client about hormone replacement therapy, the nurse should address what topic?

The need for lifelong steroid replacement

A nurse is caring for a client who has just had a total laryngectomy. What is part of the client's plan of care related to the surgery?

The nurse is caring for a patient in the outpatient clinic with suspicion of cancer due to recent weight loss for unidentifiable reasons. The patient has a 25-year history of smoking. The nurse performs an assessment and asks the patient about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer?

A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube?

"The ET tube will maintain your airway while you're under anesthesia."

A client recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the client?

Express empathy and then encourage the client to write, use a picture board, or spell words with an alphabet board.

A nurse is completing a head to toe assessment on a client diagnosed with right-sided heart failure. To assess peripheral edema, which of the following areas should be examined?

Feet and ankles

After reviewing the action of hormones, a group of students demonstrate understanding when they identify that the secretion of testosterone stimulates which of the following?

Male secondary sex characteristics

A patient who is diagnosed with type 1 diabetes would be expected to:

Need exogenous insulin.

During postoperative assessment of a client who has undergone cardiovascular surgery, oxygen saturation is at 85%. What action should the nurse perform next?

Notify the physician immediately.

An older adult client has newly diagnosed stage 2 hypertension. The health care provider has prescribed Chlorothiazide and Benazepril. What will the nurse monitor this client for?

Postural hypotension and resulting injury

What risk factors would cause the nurse to become concerned that the client may have atherosclerotic heart disease? Select all that apply.

hypertension diabetes obesity family history of early cardiovascular events

A nurse is teaching a client how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the client?

"Breathe in deeply through the spirometer, hold your breath briefly, and then exhale."

A client seeks care for hoarseness that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question?

"Do you smoke cigarettes, cigars, or a pipe?"

A client with a strong family history of coronary artery disease asks the nurse how to reduce the risk of developing the disorder. Which is the best response by the nurse?

"Exercise, keep your blood sugar in check, and manage your stress."

A 55-year-old client comes to the clinic for a routine check-up. The client's BP is 159/100 mm Hg and the health care provider diagnoses hypertension after referring to previous readings. The client asks why it is important to treat hypertension, since the client denies any discomfort. What would be the nurse's best response?

"Hypertension greatly increases your risk of stroke and heart disease."

When teaching a client with rheumatic carditis and a history of recurrent rheumatic fever, which statement by the client indicates that teaching has been successful?

"I may have to take prophylactic antibiotics for up to 10 years."

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:

"I should become involved in a weight loss program."

The nurse instructs a patient to take diphenhydramine (Benadryl) after an allergic reaction. Which of the following statements by the patient indicates successful teaching concerning the administration of diphenhydramine (Benadryl)?

"I should not drive my car after taking this medication."

The nurse instructs the client with diabetes on self-care during days of illness. Which client statement indicates that teaching has been effective? Select all that apply.

"I will increase my intake of fluids." "I will test my blood sugar level every 3 to 4 hours." "I will call the doctor if I have vomiting or diarrhea." "I will eat soft foods if I cannot tolerate regular food."

The nurse is caring for a client newly diagnosed with hypertension. Which statement by the client indicates the need for further teaching?

"If I take my blood pressure and it is normal, I don't have to take my blood pressure pills."

A client is recovering from a tonsillectomy in the postanesthesia care unit. After an overnight stay in the hospital due to increased secretions and vomiting, the nurse delivers client education and accompanying paperwork. Which comment indicates that the client requires additional education?

"If I'm vomiting, I'll drink lemon-lime soda to keep myself hydrated."

A client who is diagnosed with aortic stenosis is scheduled for a percutaneous balloon valvuloplasty. Which statement does the nurse include when reinforcing education regarding this procedure?

"The balloon is placed in your heart valve and inflated."

When assessing a client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect:

a blood pressure of 176/88 mm Hg.

Hormones are chemicals produced in the body to perform specific functions. What is a characteristic of a hormone?

They travel through the blood to specific receptor sites throughout the body

A group of nursing students are doing a presentation on hormones. What hormone would the presentation show regulates the metabolic rate and influences the growth and development of the body?

Thyroid hormone

The nurse is caring for a client who is post-sinus surgery. When assessing the client, the nurse asks the client how many fingers the nurse is holding up. Why does the nurse assess postoperative visual acuity?

To assess damage to the optic nerve

The nurse is teaching a client diagnosed with aortic stenosis appropriate strategies for attempting to relieve the symptom of angina without resorting to taking medications. What should the nurse teach the client?

To rest and relax before taking nitroglycerin

A diabetes educator is teaching a client about type 2 diabetes. The educator recognizes that the client understands the primary treatment for type 2 diabetes when the client states:

"I will make sure to follow the weight loss plan designed by the dietitian."

A diabetic educator is discussing "sick day rules" with a newly diagnosed type 1 diabetic. The educator is aware that the client will require further teaching when the client states what?

"I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours."

Which client statement indicates a good understanding of the nutritional modifications needed to manage hypertension?

"Limiting my salt intake to 2 grams per day will improve my blood pressure."

A client scheduled for a catheter ablation procedure confides to the nurse that he is worried about having some of his heart cells destroyed. The best response by the nurse is which of the following?

"Only the specific cells causing your dysrhythmia are destroyed; your heart will function better without these cells."

A client has been waiting for a donor heart for several months. Upon receiving the call that a heart has become available, the client asks the transplant nurse, "How much time do I have to get to the hospital?" What answer should the nurse give the client?

"The heart has to be transplanted within 6 hours, so it is advisable that you go to the hospital to be prepared now."

An older adult client has been diagnosed with aortic regurgitation. Which change in blood flow should the nurse expect to see on this client's echocardiogram?

Blood to flow back from the aorta to the left ventricle

An older adult client with heart failure is being discharged home on an ACE inhibitor and a loop diuretic. The client's most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this client's subsequent care, what nursing concern should be identified?

Falls risk related to hypotension

A middle-aged female client complains of anxiety, insomnia, weight loss, the inability to concentrate, and eyes feeling "gritty." Thyroid function tests reveal the following: thyroid-stimulating hormone (TSH) 0.02 U/ml, thyroxine 20 g/dl, and triiodothyronine 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these assessment findings, the nurse should suspect:

Graves' disease.

A critical care nurse is caring for a patient with an endotracheal tube who is on a ventilator. The nurse knows that meticulous management of this patient's needs is necessary. What is the rationale for this?

Maintaining a patent airway

The nurse assesses a patient who has been diagnosed with Addison's disease. Which of the following is a diagnostic sign of this disease?

Potassium of 6.0 mEq/L

A patient with pericarditis is experiencing cardiac tamponade. Which collaborative intervention should the nurse anticipate for this patient?

Prepare for pericardiocentesis.

The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client is asking for something to drink. Which criterion will determine when the nurse should allow the client to drink fluids?

Presence of a cough and gag reflex

A client with primary hypertension reports dizziness with ambulation when taking the prescribed alpha-adrenergic blocker. When teaching this client, what should the nurse emphasize?

Rising slowly from a lying or sitting position

A client is being discharged home after a heart transplant. The nurse is preparing to provide medication education on cyclosporine and tacrolimus. Which nursing diagnosis would be prioritized for this client?

Risk for infection

Nursing students have learned that removal of specific organs may place the patient at risk for impaired immune function. The students are taught that it is important, while taking the patient's health history, to ask the patient if he or she had surgical removal of what organ that may lead to impairment of the immune system?

Spleen

The nurse is caring for the client who presents to the clinic with hoarseness for 2 months. Further testing diagnoses laryngeal cancer with the treatment plan of a radical neck dissection. When reinforcing information provided by the physician, which nursing instruction is most correct?

The physician removes lymph nodes, muscles and tissue.

A nurse is assessing a client who has diabetes for the presence of peripheral neuropathy. The nurse should question the client about what sign or symptom that would suggest the possible development of peripheral neuropathy?

The presence of a tingling sensation

The client has just been diagnosed with a arrhythmia. The client asks the nurse to explain normal sinus rhythm. What would the nurse explain is the characteristic of normal sinus rhythm?

The sinoatrial (SA) node initiates the impulse.

Which instruction should a nurse provide a client with a history of rheumatic fever before the client has any dental work done?

To take prophylactic antibiotics

Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall?

Turn onto the affected side.

A patient who had a myocardial infarction is experiencing severe chest pain and alerts the nurse. The nurse begins the assessment but suddenly the patient becomes unresponsive, no pulse, with the monitor showing a rapid, disorganized ventricular rhythm. What does the nurse interpret this rhythm to be?

Ventricular fibrillation

For a client who has undergone peripheral arteriography, how should the nurse assess the adequacy of peripheral circulation?

checking peripheral pulses

During a client education session, the nurse describes the mechanism of hormone level maintenance. What causes most hormones to be secreted?

decrease in hormonal levels

During assessment of the respiratory system, the nurse inspects and palpates the trachea in order to assess:

deviation from the midline.

A client reports light-headedness, chest pain, and shortness of breath. They physician orders tests to ascertain what is causing the client's problems. Which test is used to identify cardiac rhythms?

electrocardiogram

A client returns for a follow-up visit to the cardiologist 4 days after a trip to the ED for sudden shortness of breath and abdominal pain. The nurse realizes the client had a myocardial infarction because the results from the blood work drawn in the hospital shows:

elevated troponin levels.

The nurse is caring for a client diagnosed with hypothyroidism secondary to Hashimoto thyroiditis. When assessing this client, what sign or symptom would the nurse expect?

fatigue

A client with a history of right-sided heart failure lives in a long-term care facility. In the daily assessment, the nurse is required to record the level of this client's peripheral edema. Which would be the main area for examination?

feet and ankles

During the cold and flu season each winter, rhinoviruses run rampant infecting those susceptible. What is the most important preventive factor to reduce the spread of this viral infection?

frequent handwashing

What is a harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle?

friction rub

A nurse is caring for a client with end-stage cardiomyopathy and the client's spouse asks the nurse to clarify one of the last treatment options available that the health care provider mentioned. What is considered to be one of the last treatments for end-stage cardiomyopathy?

heart transplantation

A client with mitral stenosis asks the nurse why antibiotics are needed in addition to the other drugs the client is taking. The nurse instructs the client that the antibiotics will:

help prevent infective endocarditis.

A client is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include

hoarseness.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

impaired gas exchange

Clients with valvular disorders who are taking prescribed anticoagulants should be instructed about which possible side effects?

increased bleeding time

A client is being seen by the physician because of an unrelenting headache, facial tenderness, low-grade fever, and dark yellow nasal discharge. The client reports seeming to develop sinus infections "all the time." Which factor may predispose the client to sinusitis?

interference with sinus drainage

A client with a history of type 1 diabetes is demonstrating fast, deep, labored breathing and has fruity odored breath. What could be the cause of the client's current serious condition?

ketoacidosis

An older male client with a history of chronic laryngitis reports a persistent hoarseness. What condition is the client at risk to develop?

laryngeal cancer

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to all the cells and tissues of the body?

left ventricle

In a client's presurgical education, the nurse reinforces the purpose for cardiovascular surgery. What is not a function of cardiovascular surgery?

lung repair

A client has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, the client has an inability to fight infection because bone marrow is unable to produce a sufficient amount of:

lymphocytes.

The nurse is completing discharge teaching with a client with hyperthyroidism who has been treated with radioactive iodine at an outpatient clinic. The nurse instructs the client to

monitor for symptoms of hypothyroidism.

A young client presents with symptoms of sniffling, nasal discharge, coughing, and sneezing. The symptoms which are keeping the client awake at night, and interrupting feedings. The client is diagnosed with rhinovirus. How many strains of this virus cause coryza?

more than 100

The nurse is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's

oxygen saturation level.

Which organ is both an exocrine and an endocrine gland?

pancreas

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and:

phosphorus.

A client reports difficulty falling asleep on a nightly basis. The physician suspects a lack of melatonin. What endocrine gland secretes melatonin?

pineal gland

What does a positive Mantoux test indicate?

production of an immune response

A client with broken ribs following a motor vehicle collisionMVA is being kept overnight for observation. The nurse should notify the physician of which findings? Select all that apply.

respiratory distress signs of infection increased pain

A nurse encourages a client to eat specific foods to promote healing of a lung abscess. The nurse recommends a diet that is:

rich in protein.

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for receiving deoxygenated blood from the venous system?

right atrium

A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What type of arrhythmia would the cardiologist likely diagnose?

sinus tachycardia

A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the:

skin test doesn't differentiate between active and dormant tuberculosis infection.

A nurse is giving a speech addressing "Communicable Diseases of Winter" to a large group of volunteer women, most of whom are older than 60 years. What preventive measures should the nurse recommend to these women, who are at the risk of pneumococcal and influenza infections? Select all that apply.

vaccinations hand antisepsis

When caring for a client with diabetes insipidus, the nurse expects to administer:

vasopressin.

What are the primary functions of the lungs? Select all that apply.

ventilation gas exchange

During the winter, increased instances of acute bronchitis cause a backlog of physician appointments that spill over into ED visits. What is the most common cause of acute bronchitis infections?

viral infections

A 16-year-old client newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The client is upset because friends frequently state, "You look anorexic." Which statement by the nurse would be the best response to help this client understand the cause of weight loss due to this condition?

"Your body is using protein and fat for energy instead of glucose."

A nurse is caring for a client with type 1 diabetes. The client's medication administration record includes the administration of regular insulin three times daily. Knowing that the client's lunch tray will arrive at 11:45 AM, when should the nurse administer the client's insulin?

11:30 AM

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?

15-mm induration

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?

6 to 12 months

A client is diagnosed with sinus bradycardia. The nurse knows that the client's atrial rate is at or below what number?

60

A health care provider prescribes short-acting insulin for a patient, instructing the patient to take the insulin 20 to 30 minutes before a meal. The nurse explains to the patient that Humulin-R taken at 6:30 AM will reach peak effectiveness by:

8:30 AM.

A client with a hypertensive emergency is being treated in the intensive care unit. The nurse knows that which client is at risk for developing this type of emergency?

A client with hypertension that was diagnosed 2 years ago

The nurse is caring for a client who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output?

A heart rate of 54 bpm

Which would be least likely to contribute to a case of hospital-acquired pneumonia?

A nurse washes her hands before beginning client care.

The home care nurse is assessing the home environment of a client who will be discharged from the hospital shortly after a laryngectomy. The nurse should encourage the client to use which appliance during recovery at home?

A room humidifier

A client with thoracic trauma is admitted to the ICU. The nurse notes the client's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated?

A tracheostomy

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP?

Administration of pneumococcal vaccine to vulnerable individuals

The nurse is caring for a client who has just had a tracheostomy. What should the nurse monitor frequently?

Airway patency

A nurse is caring for a diabetic patient with a diagnosis of nephropathy. What would the nurse expect the urinalysis report to indicate?

Albumin

The nurse is an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would the nurse be sure to include in the workshop? Select all that apply.

Alcohol Age Tobacco Industrial pollutants

A client has just undergone cardiothoracic surgery. The postop nurse must perform a neurologic assessment every 30 minutes to evaluate:

All options are correct.

A client admitted for the treatment of venous thromboembolism reports chest pain and dyspnea. Which of the following is the primary intervention for the nurse to implement?

Apply oxygen as prescribed.

A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks?

Applying nasal packing

A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide?

Artificially acquired active immunity

When an attenuated toxin is administered to a client, the B-cell lymphocytes create memory cells that recognize the antigen if it invades the body at a future time. What kind of immunity is this?

Artificially acquired active immunity

The nurse is caring for a client with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which action?

Assess the client for a cough reflex.

A nurse is preparing a client for cardiac catheterization. The nurse knows that which nursing intervention must be provided when the client returns to the room after the procedure?

Assess the puncture site frequently for hematoma formation or bleeding.

A client undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The client becomes anxious because the area begins to swell. What advice should the nurse give to calm the client?

Assure the client that this is a normal reaction.

A 26-year-old woman is thankful to be alive after rear-ending a truck with her car. However, she experienced a sternal fracture from the force of her car's airbag and has been breathing shallowly to avoid exacerbating her pain. The nurse should consequently prioritize assessments related to:

Atelectasis

Which of the following cell types are involved in humoral immunity?

B lymphocytes

A client with newly diagnosed emphysema is admitted to the medical-surgical unit for evaluation. Which does the nurse recognize as a deformity of the chest wall that occurs as a result of overinflation of the lungs in this client population?

Barrel chest

A client has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The health care provider's choice of antibiotics would be primarily based on what diagnostic test?

Blood cultures

A client with heart failure has met with the primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the client begins treatment, the nurse would prioritize which assessment?

Blood pressure

Surgical removal of the thyroid gland is the treatment of choice for thyroid cancer. During the immediate postoperative period, the nurse knows to evaluate serum levels of __________ to assess for a serious and primary postoperative complication of thyroidectomy.

Calcium

Accidental removal of one or both parathyroid glands can occur during a thyroidectomy. Which of the following is used to treat tetany?

Calcium gluconate

The nurse is caring for a client who has had a dysrhythmic event. The nurse is aware of the need to assess for signs of diminished cardiac output (CO). What change in status may signal to the nurse a decrease in cardiac output?

Changes in level of consciousness

The nurse expects that emergency medical treatment for epistaxis may include insertion of a cotton pledget moistened with:

Epinephrine

The nurse assesses a client who is bleeding profusely from the nose. The nurse documents this finding as which condition?

Epistaxis

A client with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on the critical care unit. What is the priority nursing diagnosis for a client with this condition?

Excess fluid volume

The nurse is caring for a client who is status post nasal polypectomy. What would the nurse instruct this client to report?

Excessive swallowing

A nurse should perform which intervention for a client with Cushing's syndrome?

Explain that the client's physical changes are a result of excessive corticosteroids.

During a routine visit to the pulmonologist, a client is told to undergo a mediastinoscopy. After the physician leaves the room, the nurse enters and is asked about this procedure. How should the nurse respond?

Exploration and biopsy of the lymph nodes that drain the lungs

A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?

Flail chest

A woman with a progressively enlarging neck comes into the clinic. She mentions that she has been in a foreign country for the previous 3 months and that she didn't eat much while she was there because she didn't like the food. She also mentions that she becomes dizzy when lifting her arms to do normal household chores or when dressing. What endocrine condition should the nurse expect the health care provider to diagnose?

Goiter

The nurse is performing an initial assessment of a client diagnosed with heart failure. The nurse also assesses the client's sensorium and LOC. Why is the assessment of the client's sensorium and LOC important in clients with heart failure?

Heart failure ultimately affects oxygen transportation to the brain

The health care provider has ordered a fluid deprivation test for a client suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments?

Heart rate and blood pressure

A nurse caring for a client with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding?

Highly dilute urine

The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?

Hoarseness for 2 weeks

A nurse is educating a community group about coronary artery disease. One member asks about how to avoid coronary artery disease. Which of the following items are considered modifiable risk factors for coronary artery disease? Choose all that apply.

Hyperlipidemia Obesity Tobacco use

Which describes a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage?

Hypertensive emergency

In which type of cardiomyopathy does the heart muscle actually increase in size and mass weight, especially along the septum?

Hypertrophic

A client has returned to the floor after having a thyroidectomy for thyroid cancer. What laboratory finding may be an early indication of parathyroid gland injury or removal?

Hypocalcemia

Obese patients with emphysema are encouraged to lose weight in order to:

Improve breathing

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result?

Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing

A client with venous insufficiency is instructed to exercise, apply elastic stockings, and elevate the extremities. Which is the primary benefit for this nursing management regime?

Improve venous return

A 60-year-old client comes to the ED reporting weakness, vision problems, increased thirst, increased urination, and frequent infections that do not seem to heal easily. The physician suspects that the client has diabetes. Which classic symptom should the nurse watch for to confirm the diagnosis of diabetes?

Increased hunger

A nurse is providing education to a client who is newly diagnosed with diabetes mellitus. What are classic symptoms associated with diabetes?

Increased thirst, hunger, and urination

The client with a lower respiratory airway infection is presenting with the following symptoms: fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse?

Ineffective airway clearance

What would the instructor tell the students purulent fluid indicates?

Infection

A client diagnosed with hypertension informs the nurse that they are not taking prescribed antihypertensive medications due to an absence of symptoms. What is the most appropriate response by the nurse?

Inform the client that this is why hypertension is known as "the silent killer."

The nurse is providing discharge teaching to a patient diagnosed with heart failure. What should the nurse teach this patient to do to monitor fluid balance?

Monitor weight daily.

A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with a health care provider's order that will relieve anxiety and slow respiratory rate?

Morphine sulfate

The nurse is caring for a client with a diagnosis of Addison disease. What sign or symptom is most closely associated with this health problem?

Muscle weakness

The pharmacology instructor is discussing the endocrine system with a class of pre-nursing students. What would the instructor tell the students is considered to be a hormone?

Norepinephrine

The nurse is reviewing the lab work of a client diagnosed with infective endocarditis. Which diagnostic study confirms the diagnosis?

Positive blood culture

Which is a primary nursing intervention in caring for a client with the diagnosis of bronchiectasis?

Postural drainage

A nurse is teaching a client about the functions of the larynx. What should the nurse include in the teaching? Select all that apply.

Producing sound Facilitating coughing Protecting the lower airway from foreign objects

Which of the following interventions would be helpful for a client reporting nasal congestion, sneezing, sore throat, and muscle aches? Select all that apply.

Provide warm salt-water gargles. Administer oral ibuprofen. Teach the client about handwashing. Recommend guaifenesin.

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client?

Pulmonary congestion

A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.)

Pulmonary crackles Dyspnea Cough

During a community health fair, a nurse is teaching a group of seniors about promoting health and preventing infection. Which intervention would best promote infection prevention for senior citizens who are at risk of pneumococcal and influenza infections?

Receive vaccinations

The nurse is documenting assessment findings as a client is being admitted to a medical unit. Which of the following conditions, present with a diagnosis of infectious endocarditis, is correct to be documented as petechiae?

Reddish hemorrhagic spots on the skin

What is the only insulin that can be given intravenously?

Regular

A patient newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a patient with prolonged uncontrolled hypertension is at risk for developing what health problem?

Renal failure

A nurse is caring for a client with Cushing's syndrome. Which interventions would the nurse include in the client's plan of care? Select all that apply.

Report systolic BP greater than 139 mm Hg or diastolic BP greater than 89 mm Hg. Examine extremities for pitting edema. Administer prescribed diuretics. Monitor weight.

Which of the following health care teaching points would a nurse cover when talking to a patient with rhinosinusitis? Select all that apply.

Report the symptoms of a secondary infection, the major complication of a cold. Increase fluid intake and rest as much as possible. Be aware that the virus is contagious for 2 days before symptoms appear and during the first part of the symptomatic phase.

What is the most common cause of mitral stenosis?

Rheumatic endocarditis

A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant?

Rheumatic fever

The nurse is preparing a client for coronary artery bypass surgery. What vessel does the nurse know is most commonly used for grafting?

Saphenous vein

The nurse is preparing to assist a client about to undergo CABG. The physician is using a graft in the location shown in the accompanying image. What type of graft is the physician using?

Saphenous vein

A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to

Seek medical help if he experiences inability to swallow

A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?

Serum glucose level of 52 mg/dl

The nurse uses which term for the normal pacemaker of the heart?

Sinoatrial (SA) node

A client has just been diagnosed with small cell lung cancer. The client asks the nurse why the doctor is not offering surgery as a treatment for the cancer. What fact about lung cancer treatment should inform the nurse's response?

Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

A nurse providing education about hypertension to a community group is discussing the high risk for cardiovascular complications. What are risk factors for cardiovascular problems in clients with hypertension? Select all that apply.

Smoking Diabetes mellitus Physical inactivity

The most diagnostic clinical symptom of pleurisy is:

Stabbing pain during respiratory movements.

When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided?

Swimming

A nursing student is discussing a client with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for clients with viral pharyngitis?

Symptom management is the main focus of medical and nursing care.

The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the resting state of the client's heart?

T wave

The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment?

Tachypnea

A client has a history of rheumatic fever as a child. Which instructions should be provided before the client has any dental work done?

Take prophylactic antibiotics

Which may be a potential cause of hypoglycemia in the client diagnosed with diabetes mellitus?

The client has not eaten but continues to take insulin or oral antidiabetic medications.

The nurse provides care for a client, with a history of atherosclerosis, who is hospitalized for the initiation of pharmacotherapy for the treatment of hypothyroidism.

The client is at highest risk for developing CARDIAC DYSFUNCTION as evidence by ANGINA

A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis?

Correct response: Apply direct continuous pressure.

The nurse is having an information session with a women's group at the YMCA about lung cancer. What frequent and commonly experienced symptom should the nurse be sure to include in the session?

Coughing

Which disorder is characterized by a group of symptoms produced by an excess of free circulating cortisol from the adrenal cortex?

Cushing syndrome

Which is a late sign of hypoxia?

Cyanosis

A client with hypofunction of the adrenal cortex has been admitted to the medical unit. What would the nurse most likely find when assessing this client?

Decreased blood pressure

A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority?

Decreased cardiac output

The nurse is observing the monitor of a patient with a first-degree atrioventricular (AV) block. What is the nurse aware characterizes this block?

Delayed conduction, producing a prolonged PR interval

Which of the following medications is used in the treatment of diabetes insipidus to control fluid balance?

Desmopressin (DDAVP)

The nurse is caring for a client with an upper respiratory disorder. The client states having a hacky, nonproductive cough, which wakens the client during the night. Which over-the-counter medication would the nurse suggest to diminish the cough during the night?

Dextromethorphan

A patient has been diagnosed with prehypertension and has been encouraged to exercise regularly and begin a weight loss program. What other healthcare professional may be helpful for the client to see?

Dietician

Which is a cerebrovascular manifestation of heart failure?

Dizziness

What is the reason for chest tubes after thoracic surgery?

Draining secretions, air, and blood from the thoracic cavity

The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?

Dyspnea on exertion

A nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients?

Early ambulation and the use of compression stockings

Which diagnostic study is usually performed to confirm the diagnosis of heart failure?

Echocardiogram

A patient's gradual decline in activity tolerance and increased shortness of breath have prompted her health care provider to assess the structure and size of her heart. Which of the following diagnostic tests is most likely to yield these assessment data?

Echocardiography

A client is recovering in the hospital from a bout with empyema. What intervention would the nurse implement to promote healing and oxygenation?

Encourage breathing exercises.

To assist a patient with the use of an incentive spirometer, the nurse should:

Encourage the patient to pause after a deep breath, relax, and exhale.

Although not designated as endocrine glands, several organs within the body secrete hormones as part of their normal function. Which organ secretes hormones involved in increasing blood pressure and volume and maturation of red blood cells?

Kidneys

The nurse is assessing a client new to the clinic. Records brought to the clinic show that the client's hypertension has not improved. What contributing factor should the nurse first explore in an effort to identify the cause of the client's inadequate BP control?

Lack of adherence to prescribed drug therapy

The client has not eaten but continues to take insulin or oral antidiabetic medications.

Less than 70 mg/dL (3.7 mmol/L)

The nurse is developing a teaching plan for a client diagnosed with hypertension. What would be important for the nurse to emphasize as part of the plan of care?

Limiting sodium intake in the diet

A client has undergone a polysomnography and is diagnosed with sleep apnea. Which lifestyle changes are recommended for clients with sleep apnea? Select all that apply.

Lose weight. Quit smoking. Use saline spray to reduce nasal dryness.

Ralph Wilson, is a 52-year-old client in the hospital unit where you practice nursing. He is being treated for myocarditis. Which of the following nursing interventions should you perform to reduce cardiac workload in a client with myocarditis?

Maintain the client on bed rest

Which nursing intervention should a nurse perform to reduce cardiac workload in a client diagnosed with myocarditis?

Maintain the client on bed rest

Which nursing intervention would reduce cardiac workload in a client with myocarditis?

Maintain the client on bed rest.

For a client with Graves' disease, which nursing intervention promotes comfort?

Maintaining room temperature in the low-normal range

A nursing student is taking a test on the cardiovascular system. Which of the following would the student correctly identify as cardiac valves? Select all that apply.

Aortic Mitral Tricuspid Pulmonic

A nurse working at a pediatric clinic is teaching a group of parents. A parent asks the nurse if it is okay to let the young child recover from a sore throat naturally, rather than bringing the child to the clinic for diagnosis and treatment. What is the nurse's best response?

"It may be streptococcal sore throat. Rheumatic heart disease can be prevented with early treatment."

A patient has been newly diagnosed with heart failure (HF) and has come to the meet with the nurse at the clinic for health education. What lifestyle recommendation should the nurse provide to this patient when discussing dietary modifications?

"It's in your best interests to avoid excessive fluids and sodium in your diet."

A nurse is caring for a client who is recovering from a myocardial infarction (MI). The cardiologist refers the client to cardiac rehabilitation. Which statement by the client indicates an understanding of cardiac rehabilitation?

"Rehabilitation will help me function as well as I physically can."

The nurse is caring for a client who states, "I am really worried about the thoracentesis. I know I won't be able to sleep tonight." Which statement is most helpful to the client at this time?

"Tell me what you are worried about."

What is the most common cause of hyperaldosteronism?

An adrenal adenoma

Which term refers to chest pain brought on by physical or emotional stress and relieved by rest or medication?

Angina pectoris

The nurse is caring for a client who has just returned from the cardiac catheterization laboratory following a coronary angioplasty. What is the nurse's priority assessment?

Check the temperature, color, and capillary refill of the affected extremity.

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism?

Chest pain and dyspnea

When a client's gallbladder has decreased ability to release bile when he is having a high fat content meal, what hormone is not released to stimulate contractions of the gallbladder?

Cholecystokinin

Which assessment finding puts a client at increased risk for epistaxis?

Cocaine use

Health teaching for a patient diagnosed with Raynaud's phenomenon would include advising the patient to avoid the most common factor known to trigger episodes. Which of the following is the most common factor?

Cold and stress

A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?

Coma, anxiety, confusion, headache, and cool, moist skin

Which diagnostic test is done to determine a suspected pituitary tumor?

Computed tomography

The client diagnosed with acute respiratory distress syndrome (ARDS) presents with severe hypoxemia, despite oxygen administration via face mask. The nurse anticipates and prepares for which prescription from the health care provider (HCP)?

Insertion of endotracheal tube

NPH is an example of which type of insulin?

Intermediate-acting

Which term refers to a muscular, cramp-like pain in the extremities consistently reproduced with the same degree of exercise and relieved by rest?

Intermittent claudication

Which assessment would a nurse perform on a client with Cushing syndrome who is at high risk of developing a peptic ulcer?

Observe stool color.

Which type of sleep apnea is characterized by lack of airflow due to pharyngeal occlusion?

Obstructive

A 45-year-old obese man arrives in a clinic reporting daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of which health problem?

Obstructive sleep apnea

Which term will the nurse use to document the inability of a client to breathe easily unless positioned upright?

Orthopnea

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform?

P wave

Which is a key characteristic of pleurisy?

Pain

The nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment?

Palpation of the client's lymph nodes

A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have?

Passive immunity transferred by the mother

Which medication is the treatment of choice for bacterial pharyngitis?

Penicillin

Which statements are true when the nurse is measuring blood pressure (BP)? Select all that apply.

Using a BP cuff that is too small will give a higher BP measurement. The client's arm should be positioned at the level of the heart. The client should sit quietly while BP is being measured.

A nurse has been administering seasonal influenza vaccinations to the residents of a long-term care facility. One resident has refused the vaccinations, stating that he believes the vaccination to be a cause of influenza infection rather than a protection against it. The nurse's response to this resident should encompass which of the following facts about vaccination?

Vaccination prompts the body to produce antibodies against influenza.

The nurse is providing client teaching to a young parent who has brought their 3-month-old infant to the clinic for a well-baby checkup. Which recommendation will the nurse make to the client to prevent the transmission of organisms to the infant during the cold season?

Wash hands frequently.

Which findings should a nurse expect to assess in client with Hashimoto's thyroiditis?

Weight gain, decreased appetite, and constipation

While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following?

Wheezes

The nurse is suctioning a client who is unable to expectorate respiratory secretions. At which point does the nurse expect the client to experience coughing?

When the catheter reaches the point of the carina

During a mumps outbreak at a local school, a teacher has been exposed. The client has previously been immunized for mumps, and consequently possesses:

acquired immunity.

A client is diagnosed with pericarditis. What symptom will be the nurse's priority for treatment?

acute pain

A nurse is caring for clients in the emergency department and feels very stressed. What endocrine structure is releasing stress hormones to contribute to the nurse's response?

adrenal medulla

A client has had a laryngectomy as treatment for laryngeal cancer. Which postoperative instruction is of utmost importance to the client's health and safety?

avoid swimming