Med Surg- cardio and respiratory

A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax? A. Dry cough B. Rhinitis C. Sore throat D. Swollen lymph nodes

A. Dry cough A dry cough is a clinical manifestation of the prodromal stage of inhalation anthrax. During this stage, it is difficult to distinguish the condition from influenza or pneumonia because there is no sore throat or rhinitis.

A nurse is caring for a client who has femoral thrombophlebitis and a prescription for enoxaparin. Which of the following actions should the nurse take? A. Elevate the affected leg B. Place the client on bed rest C. Massage the affected leg D. Administer aspirin for discomfort

A. Elevate the affected leg The nurse should elevate the client's affected leg when the client is in bed to reduce inflammation.

A nurse is providing discharge teaching to a client who has emphysema. Which of the following instructions should the nurse include? A. "Be sure to take cough medicine to avoid coughing." B. "Try to drink at least 2 to 3 liters of fluid per day." C. "Try to reduce your smoking to 2 cigarettes per day." D. "Be sure to eat 3 full meals each day."

B. "Try to drink at least 2 to 3 liters of fluid per day." Although adequate hydration is essential for all clients, clients who have emphysema should drink 2 to 3 L per day to help liquefy secretions.

A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take? A. Obtain blood samples to test platelet function B. Prepare for replacement of the missing clotting factor C. Administer aspirin for the client's pain D. Place the bleeding joint in the dependent position

B. Prepare for replacement of the missing clotting factor Hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs. It is caused by a deficiency in the most common clotting factor, factor VIII (hemophilia A). Aggressive factor replacement is initiated to prevent hemarthrosis, which can result in a long-term loss of range of motion in repeatedly affected joints.

A nurse is caring for a client who reports calf pain. What is the first action the nurse should take? A. Notify the provider B. Elevate the affected extremity C. Check the affected extremity for warmth and redness D. Prepare to administer unfractionated heparin

C. Check the affected extremity for warmth and redness The first action the nurse should take using the nursing process is to assess the client's calf for swelling, redness, and warmth. These findings can indicate a deep vein thrombophlebitis.

A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? A. Instruct the client to cough B. Administer oxygen via face mask C. Evaluate the client for stridor D. Keep the client in a semi- to high-Fowler's position

C. Evaluate the client for stridor The first action the nurse should take using the nursing process is to assess the client. After extubation, the nurse should continuously evaluate the client's respiratory status. Stridor is a high-pitched sound during inspiration that indicates laryngospasm or swelling around the glottis. Stridor reflects a narrowed airway and might require emergency reintubation.

A nurse is reviewing the progress notes for a client who has heart failure. The provider noted some improvement in the client's cardiac output. The nurse should understand that cardiac output reflects which of the following physiologic parameters? A. The percentage of blood the ventricles pump during each beat B. The amount of blood the left ventricle pumps during each beat C. The amount of blood in the left ventricle at the end of diastole D. The heart rate times the stroke volume

D. The heart rate times the stroke volume Cardiac output is the product of the client's heart rate and stroke volume (the amount of blood the left ventricle pumps with each contraction). In systolic heart failure, the heart cannot pump enough oxygenated blood into the circulation, causing cardiac output to decrease.

A nurse is providing teaching for a client who has a prescription for a low-sodium diet to manage hypertension. Which of the following statements by the client indicates an understanding of the teaching? A. "I can snack on fresh fruit." B. "I can continue to eat lunchmeat sandwiches." C. "I can have cottage cheese with my meals." D. "Canned soup is a good lunch option."

A. "I can snack on fresh fruit." The nurse should identify that fresh fruits contain little to no sodium and are a good snack for a client who has hypertension.

A nurse is teaching a client with heart disease about a low-cholesterol diet. Which of the following client statements indicates the teaching was effective? A. "I should remove the skin from poultry before eating it." B. "I will eat seafood once per week." C. "I should use margarine when preparing meals." D. "I can use whole milk in my oatmeal."

A. "I should remove the skin from poultry before eating it." The nurse should identify the client understands the teaching when he states he will remove the skin from poultry before eating, as the skin contains the greatest amount of fat.

A nurse is providing information to a client who is scheduled for an exercise electrocardiography test. Which of the following client statements indicates an understanding of the teaching? A. "I will not drink coffee 4 hr prior to my test." B. "I can eat a light meal 1 hr prior to the test." C. "I can have a cigarette up to 30 min prior to the test." D. "I will take my heart medication on the day of the test."

A. "I will not drink coffee 4 hr prior to my test." The client should avoid coffee, alcohol, and caffeine on the day of the test. These can affect the client's heart rate and blood pressure during the test.

A nurse is caring for a client who is undergoing treatment for hypertension. Which of the following statements indicates that the client is adhering to the treatment plan? A. "I would never have believed I could get used to enjoying my food without salt." B. "My blood pressure device at home usually shows about 156 over 98 or so." C. "I make sure I take my blood pressure medicine when I have headaches." D. "My blood pressure pills are very expensive. Could I take a cheaper medication?"

A. "I would never have believed I could get used to enjoying my food without salt." This statement implies that the client has stopped adding salt to food. Sodium restriction is a single aspect of the treatment plan, but it does indicate dietary adherence by the client.

A nurse is providing preoperative teaching to a client who has lung cancer and will undergo a pneumonectomy. Which of the following statements should the nurse include? (Select all that apply.) A. "You will have a chest tube in place after surgery." B. "We'll frequently help you turn, cough, and breathe deeply after surgery." C. "You will have to remain in bed for about 2 days after the surgery." D. "We'll give you oxygen to support your breathing if you need it." E. "You should expect pain for the first few days after surgery."

A. "You will have a chest tube in place after surgery." B. "We'll frequently help you turn, cough, and breathe deeply after surgery." D. "We'll give you oxygen to support your breathing if you need it." After a pneumonectomy, some clients have a clamped chest tube briefly to help reduce mediastinal shift. They do not usually have closed-chest drainage. Helping the client turn, cough, and breathe deeply is standard preventive postoperative care after thoracic surgery. After thoracic surgery, clients typically receive oxygen by nasal cannula or mask for the first 2 days and then as needed.

A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus? A. A client who has a chest tube following a pneumothorax B. A client who has an acute exacerbation of Crohn's disease C. A client who is postoperative following a laparoscopic appendectomy D. A client who is recovering from thyroid storm

A. A client who has a chest tube following a pneumothorax Crepitus, a crackling sound resulting from air trapped under the skin, can be palpated following a pneumothorax. The nurse should report this finding to the provider.

A nurse in the emergency department is assessing a client for closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi

A. Absence of breath sounds A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.

A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the following actions should the nurse take? (Select all that apply.) A. Assess and document the client's vital signs B. Restart the IV with a 22-gauge needle C. Verify with another nurse the blood type and Rh of the packed RBCs D. Hang a bag of lactated Ringer's IV solution E. Change IV tubing to a set that has a filter

A. Assess and document the client's vital signs C. Verify with another nurse the blood type and Rh of the packed RBCs E. Change IV tubing to a set that has a filter The nurse should assess and document the client's vital signs prior to initiating a blood transfusion to obtain a baseline for comparison. Monitoring the client's vital signs helps the nurse identify adverse reactions to the packed RBCs and determine whether the client is tolerating the volume of the prescribed blood product. The nurse should verify the blood type and Rh of the packed RBCs with another RN and compare these data with the client's information for compatibility. This action decreases the risk of an ABO incompatibility reaction. The nurse should administer packed RBCs through IV tubing that has a filter to prevent the administration of aggregates and possible contaminants.

A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (Select all that apply.) A. Assign the client to a private room with negative-pressure airflow. B. Add contact precautions to the client's plan of care. C. Wear an N95 respirator when entering the client's room. D. Ensure the client's environment provides 4 exchanges of fresh air per minute. E. Institute protective environment precautions as soon as the client arrives on the unit.

A. Assign the client to a private room with negative-pressure airflow. C. Wear an N95 respirator when entering the client's room. This client's history and present status suggest tuberculosis, a communicable infection that mandates a private room with negative-pressure airflow. Airborne precautions will be required, including wearing an N95 respirator when entering the client's room.

A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm^3. Which of the following interventions should the nurse include? A. Avoid IM injections B. Assess the client for ecchymosis once per shift C. Do not allow the client to have visitors D. Encourage daily flossing between teeth

A. Avoid IM injections This client's platelet count of 48,000/mm^3 indicates thrombocytopenia; therefore, the nurse should avoid invasive procedures such as an IM injection which can increase the client's risk of bleeding.

A nurse is teaching about a low-cholesterol diet to a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching? A. Chicken breast and corn on the cob B. Shrimp and rice C. Cheese omelet and turkey bacon D. Liver and onions

A. Chicken breast and corn on the cob The nurse should identify that chicken breast is low in cholesterol, and all vegetables, including corn, are cholesterol-free; therefore, this food selection by the client indicates an understanding of the teaching.

A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation? A. Discuss ways the client can reduce the number of cigarettes smoked per day B. Suggest the client switch from smoking cigarettes to smoking a pipe C. Inform the client that treatment will be ineffective if smoking continues D. Discourage the use of nicotine gum

A. Discuss ways the client can reduce the number of cigarettes smoked per day The nurse should discuss ways the client can reduce the number of cigarettes smoked per day to assist the client in creating a realistic goal to decrease smoking gradually.

A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD) and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? A. Eat high-calorie foods first B. Increase intake of water at meal times C. Perform active range-of-motion exercises before meals D. Keep saltine crackers nearby for snacking

A. Eat high-calorie foods first Clients who have COPD often experience early satiety. Therefore, the client should eat calorie-dense foods first.

A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? A. Elevated ST segments B. Absent P waves C. Depressed ST segments D. Varying PP intervals

A. Elevated ST segments Elevated ST segments can indicate hyperkalemia and pericarditis.

A nurse is reviewing the laboratory results of a client who has end-stage renal disease and reports fatigue. The client's hemoglobin level is 8 g/dL. The nurse should expect a prescription for which of the following medications? A. Erythropoietin B. Erythromycin C. Filgrastim D. Calcitriol

A. Erythropoietin Erythropoietin stimulates the production of RBCs and is used to treat anemia associated with chronic renal failure.

A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (Select all that apply.) A. Explain that the client will receive sedation and will not remember the procedure. B. Verify that the client understands the purpose and nature of the procedure. C. Offer the client sips of clear liquids until 1 hr before the test. D. Obtain a pre-procedural sputum specimen. E. Instruct the client to keep his neck in a neutral position.

A. Explain that the client will receive sedation and will not remember the procedure. B. Verify that the client understands the purpose and nature of the procedure. For a bronchoscopy, clients typically receive premedication with a benzodiazepine or an opioid to ensure sedation and amnesia. The client will have signed a consent form, so the nurse should verify that the provider explained the procedure and that the client understands it.

A nurse is assessing a client who has deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find? (Select all that apply.) A. Hardening along the blood vessel B. Absence of a peripheral pulse C. Tenderness in the calf D. Cool skin on the leg E. Increased leg circumference

A. Hardening along the blood vessel C. Tenderness in the calf E. Increased leg circumference Deep-vein thrombosis can cause hardening along the affected blood vessel and prominence of superficial veins, pain or tenderness in the calf, and an increase in the circumference of the leg due to swelling.

A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? A. Hyperkalemia B. Hyponatremia C. Hypercalcemia D. Hypomagnesemia

A. Hyperkalemia The nurse should monitor the client for hyperkalemia because chronic respiratory acidosis can result in high potassium levels due to potassium shifting out of the cells into the extracellular fluid.

A nurse is assessing a client who has isotonic dehydration. Which of the following findings should the nurse expect? A. Increased hematocrit level B. Bradycardia C. Distended neck veins D. Decreased urine specific gravity

A. Increased hematocrit level The nurse should expect the client to have an increased hematocrit level due to hemoconcentration caused by reduced plasma fluid volume.

A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? A. Initiate bag-valve-mask ventilation B. Provide the client with a communication board C. Obtain a blood sample for ABG analysis D. Document the ventilator settings

A. Initiate bag-valve-mask ventilation The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse should first provide ventilations with a bag-valve-mask device.

A nurse is planning postoperative education for a client who will undergo a radical neck dissection for cancer of the larynx. The nurse should include which of the following topics? (Select all that apply.) A. NPO status B. Alternative methods of communication C. Endotracheal intubation D. Changes in body image E. Swallowing exercises

A. NPO status B. Alternative methods of communication D. Changes in body image E. Swallowing exercises The client will receive fluids and nutrition via an enteral tube while healing from the surgery. Radical neck dissection interrupts vocal communication, so the nurse should determine with the client and family how the client will prefer to communicate. Extensive resection can result in some disfigurement and permanent tracheostomy; the nurse should help prepare the client for these changes. Swallowing can be challenging after an extensive resection. The client might require the assistance of a speech-language pathologist to provide swallowing exercises and techniques.

A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction (MI). Which of the following manifestations should the nurse identify as indications of MI? (Select all that apply.) A. Nausea and vomiting B. Diaphoresis and dizziness C. Chest and left arm pain that subsides with rest D. Anxiety and feelings of doom E. Bounding pulse and bradypnea

A. Nausea and vomiting B. Diaphoresis and dizziness D. Anxiety and feelings of doom Nausea, vomiting, epigastric distress, diaphoresis (sweating), dizziness, fatigue, anxiety, and feelings of doom and fear are common manifestations of MI.

A nurse is completing a medication history for a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client? A. Omega-3 fatty acids B. Antioxidants C. Vitamins A, D, and C D. Beta-carotene

A. Omega-3 fatty acids Fish oil contains omega-3 fatty acids, which can help lower the risk of cardiovascular disease and stroke by decreasing triglyceride levels. Incorrect Answers:

A nurse is caring for an older adult client who had an acute myocardial infarction (MI). When assessing this client, the nurse should identify that older adults are prone to complications of MI from poor tissue perfusion because of which of the following age-related factors? A. Peripheral vascular resistance increases. B. The sensitivity of blood pressure-adjusting baroreceptors increases. C. Blood is hypercoagulable and clots more quickly. D. Cardiac medications are less effective.

A. Peripheral vascular resistance increases. Older adult clients are more prone to complications from poor tissue perfusion following an acute MI because peripheral vascular resistance increases with aging. This results from calcification and loss of elasticity of the blood vessels.

A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take? A. Position the client supine with his legs elevated when in bed B. Encourage the client to ambulate for 15 min every hour while awake for the first 24 hr C. Tell the client to sit with his legs dependent after ambulating D. Instruct the client to wear knee-length socks for 2 weeks after surgery

A. Position the client supine with his legs elevated when in bed The nurse should elevate the client's legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart.

A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review? A. Prothrombin time B. WBC count C. Platelet count D. Hematocrit

A. Prothrombin time The nurse should review the client's prothrombin time after the administration of FFP, which is plasma-rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time.

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A. Stabbing chest pain B. Calf tenderness C. Elevated temperature D. Bradycardia

A. Stabbing chest pain A manifestation of a pulmonary embolism is sudden chest pain that is sharp and stabbing. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood), tachypnea, tachycardia, diaphoresis, and a feeling of impending doom

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? A. Sudden onset of dyspnea B. Tracheal deviation C. Bradycardia D. Difficulty swallowing

A. Sudden onset of dyspnea Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs.

A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume

A. Total lung capacity Pulmonary function tests are used to examine the effectiveness of the lungs and to identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation.

A nurse is reviewing the menu selections of a client who has heart failure and anticipates discharge to home the following day. Which of the following lunch choices should the nurse identify as an indication that the client understands his dietary instructions? A. Turkey on whole-wheat bread B. Hamburger and french fries C. Frankfurter on a white roll D. Macaroni and cheese

A. Turkey on whole-wheat bread The primary dietary alteration for a client who has heart failure is sodium restriction. A turkey sandwich with whole-wheat bread has a relatively low sodium content. Incorrect Answers:

A nurse is providing discharge teaching about improving gas exchange for a client who has emphysema. Which of the following instructions should the nurse include in the teaching? A. Use pursed-lip breathing during periods of dyspnea B. Limit fluid intake to 1,500 mL per day C. Practice chest breathing each day D. Wear home oxygen to maintain an SaO2 of at least 94%

A. Use pursed-lip breathing during periods of dyspnea The nurse should instruct the client about using pursed-lip breathing during periods of dyspnea to slow expiration, increase airway pressure, and facilitate effective gas exchange.

A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial infarction (MI). Which of the following indicators should the nurse identify to confirm reperfusion? A. Ventricular dysrhythmias B. Appearance of Q waves C. Elevated ST segments D. Recurrence of chest pain

A. Ventricular dysrhythmias The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery.

A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? A. Weight gain of 1 kg (2.2 lb) in 1 day B. Pitting edema +1 C. Client report of a nocturnal cough D. B-type natriuretic peptide (BNP) level of 100 pg/mL

A. Weight gain of 1 kg (2.2 lb) in 1 day A weight gain of 1 kg (2.2 lb) in 1 day indicates that the client is retaining fluid and is at risk of fluid volume overload. This suggests the client's heart failure is worsening.

A nurse is completing dietary teaching with a client who has heart failure and is prescribed a 2 g sodium diet. Which of the following statements by the client indicates an understanding of the teaching? A. "I should use salt sparingly while cooking." B. "I can have yogurt as a dessert." C. "I should use baking soda when I bake." D. "I should use canned vegetables instead of frozen."

B. "I can have yogurt as a dessert." The client understands the teaching when he selects yogurt as a dessert. Yogurt is low in fat and sodium and is a good source of calcium and protein. Incorrect Answers: A. The client requires further teaching when he states he will use salt sparingly while cooking. Salt should be eliminated from the client's diet. Spices or vinegar, which are low in sodium, can be used to season the client's food.

A nurse is providing discharge teaching to an adult female client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates an understanding of the teaching? A. "I will ask my provider to change my contraception to an intrauterine device." B. "I will notify my doctor before I have dental procedures." C. "I will avoid using antiseptic mouthwash for oral care." D. "I will wear a mask when I go out in public."

B. "I will notify my doctor before I have dental procedures." The nurse should inform the client of ways to decrease the risk of recurrence of infective endocarditis. The client should notify the provider prior to invasive or dental procedures due to the need for prophylactic antibiotic therapy to reduce the risk of a streptococcal infection.

A nurse in a provider's office is reviewing the medical records of a group of clients. Which of the following clients is at risk for iron deficiency? (Select all that apply.) A. A client who is postmenopausal B. A client who is a vegetarian C. A middle adult male client D. A client who is pregnant E. A toddler who is overweight

B. A client who is a vegetarian D. A client who is pregnant E. A toddler who is overweight A client who is a vegetarian might require additional iron because the availability of iron in vegetable food sources is limited. During pregnancy, maternal blood volume increases, and the fetus requires additional iron. Therefore, the RDA of iron for clients who are pregnant is increased to 27 mg per day. Toddlers who are overweight may get most of their calories from milk and foods that are not considered healthy, which increases their risk for iron-deficiency anemia.

A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? A. Excessive airway secretions B. A leak within the ventilator's circuitry C. Decreased lung compliance D. The client coughing or attempting to talk

B. A leak within the ventilator's circuitry The low-pressure alarm means that either the ventilator tubing has come apart or the tubing detached from the client. Low-pressure alarms are often the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator.

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? A. Eliminating environmental triggers that precipitate attacks B. Addressing the client's perception of the disease process and what might have triggered past attacks C. Overviewing the client's medication regimen D. Explaining manifestations of respiratory infections

B. Addressing the client's perception of the disease process and what might have triggered past attacks The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing the client will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first assess the client's current knowledge.

A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity? A. Absent pedal pulses B. Ankle swelling C. Hair loss D. Skin atrophy

B. Ankle swelling The nurse should identify that swelling of the ankle is a manifestation of venous insufficiency due to poor venous return. Other manifestations can include brown pigmentations and cellulitis.

A nurse is caring for a client who has a platelet count of 50,000/mm^3. After discontinuing the client's peripheral IV site, which of the following actions should the nurse take? A. Apply warm compresses B. Apply pressure to the catheter removal site for 5 min C. Place the affected arm in a dependent position D. Clean the insertion site with alcohol

B. Apply pressure to the catheter removal site for 5 min A platelet count below 100,000/mm^3 indicates thrombocytopenia, which puts the client at an increased risk of bleeding. By applying pressure to the site for at least 5 minutes, the nurse promotes coagulation and prevents additional blood loss.

A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? A. P waves occurring at 0.16 seconds before each QRS complex B. Atrial rate of 300/min with QRS complex of 80/min C. Ventricular rate of 82/min with an atrial rate of 80/min D. Irregular ventricular rate of 125/min with a wide QRS pattern

B. Atrial rate of 300/min with QRS complex of 80/min The nurse should interpret this finding as atrial flutter, which indicates a lack of conduction between the atria and ventricles. The additional atrial beats are not conducting.

A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Bleeding at the venipuncture site C. Petechiae on the chest and arms D. Flushed, dry skin E. Abdominal distension

B. Bleeding at the venipuncture site C. Petechiae on the chest and arms E. Abdominal distension The formation of large amounts of microemboli in the circulation depletes the body's platelets and clotting factors. As a result, uncontrollable bleeding can occur, as manifested by bleeding at the venipuncture site, petechiae on the chest and arms, and bleeding in the abdominal cavity resulting in abdominal distension due to internal bleeding.

A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications? A. Cardiogenic shock B. Dysrhythmias C. Heart failure D. Pulmonary edema

B. Dysrhythmias According to evidence-based practice, dysrhythmias (specifically ventricular fibrillation) are the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately.

A nurse is caring for a client who is experiencing acute opioid toxicity. Which of the following actions should the nurse identify as the priority? A. Insert a large-bore IV catheter B. Ensure an adequate airway C. Obtain an accurate medication history D. Prepare to administer an antagonist

B. Ensure an adequate airway The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to ensure the client's airway is adequate, as respiratory depression is a manifestation of opioid toxicity.

A nurse is caring for a client who has acute lymphocytic leukemia and reports a fever, chills, fatigue, and pallor over the past week. When checking the client's laboratory results, which of the following values should the nurse identify as contributing to the client's fatigue and pallor? A. Magnesium 2.0 mEq/L B. Hgb 6.5 g/dL C. WBC count 9.6/mm3 D. Creatinine 0.8 mg/dL

B. Hgb 6.5 g/dL The expected reference range of Hgb is 14 to 18 g/dL for men and 12 to 16 g/dL for women. Therefore, a client who has an Hgb level of 6.5 g/dL has anemia. Typical manifestations of a low Hgb level include fatigue, headaches, pallor, dizziness, and tachycardia.

A nurse completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? (Select all that apply.) A. Hypothyroidism B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking

B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking A client who has hypertension, diabetes mellitus, hyperlipidemia, or a history of smoking tobacco is at risk for coronary artery disease (CAD). Hypertension and hyperlipidemia can be controlled by diet and exercise, along with medication if needed. Diabetes can cause damage to large and small blood vessels, which leads to poor perfusion, cell death, and organ damage. Diabetes mellitus can be managed by monitoring glucose levels and implementing diet and exercise recommendations. Cholesterol levels, such as total HDL and LDL levels, should be monitored since elevated total serum cholesterol levels increase the risk of a myocardial infarction. Finally, smoking accelerates the rate of the narrowing of the coronary arteries and increases the risk of clot formation. Smoking cessation classes or other forms of treatment can be offered to help the client quit smoking.

A nurse is assisting a provider with a comprehensive physical examination of a client. When the provider uses transillumination, the nurse should explain to the client that this technique helps evaluate which of the following structures? A. Lymph nodes B. Maxillary sinuses C. Intercostal spaces D. Salivary glands

B. Maxillary sinuses Transillumination is a procedure that allows the passage of light, often bright halogen light, through body tissues. Occluded sinuses prevent the passage of light rays through the sinus air sacs. Clear sinus air spaces allow transillumination.

A nurse is examining the ECG of a client who has frequent premature ventricular contractions (PVCs). Which of the following QRS changes should the nurse expect to see on the client's ECG? A. Narrower than usual QRS complexes B. Much greater amplitude than the usual QRS complexes C. Same polarity as the usual QRS complexes D. Immediate resumption of the usual rhythm

B. Much greater amplitude than the usual QRS complexes The QRS complexes unusually have greater amplitude in height and depth in clients with PVCs.

A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect? A. Flattened T waves B. Prolonged QT intervals C. Shortened QT intervals D. Widened QRS complexes

B. Prolonged QT intervals Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea.

A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease (COPD) with emphysema. This breathing technique accomplishes which of the following? A. Increases oxygen intake B. Promotes carbon dioxide elimination C. Uses the intercostal muscles D. Strengthens the diaphragm

B. Promotes carbon dioxide elimination A client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This simple method slows the client's pace of breathing, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation in order to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently.

A nurse is teaching a client with cystic fibrosis about daily chest physiotherapy. Which of the following is the purpose of these treatments? A. To encourage deep breaths B. To mobilize secretions in the airways C. To dilate the bronchioles D. To stimulate the cough reflex

B. To mobilize secretions in the airways The purpose of chest physiotherapy is to loosen and promote the drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity

A nurse is providing discharge teaching for a client who has a newly inserted permanent pacemaker. Which of the following instructions should the nurse include in the teaching? A. "Request a provider's prescription when traveling to alert airport security." B. "Stand at least 3 feet away while using a microwave." C. "Keep your cell phone 6 inches away from your pacemaker when making a call." D. "Avoid showering for the first 2 weeks following surgery."

C. "Keep your cell phone 6 inches away from your pacemaker when making a call." The nurse should instruct the client to keep a cell phone 6 inches away from the pacemaker when making a call to avoid interfering with the function of the generator inside the client's pacemaker.

A client who has thrombocytopenia asks the nurse why platelets are so important. Which of the following responses should the nurse make? A. "Platelets help the body fight infection." B. "Platelets help break down clots in the body." C. "Platelets plug breaks in blood vessels." D. "Platelets produce the molecules that carry oxygen."

C. "Platelets plug breaks in blood vessels." Platelets help maintain hemostasis and coagulation by plugging disruptions in the integrity of blood vessels. When an injury occurs to a blood vessel, platelets collect at the edge of the break and adhere to each other to plug the injured area and limit blood loss.

A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make? A. "Two tubes were necessary due to excessive bleeding from the area of the surgery." B. "The tubes drain blood from 2 different lung areas." C. "The lower tube will drain blood, and the higher tube will remove air." D. "The second tube will take over if blood clots block the first tube."

C. "The lower tube will drain blood, and the higher tube will remove air." The tube that is lower on the thorax will drain blood, and the tube that is higher on the thorax will allow for removal of air.

A client who just learned that he has variant (Prinzmetal's) angina asks the nurse how this type of angina compares with stable angina. Which of the following replies should the nurse make? A. "Exertion often brings on pain." B. "Variant angina occurs randomly at various times." C. "Variant angina can cause changes on your electrocardiogram." D. "Reducing your cholesterol can help you experience less pain."

C. "Variant angina can cause changes on your electrocardiogram." Variant angina causes ECG changes that reflect coronary artery spasms, which results in less oxygen supplying the myocardium.

A nurse is teaching breathing techniques to a client who has emphysema. Which of the following statements indicates that the client understands the mechanics of pursed-lip breathing? A. "I'll inhale slowly through pursed lips to help me breathe better." B. "When I do my pursed-lip breathing, I'll lie down first." C. "When I breathe out through pursed lips, my airways don't collapse between breaths." D. "I'll relax my stomach muscles when I am doing my pursed-lip breathing exercises."

C. "When I breathe out through pursed lips, my airways don't collapse between breaths." Breathing through pursed lips slows exhalation and maintains inflation of the distal airways, which enhances respiration for clients who have emphysema. The client should use this technique during physical activity and episodes of dyspnea. Incorrect Answers:

A nurse is assessing a client who had coronary artery bypass grafts for cardiac tamponade. Which of the following actions should the nurse take? A. Check for hypertension B. Auscultate for loud, bounding heart sounds C. Auscultate blood pressure for pulsus paradoxus D. Check for a pulse deficit

C. Auscultate blood pressure for pulsus paradoxus The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mmHg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles.

A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? A. Friction rub B. Crackles C. Crepitus D. Tactile fremitus

C. Crepitus Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of pneumothorax.

A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalances should the nurse expect? A. Hypokalemia B. Hypernatremia C. Elevated Hct D. Decreased Hgb

C. Elevated Hct The nurse should expect a client who is experiencing third spacing resulting from a major burn to have an elevated hematocrit level as blood volume is reduced by vascular dehydration.

A nurse is caring for an adult male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder? A. Cholesterol level 195 mg/dL B. Elevated HDL levels C. Elevated LDL levels D. Triglyceride level 135 mg

C. Elevated LDL levels An elevated LDL level increases a client's risk of atherosclerosis. The client's desirable LDL level is <100 mg/dL.

A nurse is caring for a client who has a peripherally inserted central catheter (PICC) in place. Which of the following actions should the nurse take when handling this central venous access device? (Select all that apply.) A. Use a 5 mL syringe to flush the line B. Cleanse the insertion site with half-strength hydrogen peroxide C. Flush the line with sterile 0.9% sodium chloride before and after medication administration D. Access the PICC for blood sampling E. Perform a heparin flush of the line at least daily when not in use

C. Flush the line with sterile 0.9% sodium chloride before and after medication administration D. Access the PICC for blood sampling E. Perform a heparin flush of the line at least daily when not in use The nurse should flush the line with 10 mL of sterile 0.9% sodium chloride solution before and after administering medication through the PICC. The nurse should use a PICC to deliver fluids, medications, and total parenteral nutrition to the client. The PICC is also used to obtain blood samples, and the nurse should practice the appropriate technique to access and flush the line. Ideally, blood samples should come from a 4 French lumen catheter or larger. PICCs can remain in place for months or years. When not actively in use, the nurse should perform heparin flushes at least daily to prevent clotting within the line.

A nurse is teaching a client about dietary modifications to control blood pressure. Which of the following food choices should the nurse identify as an indication that the client understands the instructions? A. Onion soup and salad B. Vegetarian wrap with potato chips C. Grilled chicken salad with fresh tomatoes D. Chicken bouillon and crackers

C. Grilled chicken salad with fresh tomatoes Sodium reduction helps control blood pressure. Grilled chicken salad and fresh tomatoes are free of preservatives and, therefore, are likely to be low in sodium. However, it is essential to make sure the food preparer has not added salt generously to the chicken and the salad.

A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? A. Place a nonrebreather mask on the client and increase the oxygen flow to 3 L/min B. Prepare the client for possible endotracheal intubation and mechanical ventilation C. Increase the oxygen flow and request an arterial blood gas determination D. Position the client supine and administer an antianxiety medication

C. Increase the oxygen flow and request an arterial blood gas determination The client requires oxygen therapy at a rate that will keep the oxygen saturation between 88% and 92%. The nurse should increase the client's oxygen flow and evaluate its effectiveness with ABG results and oxygen saturation via pulse oximetry measurements.

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse include in the plan? A. Administer ferrous sulfate supplementation B. Increase dietary intake of folic acid C. Initiate weekly injections of vitamin B12 D. Initiate a blood transfusion

C. Initiate weekly injections of vitamin B12 The nurse should initiate weekly injections of vitamin B12 for a client who has pernicious anemia and then decrease the injections to a monthly schedule. Pernicious anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract.

A nurse is assessing a client who has pharyngitis. Which of the following findings is the nurse's priority to report to the provider? A. Elevated temperature B. Swollen cervical lymph nodes C. Inspiratory stridor D. Purulent nasal discharge

C. Inspiratory stridor When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should determine that the priority finding is inspiratory stridor, which is a manifestation of airway obstruction. The nurse should notify the rapid response team and administer humidified oxygen.

A nurse is caring for a client who is having a possible myocardial infarction (MI). Which of the following findings should the nurse identify as an associated manifestation of an MI? A. Headache B. Hemoptysis C. Nausea D. Diarrhea

C. Nausea Nausea is an associated manifestation of MI. Manifestations of MI include chest pain and pain in the jaw, shoulder, or abdomen.

A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? A. Pericardial friction rub B. Weight gain C. Night sweats D. Cyanosis of the fingertips

C. Night sweats Night sweats and fevers are clinical manifestations of tuberculosis.

A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect? A. Thick, white coating on the client's tongue B. Decreased pulse rate C. Paresthesias in the hands and feet D. Joint pain in the extremities

C. Paresthesias in the hands and feet The nurse should identify that paresthesias (tingling sensations) in the hands and feet is an expected finding of pernicious anemia. Other manifestations include weight loss and fatigue.

A nurse is preparing to assist a provider with an arterial blood withdrawal from a client's radial artery for ABG measurement. Which of the following actions should the nurse plan to take? A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen B. Apply ice to the site after obtaining the specimen C. Perform an Allen's test prior to obtaining the specimen D. Release the pressure applied to the puncture site 1 min after the needle is withdrawn

C. Perform an Allen's test prior to obtaining the specimen The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery.

A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings indicates that the AAA is expanding? A. Increased BP and decreased pulse rate B. Jugular vein distention and peripheral edema C. Report of sudden, severe back pain D. Report of retrosternal chest pain radiating to the left arm

C. Report of sudden, severe back pain An aortic aneurysm is a weak spot in the wall of the aorta (the primary artery that carries blood from the heart to the head and extremities) that allows the aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots.

A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). What is the most common assessment finding with acute MI? A. Dyspnea B. Pain in the shoulder and left arm C. Substernal chest pain D. Palpitations

C. Substernal chest pain Evidence-based practice indicates that the most common manifestation of acute MI is substernal chest pain that does not subside with rest or nitroglycerin. Therefore, nurses should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation.

A nurse is assessing a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? A. Severe hypertension B. Low body temperature C. Sudden oliguria D. Decreased respirations

C. Sudden oliguria The nurse should identify sudden oliguria as an indication of an acute intravascular hemolytic reaction. This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This reaction results from the client's antibodies reacting to the transfused RBCs.

A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? A. Clamp the chest tube if there is continuous bubbling in the water seal chamber B. Keep the chest tube drainage system at the level of the right atrium C. Tape all connections between the chest tube and drainage system D. Empty the collection chamber and record the amount of drainage every 8 hr

C. Tape all connections between the chest tube and drainage system The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidentally disconnecting. Incorrect Answers:

A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr? A. Infective endocarditis B. Pericarditis C. Ventricular dysrhythmias D. Pulmonary emboli

C. Ventricular dysrhythmias After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system.

A nurse is caring for a client who has a new diagnosis of pernicious anemia. The nurse should expect the client's provider to prescribe which of the following medications for this client? A. Ferrous sulfate B. Epoetin alfa C. Vitamin B12 D. Folic acid

C. Vitamin B12 The nurse should expect the client's provider to prescribe vitamin B12 for pernicious anemia.

A nurse is providing preoperative teaching to a client who is to undergo a pneumonectomy. The client states, "I am afraid coughing will hurt after the surgery." Which of the following statements by the nurse is appropriate? A. "After the surgeon removes the lung, you will not need to cough." B. "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough." C. "Don't worry. You will have a pump that delivers pain medication as needed, so you will have very little pain." D. "I will show you how to splint your incision while coughing."

D. "I will show you how to splint your incision while coughing." A client who had a pneumonectomy should cough to clear secretions from the remaining lung. The nurse should show the client how to splint the incision to reduce pain when coughing.

A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? A. 0.45% sodium chloride B. Dextrose 5% in 0.9% sodium chloride C. Dextrose 10% in water D. 0.9% sodium chloride

D. 0.9% sodium chloride Solutions of 0.9% sodium chloride, as well as Lactated Ringer's solution, are used for fluid volume replacement. Sodium chloride (a crystalloid) is a physiologically isotonic solution that replaces lost volume in the bloodstream and is the only solution to use when infusing blood products.

A charge nurse is observing a newly licensed nurse administer an IV medication to a client who has an implanted venous access port. Which of the following observations requires intervention by the charge nurse? A. A dressing is not applied to the port site after use. B. A 22-gauge non-coring needle is used to access the port. C. Blood return is noted prior to administering the medication. D. A solution of 5 mL heparin 1,000 units/mL has been prepared.

D. A solution of 5 mL heparin 1,000 units/mL has been prepared. Implanted ports should be flushed after each use and at least once a month when not in use. This practice is sometimes referred to as "locking" or "de-accessing." It is performed to prevent the formation of blood clots in the catheter, which would disrupt the proper functioning of the catheter. The solution of 5 mL heparin should be 100 units/mL; therefore, this action requires intervention by the charge nurse.

A nurse is admitting a client who is in sickle cell crisis. Besides pain management, which of the following interventions should the nurse include in the client's plan of care? A. Flexion of the extremities B. Therapeutic hypothermia C. Upright positioning D. Ample hydration

D. Ample hydration A client who is in sickle cell crisis needs ample hydration (either IV, oral, or both) to shorten the duration of painful episodes. The nurse should plan to offer the client water, juice, or a favorite beverage that does not contain caffeine.

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? A. Have the client gently blow clots from the nose every 5 min B. Instruct the client to sit with his head hyperextended C. Apply ice compresses to the back of the client's neck D. Apply lateral pressure to the client's nose for 10 min

D. Apply lateral pressure to the client's nose for 10 min The nurse should apply direct, lateral pressure to the nose for 10 minutes to control epistaxis. If after 10 minutes the epistaxis continues, the client might require nasal packing or other interventions. Incorrect Answers:

A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? A. Chest pain is relieved soon after resting. B. Nitroglycerin relieves chest pain. C. Physical exertion does not precipitate chest pain. D. Chest pain lasts for longer than 15 min.

D. Chest pain lasts for longer than 15 min. A client who has unstable angina will have chest pain lasting longer than 15 minutes. This is due to reduced blood flow in a coronary artery from atherosclerotic plaque and thrombus formation causing partial arterial obstruction or from an artery spasm.

A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care? A. Maintain the client's knees and hips in a flexed position B. Apply cold compresses to painful joints C. Withhold opioids until the crisis is resolved D. Encourage increased fluid intake

D. Encourage increased fluid intake The nurse should encourage increased fluid intake to promote hydration because dehydration increases the viscosity of the blood, which can aggravate sickling and client discomfort.

A nurse is caring for a client who has peripheral vascular disease (PVD) and ulcers on the toes. Which of the following findings of PVD is a risk factor for ulceration of the extremities? A. Insufficient skin care B. Dehydration C. Immobility D. Impaired circulation

D. Impaired circulation Prolonged arterial insufficiency from PVD can contribute to the formation of ulcerations on the client's toes. Severe arterial disease is identified through an assessment of the quality of the client's posterior tibial pulses by comparing the pulses in both feet.

A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first? A. Obtain coagulation laboratory studies from the client B. Apply pneumatic compression boots to the client C. Request a referral for a speech-language pathologist D. Keep the client NPO

D. Keep the client NPO The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to keep the client NPO due to the risk of aspiration as a result of the stroke. The client should be screened for the ability to swallow and should not receive anything by mouth until this has been completed. A client who has experienced a cerebrovascular accident is at risk for dysphagia, which increases the change of life-threating aspiration.

A nurse is assessing a client who is receiving a unit of whole blood. Which of the following findings should the nurse identify as a manifestation of a hemolytic transfusion reaction? A. Bradycardia B. Paresthesia C. Hypertension D. Low back pain

D. Low back pain Low back pain is a manifestation of a hemolytic transfusion reaction. Other manifestations include a headache, chest pain, tachypnea, tachycardia, and dark urine.

A nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the post-procedure plan of care? A. Instruct the client about a long-term cardiac conditioning program B. Administer scheduled doses of acetaminophen C. Check for peak laboratory markers of myocardial damage D. Monitor for bleeding

D. Monitor for bleeding Bleeding is a post-procedure complication of PTCA because of the administration of heparin during the procedure and the removal of the femoral (or brachial) sheath. Manual pressure or a closure device is used to obtain hemostasis to the site. The client should remain on bed rest until hemostasis is assured.

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing shortness of breath. Which of the following actions should the nurse perform first? A. Monitor the client's arterial blood gas results B. Instruct the client to perform controlled coughing C. Teach the client how to use pursed-lip breathing D. Place the client in an upright position

D. Place the client in an upright position Using the airway, breathing, and circulation (ABC) approach to client care, the nurse should place the client in an upright position to facilitate chest expansion and proper diaphragmatic contraction. Positioning the client upright will also assist with mobilizing secretions that might be impeding airflow.

A nurse is preparing a client for thoracentesis. In which of the following positions should the nurse place the client? A. Lying flat on the affected side B. Prone with the arms raised over the head C. Supine with the head of the bed elevated D. Sitting while leaning forward over the bedside table

D. Sitting while leaning forward over the bedside table When preparing a client for thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table. This position maximizes the space between the client's ribs and allows aspiration of accumulated fluid and air.

A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first? A. Elevate the client's feet and legs B. Administer epinephrine C. Infuse 0.9% sodium chloride D. Stop the medication infusion

D. Stop the medication infusion The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk to this client is an allergic reaction that can progress to anaphylaxis. The nurse should stop the infusion immediately to halt further exposure of the client to the allergen.

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions? A. The client is unable to speak. B. The client's airway secretions were last suctioned 2 hr ago. C. The client coughs and expectorates a large mucous plug. D. The nurse auscultates coarse crackles in the lung fields.

D. The nurse auscultates coarse crackles in the lung fields. The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions.

A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication? A. Hallucinations B. Pruritus C. Hand and foot syndrome D. Tinnitus

D. Tinnitus An adverse effect of cisplatin is ototoxicity, which can cause tinnitus.

A nurse observes tachycardia, dyspnea, a cough, and distended neck veins in a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following interventions should the nurse use to prevent these manifestations with the client's next transfusion? A. Warm the unit of blood to room temperature before administering it B. Administer acetaminophen prior to the blood transfusion C. Give an antihistamine prior to the transfusion D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate

D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate These are the manifestations of a hypervolemic reaction due to circulatory overload, which likely occurs when the blood transfusion is too rapid for the client's size or status. To prevent this problem with future transfusions, the nurse should use a transfusion pump to regulate the transfusion at a slower rate.

A nurse is caring for a client who has pernicious anemia. Which of the following factors should the nurse identify with this condition? A. Iron deficiency B. Hemolytic blood loss C. Folic acid deficiency D. Vitamin B12 deficiency

D. Vitamin B12 deficiency A client who has pernicious anemia is deficient in vitamin B12 due to a deficiency in an intrinsic factor normally supplied by the gastric mucosa that is essential for the absorption of vitamin B12.