Med-Surg Test 1

What is the nurses BEST response when a client with peripheral arterial disease asks why he or she should exercise when walking causes pain?

"Exercise can improve blood flow to your legs because small blood vessels will compensate for the blood vessels that are blocked off."

Which statement made by the client suggests to the nurse that an alkaline condtions may be present?

"I have tingling in my fingers and toes"

A client is talking to the nurse about sodium intake. Which statement by a client indicates to the nurse a correct understanding of high-sodium food sources?

"I love chinese food, but I gave it up because of the soy sauce."

Which statement by a client with heart failure indicates to the nurse the need for additional teaching?

"I must weigh myself once a week and watch for signs of fluid retention."

Which client statement indicates to the nurse a correct understanding of the management of hypokalemia?

"I will avoid bananas, orange juice, and salt substitutes."

Which statement by a client with a history of hypertension and heart problems would cause the nurse to suspect development of heart failure?

"I've had to remove all my rings for the past month."

What PRIORITY teaching would the nurse provide for a client who will be dischared with a prescription for atorvastatin?

"Immediately report any muscle cramping to your primary health care provider."

Which PRIORITY teaching would the nurse provide to a client with infective endocarditis who is scheduled for an invasive dental procedure?

"Remind your health care provider to provide you with a prescription for prophylactic antibiotics."

When a client admits that he or she sometimes has trouble catching his or her breath, which question would the nurse ask to obtain more information about the clients symptoms?

"What was your most strenuous activity during the past week?"

Which PRIORITY information would the nurse be sure to provide for a client who is scheduled for a mitral valve replacement with a xenograft valve ?

"Your xenograft valve will need to be replaced in about 7 to 10 years."

Which IV fluid does the nurse expect to administer to a client who is prescribed to received HYPOTONIC fluids?

0.45% saline

What is the recommended therapeutic range for the international normalized ratio (INR) for a client receiving warfarin sodium to prevent DVT and decrease the risk factor for stroke?

1.5-2.0

Which techniques would the nurse use when preforming an initial cardiovascular assessment on a middle-aged client? Select all that apply

11 bcdef Palpate all of the major pulse sites Auscultate bruits in the radial and brachial arteries Palpate and compare temperature differences in the lower extremities Check the client for orthostatic hypotension Perform bilateral but separate palpitation of the carotid artery

Which factors would the nurse note as increasing the risk for atherosclerosis with an older african-american client? select all that apply

20-year history of type 2 diabetes Sedentary lifestyle 25 pounds overweight Grandmother died of heart attack

Which adult would normally be expected to have the highest total body water volume?

25-year-old man

Which clients will the nurse observe MOST CLOSELY for development of a base excess metabolic alkalosis?

26-year-old who received a massive blood transfusion

Which statements about percutaneous vascular interventions are accurate? Select all that apply

32 abde One or more arteries are dilated with a balloon catheter to open the vessels. Stents are often placed to ensure adequate blood flow. Some clients are occlusion free for 3 to 5 years A percutaneous vascular intervention is considered to be a minor surgical procedure.

When nursing actions are included in the routine postprocedural care for a client after percutaneous vascular intervention. Select all that apply.

33 abdef Observe for bleeding at the puncture site. Perform frequent distal pulse checks on both limbs Administer antiplatelet therapy prescribed Monitor for signs of shock Check vital signs frequently as ordered.

Which metho would the post anesthesia care unit (PACU) nurse use to assess the patency of the graft after a clients arterial revascularization with graft placement?

35 d Check the affected extremity, comparing it to the unaffected, for changes in color, temperature, and pulse intensity every 15 minutes for the first hour, then hourly.

What is the minimum about of urine output per day needed to excrete toxic waste products?

400 to 600 mL

Which serum potassium value indicates to the nurse that a client has hyperkalemia?

5.9 mEq/L

Which are characteristics a nurse would expect in clients with Raynaud's disease? Select all that apply.

54 ace Occurs more often in young women Clients experience cold intolerance Causes red-white-blue skin color changes on exposure to cold or stress

Which lifestyle changes would the nurse teach a client to help control hypertension? Select all that appy

5abdf Weight reduction if overweight or obease Implement a healthy diet such as the DASH diet Use relaxation techniques to decrease stress Increase activity by use of a structured exercise program

Which arterial blood PH can be fatal?

6.85

When the nurse preforms blood pressure screenings, which clients would be referred for further evaluation? Select all that apply

6bcef Client with heart disease and blood pressure 148/90 mmHg Renal failure client with blood pressure of 180/90 mmHg Client with muscle cramping taking a statin drug with blood pressure 124/82mmHg COPD client with blood pressure 158/88 mmHg

Which PH value indicates the highest concentration of free hydrogen ions in the blood?

7.27

How many milliliters will the nurse record as being lost by a client with pulmonary edema who initially weighed 178 lbs and now weighs 161.6 lbs?

7000

With which client does the nurse remain most alert for an electrolyte imbalance ?

72-year-old with diabetes mellites who also takes a diuretic daily

Which clients would the nurse assess for problems of inadequate chest expansion that may increase the risk for respiratory acidosis? (Select all that apply)

87- year- old with osteoporosis and severe kyphoscoliosis 44-year-old severly obease client on prolonged bedrest 37-year-old with ascites 56-year-old with end-stage emphysema

Which serum calcium level in a client laboratory findings does the nurse interpret as normal?

9.5 mEq/L

which findings would the nurse expect in a client with mitral valve stenosis? Select all that apply

A client with mild mitral valve stenosis will likely be asymptomatic. Classic signs include dyspnea, angina, and syncope Rumbling apical diastolic murmur Right-sided heart failure with jugular (neck) vein distention

Which client assessment findings are related to hypercalcimia? (select all that apply)

ACDEF Increased heart rate Decreased deep tendon reflexes Hypoactive bowel sounds Shortened QT interval Profound muscles weakness

Which location would the nurse expect to be the most common for a client to form an aneurysm?

Abdominal aorta

What would the nurse assess for when a client is suspected of having an abdominal aortic aneurysm

Abdominal, flank, or back pain Gnawing pain unaffected by movement Pulsation in the upper abdomen Auscultation of a bruit in the upper abdomen

What cause does the nurse expect to see for a client's arterial PH of 7.28 after he has been NPO for 5 days and receiving only dextrose 5% in lactated Ringer's solution (4 liters daily)?

Acidosis in response to the presence of excessive ketoacidosis

What would the nurse expect to find in the history of a client admitted with acute arterial occlusion?

Acute myocardial infarction or atrial fibrillation within the previous weeks.

What does te nurse suspect when a client describes substernal pain that radiates to the left shoulder, is grating, and worsens with inspiration and coughing?

Acute pericarditis

Which intervention does the nurse anticipate for a client who has hypernatremia caused by reduced kidney sodium excretion?

Administer furosemide

What is the PRIORITY intervention when a client comes to the emergency department (ED) with extreme anxiety, tachycardia, struggling for air, and a moist cough productive of frothy and blood-tinged sputum?

Administer high-flow oxygen therapy by face mask

What action does the nurse anticipate in the management of a client who has mild hypercalcimia?

Administering IV normal saline (0.9% sodium chloride)

Which client factors affect the amount and distribution of body fluids? (select all that apply)

Age Gender Body fat Muscle mass

Which criteria are appropriate for a client with dialated cardiomyopathy to become a candidate for heart transplant surgery?

Age generally less then 65 years Now York Heart Association Class III or IV Normal or only slightly increased pulmonary vascular resistance Absence of active infection

Which are potential causes of dilated cardiomyopathy?

Alcohol abuse Infection Chemotherapy Poor nutrition

What is the nurses PRIORITY action when a client with AAA suddenly exhibits decreased level of consiousness, blood pressure 82/48 mmHg, irregular apical pulse, and perfuse diaphoresis?

Alert the rapid response team

For which finding in a client with mitral valve stenosis would the nurse IMMEDIATELY notify the primary health care provider because of the potential for decompensation?

An irregular heart rhythm and ECG strip that indicate atrial fibrillation

Which ESSENTIAL medications would the nurse provide teaching about postoperatively for a client who received a prosthetic valve replacement?

Anticoagulants

Overdose of which drug or drug category could cause metabolic acidosis

Aspirin

When drugs are useful in promoting circulation for client with CHRONIC peripheral arterial disease? Select all that apply.

Aspirin Pentoxifylline Clopidogrel Cilostazol

What is the nurses BEST response when a client asks about the difference between arteriosclerosis and atherosclerosis?

Atherosclerosis is forming plaques in arteries but arteriosclerosis is thickening of arterial walls associated with aging.

What would the nurse teach a client with peripheral arterial disease about positioning and position changes?

Avoid crossing legs at all times.

Which finding on lower limb assessment indicates to the nurse that the client has acidosis? (select all that apply)

Bilateral weakness Hypoactive patellar reflex

Which mechanism do buffers help maintain arterial blood PH within the normal range?

Binding Excess free hydrogen ions

What are complications that the nurse would monitor for after a client receives an endovascular stent graft for emergent repair of an abdominal aortic aneurysm?

Bleeding Misplacement of stent graft Peripheral embolization Endoleak Aneurysm rupture

Which piece of equipment would the nurse recommend for a client to manage hypertension at home

Blood pressure monitoring device

Which assessment findings does a nurse expect to see in a client who has severe hypomagnesemia?

Bradycardia and hypotension

Which foods does the nurse recommend to an client who remains at continued risk for hyperkalemina? (select all that apply)

Butter Cranberries Lettuce Eggs Grapefruit Strawberries

Which drug would the nurse expect the primarycare physician to prescribe for a client to DECREASE blood pressure, decrease triglycerides, increase high-density lipoprotein cholesterol (HDL-C), and lower low-density lipoprotein cholesterol (LDL-C)?

Caduet

The electrolyte magnesium is responsible for which functions? (select all that apply)

Carbohydrate metabolism Contraction of skeletal muscle Vitamin activation Blood coagulation

For which serious complication will the nurse administering an IV potassium solution to a client carefully monitor to PREVENT HARM?

Cardiac dysrhythmia

Which complication is a client at MOST risk for when the nurse notes that excessive fluid was seen in the pericardial cavity on echocardiogram?

Cardiac tamponade

Which system is most important for the nurse to monitor closely for a client who has severe hypomagnesemia?

Cardiovascular

What is the MOST important teaching point for the nurse to emphasize with a client who has Buerger's diease?

Cease cigarette smoking and all exposure to tobacco to arrest the disease process

With which client conditions does the nurse remain alert for potential hypocalcemia? (select all that apply)

Chrons disease Acute pancreatitis Removal or destruction of parathyroid glands Immobility GI wound drainage

For which client will the nurse remain MOST alert for the possibility to develop respiratory alkalosis?

Client who is anxious and breathing rapidly

Based on the etiology and main cause of heart failure, the nurse knows that which client has the GREATEST need for health promotion measures to prevent heart failure?

Client with hypertension

Which clients are at INCREASED risk for peripheral arterial disease (PAD)?

Client with hypertension Client with diabetes mellites Client who smokes cigarettes Client who is African American

For which client would the nurse question the prescription of hydrochlorothiazide?

Client with hypokalemia

Which client does the nurse anticipate will have acidosis because of a decreased arterial bicarbonate level?

Client with pancreatitis

Which clients are at GREATEST risk for development of infective endocarditis? Select all that apply

Clients who are IV drug users Clients who have poor dental health Clients with opioid addictions Clients with systemic alterations in immunity Clients postoperative after valve replacement

Which key points would the nurse include when teaching a client about signs and symptoms of return or worsening of heart failure, that must be reported to the primary health care provider? select all that apply

Cold symptoms (e.g. cough) lasting more than 3 to 5 days Excess awakening at night to urinate. Development of dyspnea or angina at rest or worsening angina Increased swelling in feet ankles or hands

Which drug therapy does the nurse expect the health care provider to prescribe for a client with low serum sodium and signs of hypovolemia?

Conivaptan

Which instructions would the nurse give a client for following dietary recommendations of the American College of Cardiology (ACC) and the American Heart Association (AHA)? Select all that apply.

Consume low-fat dairy products, poultry, and fish Lower sodium intake to no more than 2400 mg/day Limit intake of sweets and red meats. Eat legumes, tropical vegetable oil (e.g. canola oil), and nuts

With which client condition will the nurse remain most alert for insensible water loss?

Continuous GI suctioning

Which EARLY symptoms indicate to the nurse that a client's HF is getting worse and pulmonary edema is developing? Select all that apply

Crackles in the lung bases Dyspnea at rest Disorientation

What response does the nurse expect to see in the blood volume and blood osmolarity of a client whose secretion of antidiuretic hormone (ADH) is extremely low?

Decreased blood volume; increased blood osmolarity

Which symptom in a client with psychiatric issues who is continuously drinking water will the nurse monitor as in indicator of potential hyponatremia?

Decreased cognition

What would the nurse expect to see FIRST as compensation in a client who has a decreased amount of hydrogen ions and a decreased amount of carbon dioxide in the body to restore acid-base balance?

Decreased rate and depth of respirations

What is the main reason a nurse caring for a postoperative surgical client in the recovery room carefully monitoring the client's urine output?

Decreasing urine output may mean hemorrhage and risk for shock.

What does the nurse suspect when assessing a client on bedrest and finding that he or she has a left calf that is swollen, warm to the touch, reddened, and moderately painful?

Deep vein thrombosis

What is the nurse's interpretation of a client's urine specific gravity of 1.039?

Dehydration

What assessment finding would the nurse expect to find in a client with right heart failure?

Dependent edema Neck vein distention Hepatomegaly

Which action is MOST IMPROTANT for the nurse to before to PREVENT HARM before starting an IV infusion of potassium to a client who has a low serum potassium level?

Determine IV line patency and blood return Check the apical pulse for a full minute

What symptom would the nurse expect on assessment of a client with inflow peripheral arterial disease?

Discomfort in the lower back, buttocks, or thighs after walking.

What is the PRIORITY action for the nurse a client is to have unfractionated heparin (UFH) discontinued and to start receiving subcutaneous low-molecular-weight heparin (LMWH)?

Discontinue the UFH at least 30 minutes before giving the first LMWH injection.

Which specific type of medication reported as taken daily by an older client will cause a nurse to assess for indication of acid-base imbalance?

Diuretics

What is the nurses BEST advice for a client, who is an avid golfer, but has been recently diagnosed with thoracic outlet syndrome?

Dont elevate your arms above your head.

The pharmacy sends a 250 ml IV bag of dextrose in water with 40 mEq of potassium, marked "to infuse over 1 hour" for a client with hypokalemia. What is the BEST action?

Double-check the prescription and call the pharmacy.

Which signs and symptoms would the nurse expect to assess when a client is diagnosed with aortic stenosis? select all that apply

Dyspnea on exertion Angina Harsh, systolic crescendo-decrescendo murmur Orthopnea

Which essential teaching would the nurse provide for a client being discharged with chronic venous insuffenciency? Select all that apply.

Elevate your legs at least 20 minutes four to five times daily Avoid crossing legs at all times Avoid standing still for any length of time Avoid tight restrictive pants, girdles, or garters.

For which client problem will the nurse question a prescription for a diuretic?

End-stage renal disease

Which signs or symptoms would the nurse expect when assessing a client with chronic constrictive pericarditis? select all that apply

Exertional fatigue and dyspnea Dependent edema Hepatic engorgement

What IMMEDIATE RESPONSE does the nurse expect as a result of infusing 1 liter of an isotonic intravenous solution into a client over a 3-hour time period of urine output remains at 100mL per hour?

Extracellular fluid (ECF) osmolarity is unchanged; body weight increases

With which client will the nurse remain most alert for repiratory alkalosis?

Fearful client having a panic attack

Clients with which problems will the nurse assess most frequently for dehydration? (select all that apply)

Fever of 103 F (39.4 C) Extensive burns Thyroid crisis Continuous fistula drainage Diabetes insipidus

Ankle and foot edema in a nurse who has been standing for 12 hours is a result of which type of pressure, force, or influence?

Filtration from the plasma volume to the interstitial space as a result of increased capillary hydrostatic pressure.

During which timeframe is it MOST important for the nurse to monitor a client for graft occlusion after receiving revascularization graft placement?

First 24 hours

Which nonsurgical management techniques would the nurse expect when caring for a client with DVT? Select all that apply.

Gradual increase in ambulation as tolerated by client Elevation of legs when in bed or sitting in a chair Knee or thigh-high compression stockings Anticoagulant drugs as prescribed

Which activity would the nurse advise during the recovery period for a client returning home after AAA repair?

Gradually increased walking

Which are conservative management measures for a clients vericose veins? Select all that apply.

Graduated compression stockings (GCSs) Exercise to increase venous return Endovenous ablation

Which specific discharge instruction will the nurse provide to PREVENT HARM in a client with advanced heart failure who is at continued risk for fluid volume overload?

Greater then 3lb gained in a week or greater then 1 to 2 lb gained in a 24 hour period

Which laboratory value indicates to the nurse that a client has acidosis as a result of a metabolic problem?

HCO3- = 17 mEq/L (mmol/L)

Which client conditions does the nurse assess for as a cause of the underproduction or over elimination of bicarbonate? (select all that apply)

High PH; normal bicarbonate; low PaCO2

Which findings would the nurse expect to assess when a client presents with a thoracic aortic aneurysm? Select all that apply.

Hoarseness Shortness of breath Difficulty swallowing Visible mass above the suprasternal notch

Which treatment BEST applies to the care of a client newly diagnosed with i nfective endocarditis?

Hospitalization for initial IV antibiotics, followed by continued IV antibiotics at home.

Which type of cardiomyopathy may present with sudden death as the first symptom?

Hypertrophic

Which possible imbalance does the nurse suspect when assessment findings on a newly admitted client include pitting dependent edema, engorged neck and hand veins, and headache?

Hypervolemia

Which assessment findings would indicate to the nurse that the client may have hyponatremia?

Hypoactive bowel sounds on auscultation acute-onset confusion muscle weakness decreased deep tendon reflexes abdominal cramping nausea

Which type(s) of electrolyte imbalance does the nurse expect to see in client with metabolic alkalisis? (select all that apply)

Hypokalemia Hypocalcemia

Whih symptoms would indicate to the nurse that a client's aneurysm had ruptured? Select all that apply.

Hypotension Diaphoresis Decreased level of consciousness Loss of pulses distal to rupture Scant urine output

Which drug would the nurse prepare to administer when a client enters the emergency department with chest pain described at "tearing" sensation, diaphoresis, blood pressure of 200/130 mmHg, weak pulses, and a sense of apprehension?

IV beta blocker such as esmolol.

When a client has an ejection fraction of less than 30%, about which potential treatment does a nurse prepare for the client?

Implantable cardioverter/defibrillator

Which alteration in acid-base balance does the nurse expect to see as a compensatory response in a client who has a long-term severe respiratory impairment?

Increase arterial blood oxygen

Which findings indicate to the nurse that a client may have hypervolemia (fluid overload)? (Select all that appy)

Increased bounding pulse Jugular venous distention Presence of crackles Orthostatic hypotension

Which additional laboratory changes does the nurse anticipate in a client who has hyperkalemia resulting from dehydration?

Increased hematocrit and hemoglobin levels

Which common signs and symptoms will the nurse be sure to assess for in the older client whose serum sodium is 152 mEq/L? (select all that appy)

Increased pulse rate Hypertension Muscle weakness Difficulty palpating peripheral pulses

What change in respiratory function does the nurse expect to find in a client who is dehydrated from severe diarrhea and vomiting?

Increased respiratory rate, because the body perceives dehydration as hypoxia

What sign or symptom does the nurse expect to see in a client whose blood osmolarity is 310 mOsm/L (mOsm/kg)?

Increased thirst

Which condition or response is an example of physiologic compensation to maintain acid-base balance?

Increasing rate and depth of respiration when running 2000 feet.

What body fluid compartment is considered the "third space?"

Interstitial fluid

How does the nurse prepare to administer the prescribed magnesium sulfate (MgSO4) for a client with severe hypomagnesemia?

Intravenously

What is the nurses BEST explanation to a client for use of LOW-dose niacin to decrease LDL-C and very-low-density lipoprotein (VLDL) cholesterol levels?

It helps reduce side effects of flushing and feeling too warm.

Which statements pertaining to the use of an Unna boot for a client are accurate? Select all that apply.

It is constructed from gauze and zinc oxide. It promotes venous return and prevents stasis It forms a sterile environment for the ulcer. The client is instructed to repot any increase in pain

Which IV potassium solution can the nurse safely administer to a client with severe hypokalemia?

KCL 10 mEq in 100 mL NS

Which client conditions does the nurse assess for as a cause of the underproduction or over elimination of bicarbonate? (select all that apply)

Kidney Failure Liver Failure Dehydration Diarrhea

The continuous normal function of which organs is most critical for acid base balance? (select all that apply)

Kidney, Lungs

Which signs and symptoms would the nurse expect to find in a client with severe metabolic acidosis? (select all that apply)

Kussmaul respirations Warm, flushed skin Decreased bicarbonate

Which potential problem does the nurse assess for when caring for a client whose urine output is less then what is needed as the obligatory urine output? (select all that apply)

Lethal electrolyte imbalances Toxic buildup of nitrogen Acidosis

Which information would the nurse be sure to include when teaching a client with peripheral arterial disease about methods to promote vasodialation? Select all that apply.

Maintain a warm environment at home. Wear socks or insulated shoes at all times Prevent cold exposure to the affected limb Completely abstain from smoking or chewing tobacco Avoid emotional stress and excessive caffine.

What is the BEST nonsurgical intervention for a client with a 3-cm abdominal aortic aneurysm to decrease the risk of rupture?

Maintenance of normal blood pressure and avoidance of hypertension

Which condition would the nurse suspect when a client had these findings (BP 200/130 mmHg; sudden headache, blurred vision, dyspnea)?

Malignant hypertension

For which indication of a fluid balance problem will the nurses assess in an older client at risk for fluid and electrolyte problems?

Mental status changes

Which alteration will the nurse expect in a client who has taken antacides for the past 3 days to relieve "heartburn?"

Metabolic Alkalosis (base excess)

Which acid-base imbalance will the nurse expect in a client who has chronic kidney disease?

Metabolic acidosis

Which alterations in acid-base balance does the nurse expect to see in a client who has acute pancreatitis with severe pain and is hyperventilating? (select all that apply)

Metabolic acidosis Low or normal PaCO2 Underproduction of bicarbonate

Which type of heart valvular disease does the nurse suspect when a clients assessment reveals pitting edema?

Mitral valve stenosis and regurgitation

Which sign or symptom does the nurse expect to see in a client who has mild hypernatremia?

Muscle twitching and irregular muscle contractions

Which assessment findings would cause the nurse to suspect cardiac tamponade in a client?

Neck vein distention Paradoxical pulse Muffled heart sounds Tachycardia

Which drug would the nurse expect to administer to a client with Raynaud's or Buerger's disease?

Nefedipine

Which drugs would the nurse prepare to administer to a client with HF who has developed pulmonary edema? Select all that apply

Nitroglycerin sublingual Furosemide IV Nitroglycerin IV

Which features would the nurse recognize as indicating that a client had a venous ulcer? Select all that apply.

No caudation or rest pain Ulcer located in the ankle area Brown pigmentation Ulcer bed is pink Pulses are present

What EARLY sign of left ventricular failure is a client most likely to report to the nurse?

Nocturnal coughing

What would the nurses BEST action when a client reports dizziness when changing position from sitting to standing and a sudden dry cough after starting a prescription for captopril?

Notify the primary health care provider immediately about these side effects.

Which assessment finding does the nurse expect to see in a client who has mild hyperkalemia? (select all that apply)

Numbness in hands, feet, and around the mouth Hyperactive bowel sounds Irregular heart rate Skeletal muscle twitching

Which client with valvular heart disease would benefit from the nonsurgical invasive procedure balloon valvuloplasty?

Older adult who is not a surgical candidate

Which findings does the nurse expect when assessing a client with infective endocarditis? Select all that apply

Osler nose on palms of hands and soles of feet Splinter hemorrhages Janeway lesions on the hands and feet Anorexia and weight loss

Which acid-base and electrolyte changes would the nurse monitor for in a client who has had diarrhea for the past 2 days? (select all that apply)

Over elimination of bicarbonate metabolic acidosis Hyperkalemia

Which relatively NEW therapy would be tried for clients with familial hypercholesterolemia or for those who are unable to reduce LDLs with existing therapies?

PCSK9 inhibitors

Which client arterial blood gas results would the nurse interpret as within normal limits?

PH 7.28, PaCo2 41, bicarbonate 25, PaO2 97

When arterial blood gas (ABG) results would the nurse expect for a client admitted to the hospital for diabetic ketoacidosis? Select all that apply

PH 7.32 PaCo2 50 mmHg Bicarbonate 29 mEq/L PaO2 99 mmHg

Which laboratory values indicate to the nurse that a clients acid-base imbalance is specifically a respiratory acidosis? (select all that apply)

PaCO2 58 mmHg PaO2 75 mmHg

Which assessment findings indicate to the nurse that a client has stage III peripheral arterial disease (PAD)? Select all that apply

Pain is described as numbness, burning, toothache-type pain. Pain is relieved by placing the extremity in a dependent position Pain usually occurs in the distal part of the extremity (toes, arch, forefoot, or heel.) Pain while resting commonly awakens the client at night.

What is the PRIORITY concept for a client who has heart failure?

Perfusion

Which are proposed criteria for diagnosis of a client with acute pericarditis? Select all that apply.

Pericardial chest pain Presence of a pericardial friction rub New ST elevation in all ECG leads or PR-segment depression New or worsening pericardial effusion

What would the nurse suspect when assessing a client's lower extremities and finding decreased pedal pulses, skin that is cool to touch, loss of hair, and thickened toenails?

Peripheral arterial disease

Which is the best technique to use for assessing the skin turgor of an 80-year-old patient?

Pinching the skin over the sternum and observe for tenting and resumption of skin to its normal position after release.

What is the BEST method for the nurse to use when auscultating a client's pericardial friction rub with a stethoscope?

Place the diaphragm at the apex of the heart

The nurse will monitor which clients for development of hyponatremia? (Select all that appy)

Postoperative client who has been NPO for 24 hours with no IV fluid infusing Client receiving excessive intravenous fluids with 5% dextrose in water Client with diabetes who has a blood glucose of 250mg/dL Tennis player in 100F (37.7C) weather who has been drinking water.

Which serum electrolyte finding on a newly admitted client does the nurse report immediately to the health care provider? (select all that apply)

Potassium 2.8 mEq/L Magnesium 1.2 mEq/L

Which serum laboratory value does the nurse expect to see in the client with hypokalemia?

Potassium has less then 3.5 mEq/L

What are the PRIORITY nurseing care concepts for clients with vascular problems?

Profusion and clotting

What are the purposes for a client with a venous stasis ulcer to be prescribed the topical drug Accuzyme?

Promote healing Chemically debride the ulcer Eliminate necrotic tissue

Which nursing interventions promote a clients compliance with antihypertensive therapy? Select all that apply.

Provide oral and written instructions related to all prescribed medications. Stress that suddenly stopping beta blockers can cause angina or heart attack Suggest that the client have a home scale for weight monitoring. Teach clients to report unpleasant side effects to the primary health care provider.

What does the nurse suspect when assessment of a client with HF reveals pulses that alternate in strength?

Pulsus alternans

Which precaution is MOST IMPORTANT for the nurse to teach a client at continued risk for hypernatremia?

Read labels on canned or packaged foods to determine sodium content.

Which are POTENTIAL benefits of a client receiving the drug digoxin?

Reduced heart rate increased contractility slowed conduction through the AV node Inhibition of sympathetic activity with enhanced parasympathetic activity

By which mechanisms does parathyroid hormone (PTH) increase serum calcium levels? (Select all that appy)

Releasing free calcium from the bones Stimulating kidney reabsorption of calcium Activating vitamin D Increasing calcium absorption in the GI tract

Which statements correctly apply to acid-base balance in the body? (Select all that apply)

Renal mechanisms are stronger in regulating acid-base balance but slower to respond then respiratory mechanisms, The immediate binding or excess hydrogen ions occurs primarily in the red blood cells, Acid-base balance occurs through control of hydrogen ion production and elimination.

Which topics would the nurse be sure to cover when providing discarge instructions for a client with prosthetic valve surgery? select all that apply

Report dyspnea, syncope, dizziness, edema, and palpitations to your health care provider Use an electric razor to avoid skin cuts Notify your health provider for any bleeding or excessive bruising Watch for and repot any fever or drainage and redness at the surgical site.

What type of acid-base problem does the nurse expect in a client who is being insufficiently mechanically ventilated for the past 4 hours and whose most recent arterial blood gas results include a PH of 7.29?

Respiratory acidosis with acid excess

which instruction would the nurse give the assistive personnel (AP) who is helping a client with HF and excessive aldosterone secretion?

Restrict the client's fluids to 2L/day and keep accurate intake and output.

What is the nurses BEST interpretation when reviewing a clients abnormal CT scan and noting that there is an outpouched segment coming off the abdominal aorta?

Saccular aneurysm

Which laboratory result will the nurse check immediately to prevent harm for a client with metabolic acidosis who now has tall, peaked T waves on his or her ECG?

Serum Potassium

Which effect on respiratory effort does the nurse expect to find in a client with severe hypokalemia?

Shallow respirations and low oxygen saturation

Which health problems are the most likely to activate the renin-angiotensin-aldosterone system (RAAS)? (select all that apply)

Shock Dehydration

Which assessment findings would suggest to a nurse that a client who received a heart transplant was experiencing organ rejection? Select all that apply

Shortness of breath Hypotension Decreased activity tolerance Fluid gain (edema, increased weight) Atrial fibrillation or flutter

What does the nurse instruct a client with pericarditis to do to make him or her feel more comfortable?

Sit up and lean forward

Which electrolyte plays the largest role in maintaining blood osmolarity?

Sodium

Which serum value indicates to the nurse that the client has hyponatremia?

Sodium 129 mEq/L (mmol/L)

Which serum value indicates to the nurse that the client has hypernatremia?

Sodium 149 mEq/L (mmol/L)

Which interventions would the nurse expect to include in the care of client with pulmonary edema caused by HF? Select all that apply

Sodium restriction Position the client in semi-fowler or high-fowler Administration of loop diuretics

Which foods does the nurse teach a client to include in his or her diet to help prevent future episodes of hypokalemia? (Select all that apply)

Soybeans Bananas Cantaloupe Potatoes

Which medication or class of drugs taken regularly at home does the nurse associate with a newly admitted client's laboratory finding of hyperkalemia?

Spironolactone

For prevention of DVT, which drug would the nurse expect the health care provider to prescrube?

Subcutaneous low-molecular-weight heparin (LMWH)

Which URGENT intervention is required when the nurse reviews the results of diagnostic testing for a client with aortic stenosis and discovers that the surface area of the valve is less then 1cm?

Sugical aortic heart valve replacement

What is the DEFINITIVE treatment for chronic constrictive pericarditis?

Surgical removal of the pericardium

Which type of fluid loss are considered "insensible fluid loss?" (select all that apply)

Sweat Salivation Diarrhea vomit wound drainage

When a client develops heart failure, what INITIAL compensatory mechanism of the heart does the nurse expect to occur that will maintain cardiac output (CO)?

Sympathetic stimulation

Which major self-management categories will the nurse include when teaching a client, newly diagnosed with heart failure, who is about to be discharged? Select all that apply.

Symptoms, what to do when they get worse Medications Activity Weight Diet

In reviewing a client's electrocardiogram (ECG), which finding does the nurse associate with hyperkalemia?

Tall peaked T waves

Which action increases the effectiveness of an angiotension II receptor blockers (ARBs) and angiotension-converting enzyme inhibitors (ACEIs) in controlling hypertension for African-American clients?

The ARB and ACEI is given with a diuretic beta blocker or a calcium channel blocker.

When a client with heart failure walks 200 feet down the hall and develops a feeling of heaviness in the legs, how does the nurse interpret this finding?

The activity is too stressful

Which statements are accurate about a clients true aneurysm? Select all that apply

The aneurysm may be described as fusiform or saccular The aneurysm creates a permanent dilation of the artery A congenitally weakened arterial wall may result in an aneurysm The aneurysm section of the arterial wall is enlarged to at least twice its normal diameter.

Which control systems play an important role in maintaining a client's blood pressure? Select all that apply.

The arterial baroreceptor system Regulation of body fluid volume. Vascular autoregulation The renin-angiotensin-aldosterone system

How does the nurse BEST interpret a client's low-density lipoprotein cholesterol (LDL-C) value which is greater then 190 mg/dL and does not respond to dietary intervention.

The client should be evaluated for secondary causes of hyperlipidemia and treated with statin therapy because of the high LDL-C level.

Which statement most accurately describes the relationship between the hydrogen ion concentration and the carbon dioxide concentration in extracellular fluids?

The concentrations of hydrogen ions and carbon dioxide are directly related, with an increase or decrease in one always resulting in a corresponding increase or decrease in the other.

Plasma is part of which body fluid space compartments? (select all that apply)

The extracellular compartment Intravascular fluid

Which is the correct technique for the nurse to use when assessing the client for a positive Chvostek sign?

The nurse taps the client's face just below and in front of the ear.

Which statement about compensation for acid-base imbalance is accurate?

The respiratory system can begin compensation within seconds to minutes

What drug would the nurse expect to be prescribed for a cient with hypertension and for whom lifestyle modifications have failed to control blood pressure?

Thiazide diuretic

Which diagnostic tests would the health care provider prescribe to confirm a diagnosis of abdominal aortic aneurysm (AAA) suspected in a client? Select all that apply.

Ultrasound Computed tomography scan

Which measure put into place by the nurse while caring for a client with severe hypocalcemia is most likely to PREVENT HARM?

Use a lift sheet to move or reposition the client

which are the characteristics that the nurse would expect when a client is diagnosed with mitral valve prolapse (MVP)? select all that apply

Valve leaflets enlarge and bulge up into the left atrium during syncope Most clients are asymptomatic and this abnormality is benign Many clients have normal heart rates and blood pressures A midsystolic click and late systolic murmur is best heard at the apex of the heart

what is the MOST reliable method of monitoring for fluid gain or loss in a client with heart failure?

Weigh the client daily at the same time and using the same scale

Which actions will the nurse teach to the spouse of a client with reduced cognition who has been treated twice in the emergency department for dehydration to prevent this condition? ( Select all that apply)

Weigh the client daily to check fluid status Offer frequent snacks of gelatins and ice cream Offer four ounces of the client's favorite fluids every hour while awake Watch the client while he or she drinks any liquids to ensure it is ingested. Estimate or measure the number of liquid ounces ingested daily to ensure an intake of at least 1500 mL.

Which assessment findings would yhe nurse expect to find in a client with left heart failure? (select all that apply)

Wheezes or crackles S3 heart sounds Paroxysmal nocturnal dyspnea oliguria during the day

When would the nurse expect the release of B-type natriutetic peptide (BNP) for a client with heart failure

When a client has fluid overload

To improve gas exchage, how much supplemental oxygen would the nurse provide a client with HF?

Within the range prescribed by the HCP to keep saturation at 90% or more

What are the PRIORITY nursing actions related to caring for an older adult client with HF who is prescribed digoxin? Select all that apply

abcdef Monitor the ECG strip for early signs of toxicity such as bradycardia Auscultate the apical pulse heart rate and rhythem for a full minute before administering the drug Observe for signs of toxicity, which are often nonspecific such as anorexia, fatigue, and blurred vision Repot any changes in heart rate or rhythm to the health care provider Monitor serum digoxin and potassium levels. Check the health care providers prescription for parameters to hold the drug.

Which symptom does the nurse expect to see FIRST in a client whose plasma volume has an increased hydrostatic pressure?

dependant edema

when the client asks the nurse about the BEST method of diagnosing heart failure, what teaching would the nurse provide?

echocardiography

Which electrolyte change does the nurse expect to see in a client who produces excessive amounts of aldosterone?

high serum sodium level

Which symptom caues MOST clients to seek medical attention for peripheral arterial disease (PAD)?

intermittent claudication

Which conditions or health problems increase a client's risk for hypokalemia? (select all that apply)

metabolic alkalosis cushing syndrome

What frequency of drug dosage therapy would the nurse advocate for an older client with hypertension and for who lives alone and is able to manage his or her self-care?

once a day

Which client ABG results would the nurse interpret as metabolic alkalosis?

pH 7.50; PaCO2 45; bicarbonate 36; PaO2 95

Which GI complication will the nurse monitor for in a client who has a serum potassium level of 2.4 mEq/L?

paralytic ileus

What changes in the body functions does the nurse anticipate in a client who has lower than normal blood PH levels? (Select all that apply)

reduced function of hormones, Decreased electrical conduction in the heart, Decreased skeletal muscle strength.

What would the PRIORITY nursing action be when a client experiences increasing pain?

report these symptoms to the health care provider immidiately.

The nurse observes clients with which of the following conditions for potential hypernatremia? (select all that appy)

severe diarrhea decreased kidney function profound diaphoresis cushing's syndrome