medsurg exam #2

a nurse is providing care for four clients on a medsurg unit. which of the following clients should the nurse identify as being at risk for the development of pressure injury? -client who is ambulatory following cardiac cath 4 hours ago. -client who has T1DM and is hyperglycemic -client with protein calorie malnutrition -client who has right sided HF and 4+ edema to LE -client who has postop delirium

-protein malnutrition -HF and edema -postop delirium (decrease in consciousness)

nurse is assessing a client who has pressure ulcer. the nurse should recognize which of the following findings as a manifestation of a pressure stage 4 pressure ulcer?

exposed bone, full thickness loss, muscle visible.

Nurse is caring for a client with a stage III pressure injury. what kind of dressing should the nurse plan to apply?

hydrogel dressing, which rehydrates the bed of a wound and promotes autolytic debridement, Used for stage II to stage IV

nurse is assessing a client who has aortic stenosis. which of the following findings should the nurse expect?

hypotension (from decreased CO) weak pulses (also from decreased CO) murmur

a nurse is caring for a client with PAD. which of the following symptoms should the nurse expect to find in the late stage of the disease?

-dependent rubor (dark red color to the feet and lower legs when the leg is in dependent position as a result of dilation of the arteries as compensatory response to poor arterial blood flow). -rest pain -foot ulcers

nurse is teaching a client who has new diagnosis of a fib. the client should know to monitor for what complications?

pulmonary embolism, heart failure

a nurse is assessing a client's wound dressing, and observes thick and odorous drainage. the nurse should document this drainage as which of the following?

purulent

a nurse is assessing a client's wound dressing, and observes bloody drainage. the nurse should document this drainage as which of the following?

sanguineous

a nurse is assessing a client's wound dressing, and observes water red drainage. the nurse should document this drainage as which of the following?

serosanguineous

a nurse is assessing a client's wound dressing, and observes yellow drainage. the nurse should document this drainage as which of the following?

serous

a nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000. The nurse should monitor for what?

spontaneous bleeding

Nurse is caring for a client with a stage IV pressure injury with heavy drainage. what kind of dressing should the nurse plan to apply?

Alginate dressing, used for stage II through IV with moderate to heavy drainage

a client has a BP of 155/92 and is refusing treatment because he has no signs and symptoms. What would you tell this client?

HTN is asymptomatic until severe and there is target organ disease (fatigue, dizziness, palpitations, angina, dyspnea, headache)

a nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin?

Prothrombin time (PT)

nurse is providing teaching to client with family hx of HTN. nurse should inform the client that his blood pressure of 141/97 is in what category?

Stage I (140-159/90-99)

nurse is providing teaching to client with family hx of HTN. nurse should inform the client that his blood pressure of 165/101 is in what category?

Stage II HTN (160+/100+)

what are modifiable risk factors for most clients developing any kind of cardiovascular disease?

elevated serum lipid levels, HTN, tobacco use, physical inactivity, obesity, DM, metabolic syndrome, substance abuse

what manifestation is an indication that a patient is having a hypertensive emergency?

a sudden rise in BP accompanies by neurologic impairment must show signs of organ affects

a nurse is caring for a client who is prescribed heparin therapy for an artificial heart valve. which of the following laboratory values should the nurse monitor for a therapeutic effect of heparin?

aPTT- activated partial thromboplastin time

What are s/s that right sided HF is worsening?

anorexia, nausea, weight gain, distended abdomen

nurse is assessing a client who has pressure ulcer. the nurse should recognize which of the following findings as a manifestation of a pressure stage 1i pressure ulcer?

blood filled blisters with skin intact

client has valvular heart disease and is at risk for developing LSHF. which of the following manifestations should alert the nurse the client is developing the condition?

breathlessness

nurse is caring for a client who has CHF and is taking digoxin daily. the client refused breakfast and is complaining of nausea and weakness. what should you do first?

check client's vital signs first to check for dig toxicity

Which term is used fro the property of the cardiac cell responding mechanically to an impulse?

contractility

a nurse is caring for an older adult client who is at risk for skin breakdown. which of the following interventions should the nurse use to help maintain the integrity of the client's skin? repo q3hrs massage bony prominences to promote circulation provide client with diet high in protein apply cornstarch to keep skin dry

diet high in protein

nurse is caring for a client who is postop and is at risk for developing VTE. the nurse should instruct the client to do what?

elevate the feet to help improve circulation, flexing ankles, ambulating ASAP after surgery

a nurse is caring for a client with PAD. which of the following symptoms should the nurse expect to find in the early stage of the disease?

intermittent claudication

nurse is caring for a client who is postop and is at risk for developing VTE. the nurse should instruct the client to avoid doing what?

massaging her legs

which medication should be used with caution in patient with diabetes because the drug may depress the tachycardia associated with hypoglycemia?

metoprolol

nurse is assessing a client who has pressure ulcer. the nurse should recognize which of the following findings as a manifestation of a pressure stage 3 pressure ulcer?

necrotic subq tissue. Stage 3 pressure ulcer include full thickness skin loss with necrotic subq tissue

a nurse is teaching a client who has angina about nitroglycerin sublingual tablets. which of the following statements should the nurse include in the teaching?

nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart do not store tablets in the bathroom (ineffective if expose to moisture or light) -made 3 doses every 5 minutes

Nurse is teaching a patient with endocarditis how to prevent recurrence of the infection, what should the nurse teach the patient?

obtain prophylactic antibiotic therapy before certain invasive medical or dental procedures

Nurse is teaching a client who has HTN about new prescription for atenolol. what are adverse affects of this medication?

olol=BB bradycardia, drowsiness, bronchospasm, N/V, diarrhea

a nurse is reinforcing teaching about self care with a client who has PID. the client does not speak english. Which of the following actions by the nurse is appropriate?

only facility approved interpreter

nurse is assessing a client who has pressure ulcer. the nurse should recognize which of the following findings as a manifestation of a pressure stage 2 pressure ulcer?

partial thickness skin loss and superficial uncer

nurse is providing teaching to client with family hx of HTN. nurse should inform the client that his blood pressure of 128/84 is in what category?

prehypertension

nurse is reviewing the hx of a client who has angina pectoris and prescription for propranolol hydrochloride PO 40mg bid. what is a contradiction and should be immediately reported to provider.

the client has history of bronchial asthma. BBs can cause bronchospasm in those with asthma

a nurse is teaching the partner of a client who had an acute MI about the reason blood was drawn. What should the nurse say about cardiac enzyme studies?

the tests help determine the degree of damage to the heart tissues

Nurse is caring for a client with a stage I pressure injury. what kind of dressing should the nurse plan to apply?

transparent dressing -stage I only involved epidermis. transparent dressing protects ulcer from moisture and bacteria which allowing O2 to reach the skin. this dressing also minimizes friction and shear on ulcerated area

a patient is admitted with diagnosis of acute left-sided infective endocarditis. What is the best test to confirm this diagnosis

two blood cultures testing positive

A client is withdrawing from alcohol. What are expected findings?

visual hallucinations, hypertension, hypoglycemia, insomnia, tremors

Patient has PAD. What should the pt do to manage ineffective peripheral tissue perfusion?

wear protective footwear, avoid hot or cold extremes, walk at least 30min/day/3x/week, inspect LE for pulse, temperature, and injury daily

Nurse is caring for a client necrotic wound. what kind of dressing should the nurse plan to apply?

wet to dry gauze dressing in order to remove necrotic tissue from wound