Practice quiz exam 2

Assess the clients affected leg

When a client with PAD returns to the nursing unit after a femoral angiogram, which action will the nurse take FIRST?

Dyspnea on exertion

When assessing a client with left sided heart failure,. Which finding would the nurse expect?

Elevated troponins

When caring for a client who presents to the emergency department with a STEMI, which lab result will the nurse expect?

Dependent edema Swollen hands and fingers Right upper quadrant discomfort

When caring for a client with a diagnosis of right heart failure, the nurse expects which assessment findings?

Crackles

When caring for a client with heart failure, which type of ung sounds would the nurse expect to hear?

Employ breathing exercises and effective coughing

When caring for a client with pneumonia, which nursing intervention is the highest PRIORITY?

Limit allergens in the home Continue the medications even if the child is asymptomatic

When preparing a child with asthma for discharge, which instructions would the nurse emphasize to the family?

Weight Tobacco use

When teaching about prevention of coronary artery disease for a 50 year old who is 6ft tall, weights 293lbs, smokes 1 pack a day of cigarettes, and has siblings with CAD, which topics are MOST important for the nurse to include?

Wear a particulate respirator when caring for the client

Which action would the nurse take when a client with TB is admitted to the nursing unit?

Walking outside on a cold day Sexual activity Smoking cigarette Use of an oral decongestant

Which activities might cause chest pain in a client with stable angina?

Decreased right side breath sounds

Which assessment finding on a client who has just had a thoracentesis for a right pleural effusion would require the MOST rapid action by the nurse?

Distended abdomen Dependent edema Decrease appetite

Which assessment findings are consistent with a client diagnosis of right sided heart failure?

"I need to change my position slowly" "I should eat more food that is high in potassium"

Which client statements indicate that the teaching about furosemide is understood?

Dyspnea Crackles Collapsed neck veins Cool extremities-decreased output

Which clinical indicator is the nurse MOST likely to identify when taking the admission history of a client with left sided heart failure?

Edema Ascites Decreased urine output

Which clinical indicator is the nurse MOST likely to identify when taking the admission history of a client with right sided heart failure?

Hyperglycemia and urine negative for ketones

Which clinical indicator should the nurse identify as expected for a client with type 2 diabetes?

Leg ulcers Loss of visual acuity Prolonged capillary refill in the toes Decreased sensation in the lower extremities

Which common complication of diabetes would the nurse assess for in a client with a long history of the disease?

Continues after rest and nitroglycerin

Which finding about a clients angina is MOST important for the nurse to communicate to the health care provider?

Angina episodes are occurring more3 frequently

Which fining in a client with a diagnosis of stable angina is MOST important for the nurse to communicate to the heath care provider?

"I have trouble breathing when I climb a flight of stairs"

Which statement by a client is consistent with a diagnosis of heart failure?

Use of peak flow meter

Which topic would the nurse plan to include in teaching a client with a new diagnosis of asthma?

Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid

Which type of acid-base imbalance would the nurse expect in a child admitted with a severe asthma exacerbation?

Place the client in the orthopneic position/tripod position

Which would the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema?

Barrel chest

While a nurse is conduction an initial assessment on a client, which classic sign would alert the nurse that the client has COPD?

Initiate oxygen via nasal cannula

While in the piston Esther's a care unit, a client reports shortness of breath and chest pain. Which priority interventions are MOST appropriate by the nurse to do first?

It is relived by rest

A client admitted to the hospital for chest pain is diagnosed with stable angina. Which information should the nurse include in the teaching session?

Administer the medication as ordered

A client diagnosed with hypertension and chronic angina is receiving metroprolol. The current vital signs are: BP 132/80, HR 62. What should the nurse do?

Decreased cardiac output

A client has had a recent myocardial infarction involving the left ventricle. Which assessment finding is expected?

Blood urea nitrogen

A client is admitted to the hospital with a lung history of uncontrolled hypertension. Which lab result will be MOST important for the nurse to review?

Maintaining potassium levels Hypoglycemia

A client is taking furosemide and digoxin for heart failure. Why does the nurse advise the client to drink a glass of orange juice every day?

Teach the client to do pursed lip breathing

A client with an acute emphysema episode is dyspneic and anxious. To decrease the dyspnea, what is the nurses FIRST action?

Teach the client to do pursed-lip breathing

A client with an acute emphysema episode is dyspneic and anxious. To decrease the dyspnea, which action would the nurse take?

Ketoacidosis

A client with type 1 diabetes has dry, hot, flushed skin; flirty odor to the breath; and is having Kussmaul respirations. Which complication does the nurse suspect that the client is experiencing?

Metabolic acidosis

A critically ill 5 year old exhibits Kussmaul respirations. What does the nurse suspect may be causing an increasing acid-base imbalance?

Assess oxygen saturation

A fine with a recent diagnosis of DVT has a sudden onset of shortness of breath and chest pain that increases with a deep breath. What should the nurse do?

Giving 4oz of fruit juice

A nurse identifies that the client is experiencing a hypoglycemic reaction. Which intervention should the nurse implement to relieve the symptoms associated with this reaction?

Additional tests are needed, such as a chest x-ray

A nurse if reading the result of a Mantoux skin test for a client who is a resident of a group home for adults with disabilities. At 48hrs after testing, a 12mm induration is measured. Which explaining of this result would the nurse give to the client?

I have trouble breathing when I walk rapidly

A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect?

Leg ulcers Loss of visual acuity Decreased sensation in the feet

A nurse is care for a client who has had Tupperware 1 diabetes for 25 years. The client stats," I have been really bad fort eh last 15 years. I have not paid attention to my diet and have done little to control my diabetes." What common complications of diabetes might the nurse expect to identify when assessing this client?

Blurry, spotty, or hazy vision

A nurse is caring for a client who has a 20-year history of type 2 diabetes. The nurse should assess for what physiologic changes associated with a long history of diabetes?

Urinating at night Cool extremities Dependent edema Distended abdomen

A nurse is caring for a client with right sided heart failure. Which assessment findings are key features of right sided heart failure?

Rapid removal of large amounts of fluid may precipitate cardiovascular collapse

A nurse is providing education to a coworker who is caring for a client who is scheduled to have a thoracentesis for a pleural effusion. Which info will be appropriate for the nurse to include?

Persistent cough

During a home visit, the nurse assesses a client who is taking HCTZ and lisinorpil for the treatment of HTN. Which symptom should indicate a need to inform the MD of a need to change medication therapy?

Troponin

Serum cardiac marker studies are prescribed for a client after a myocardial infarction. Which lab test is MOST important for the nurse to monitor

Signs and symptoms of digoxin toxicity

The nurse is providing discharge medication teaching to a client who will be taking furosemide and digoxin after discharge from the hospital. Which info is important for the nurse to include in the teaching plan?

Wear shoes when out of bed Dry between the toes after bathing

The nurse is providing instructions about for care for a client with diabetes. What should the nurse include in the instructions?

Baked chicken, baked potato, and skim milk

The nurse knows the client understands that teaching concerning a low-fat, low-cholesterol diet when the client selects which meal?

Continues after rest and nitroglycerin

The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services IMMEDIATELY if the clients pain exhibits which characteristic?

Promotes elimination of CO2

The nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise?

Demonstrates use of metered-dose inhaler

What us the PRIORITY goal for a client with asthma whi us being discharged from the hospital with prescriptions for inhaled bronchodilators?