SATA practice questions exam 1 (med surg 3)

B, D, E Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Foo choices are not comfort measures.

A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.

A, D, E The client with a tracheostomy may be shy and hesitant to go out in public. The client should have a sound communication method to ease frustration. The nurse can also suggest ways of enhancing appearance so the client is willing to leave the house. These can include wearing scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good advice.

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Don't go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

A, B, C, E Clients with PEs are often anxious. The nurse can acknowledge the clients fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the clients anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the UAP. c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medicine. e. Stay with the client and speak in a quiet, calm voice.

A, B, C Oxygen is an accelerant, which means it enhances combustion, so precautions are needed whenever using it. The nurse should assess if the client allows smoking near the oxygen, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety.

A home health nurse is visiting a new client who uses oxygen in the home For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply) a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage. d. Household light bulbs are the fluorescent type. e. The client does not have pets inside the home.

B, D, E In the first few hours postprocedure, the nurse monitors for complications such as bleeding from the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and dysrhythmias. The clients blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours.

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor

A, B, D Acute pericarditis is most commonly associated acute exacerbations of systemic connective tissue disease, including SLE; with Dresslers syndrome, or inflammation of the cardiac sac after cardiac surgery or a myocardial infarction; and with infective organisms, including bacterial, viral, and fungal infections. Abdominal and reproductive surgeries and pressure ulcers do not increase clients risk for acute pericarditis.

A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.) a. A 36-year-old woman with systemic lupus erythematosus (SLE) b. A 42-year-old man recovering from coronary artery bypass graft surgery c. A 59-year-old woman recovering from a hysterectomy d. An 80-year-old man with a bacterial infection of the respiratory tract e. An 88-year-old woman with a stage III sacral ulcer

A, C, E Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart catheterizations. Stroke and myocardial infarction are complications of left-sided heart catheterizations.

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply) a. Thrombophlebitits b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade

A, D, E Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall.

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output

A, C, D The UAP should reposition the client every 2 hours to improve oxygenation and prevent atelectasis. The UAP can also accurately record intake and output, and use the same scale to weigh the client each morning before breakfast. UAPs are not qualified to teach clients or assess the need for and provide oxygen therapy

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply.) a. Reposition the client every 2 hours. b. Teach the client to perform deep-breathing exercises. c. Accurately record intake and output. d. Use the same scale to weigh the client each morning. e. Place the client on oxygen if the client becomes short of breath.

A, B, E, F A hematocrit of 32.8% is low (should be 42.6%), indicating a dilutional ratio of red blood cells to fluid. A serum sodium of 130 mEq/L is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. These are early warning signs of decreased compliance of the heart. The potassium level is on the high side of normal and the serum creatinine level is normal.

A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L c. Serum potassium: 4.0 mEq/L d Serum creatinine: 1.0 mg/dL e. Proteinuria f. Microalbuminuria

A, B, C Clinical manifestations of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction.

A nurse is assessing a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension

A, B, E Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided heart failure occurs with problems from the pulmonary vasculature onward including pulmonary hypertension. Signs will be noted before the right atrium or ventricle included dependent edema.

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night

A, C, E The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done.

A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.

A, D The UAP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises. Oral care can be accomplished with normal saline, not products that dry the mouth. Ensuring the humidity is adequate and suctioning through the tracheostomy are nursing functions.

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying water-soluble lip balm to the clients lips b. Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy

A, B, D, E There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the clients skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.

A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply) a. Allow visitors at the clients bedside. b. Ensure the client can communicate if awake. c. Keep the television turned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.

A, B, C If the client has kidney disease (as indicated by BUN and creatinine results), fluids and Mucomyst may be given 12 to 24 hours before the procedure for renal protection. The client should be assessed for allergies to iodine, including shellfish; the contrast medium used during catheterization contains iodine. A foley catheter and central venous catheter are not required for the procedure and would only increase risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply) a. Assess for allergies to iodine b. Administer intravenous fluids c. Assess blood urea nitrogen (BUN) and creatinine results d. Insert a foley catheter e. Administer prophylactic antibiotic f. Insert a central venous catheter

B, D, E Conditions that place clients at higher risk for developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury in a rotating bed c. Middle-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur

A, B, D, E The older adult is at risk for having impairments in cognition, dexterity, range of motion, and vision that could limit the ability to perform tracheostomy care and should be assessed. Hydration is not directly related to the ability to perform self-care.

A nurse is planning discharge teaching on tracheostomy care for an older adult. What factors does the nurse need to assess before teaching this particular client? (Select all that apply) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision

A, B, C, E Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous membranes, and oxygen toxicity. Oxygen-induced hypoventilation is also a complication.

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.) a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Oxygen-induced hyperventilation e. Toxicity

A, B, D A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this clients teaching? (Select all that apply) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

B, D, E Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, should be performed. Beta blockers are often held prior to the procedure.

A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply) a. Assist the provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the clients prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will stimulate exercise for this examination.

A, B, D The Heart Failure Core Measure Set includes discharge instructions on diet, activity, medications, weight monitoring and plan for worsening symptoms, evaluation of left ventricular systolic function (usually with an echocardiogram), and prescribing an ACE inhibitor or angiotensin receptor blocker. Aspirin is not part of the Heart Failure Core Measure Set and is usually prescribed for clients who experience a myocardial infarction. Although the nurse may consult the social worker or case manager for additional resources, this is not part of the Core Measures.

A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.) a. Teach the client about dietary restrictions. b. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. c. Encourage the client to take a baby aspirin each day. d. Confirm that an echocardiogram has been completed. e. Consult a social worker for additional resources.

A, B, D To ensure safety upon discharge, the nurse should assess for structural barriers to functional ability, such as stairs. The nurse should also assess the clients available social support, which may include family, friends, and home health services. The clients ability to adhere to medication and treatments, including daily weights, should also be reviewed. The other questions do not address the clients safety upon discharge.

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this clients safety prior to discharging home? (Select all that apply) a. Are you bedroom and bathroom on the first floor? b. What social support do you have at home? c. Will you be able to afford your oxygen therapy? d. What spiritual beliefs may impact your recovery? e. Are you able to accurately weigh yourself at home?

A, B, E The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker.

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this clients teaching? (Select all that apply) a. Until your incision is healed, do not submerge your pacemaker. Only take showers. b. Report any pulse rates lower than your pacemaker settings. c. If you feel weak, apply pressure over your generator. d. Have your pacemaker turned off before having magnetic resonance imaging (MRI). e. Do not lift your left arm above the level of your shoulder for 8 weeks.

B, C, D, E Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply) a. Age b. Hypertension c. Obesity d. Smoking e. Stress

A, B, C, E Age, diabetes, ethnic background, and smoking are all risk factors for developing CAD; medication use is not.

A nursing student planning to teach about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply) a. Advanced age b. Diabetes c. Ethnic background d. Medication use e. Smoking

A, B, D, E The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion.

A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause

A, D, E Nutritional therapy for a client with CHF is focused on decreasing sodium and water retention to decrease the workload of the heart. The client should be taught to read nutritional labels on all food items, omit table salt and foods high in sodium (e.g., ham and canned foods), and limit water intake to a normal 2 L/day

After teaching a client with congestive heart failure (CHF), the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) a. Ill read the nutritional labels on food items for salt content. b. I will drink at least 3 liters of water each day. c. Using salt in moderation will reduce the workload of my heart. d. I will eat oatmeal for breakfast instead of ham and eggs. e. Substituting fresh vegetables for canned ones will lower my salt intake

B, C, E Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptoms of indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome.

An emergency room nurse assesses a female client. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram? (Select all that apply) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath

B, C, E Clinical manifestations of infective endocarditis include fever with chills, night sweats, malaise and fatigue, anorexia and weight loss, cardiac murmur, and oslers nodes on palms of the hands and soles of the feet. Abdominal bloating is a manifestation of heart transplant rejection.

The nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply) a. Weight gain b. Night sweats c. Cardiac murmur d. Abdominal bloating e. Oslers nodes

A, B, D Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity.

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. Which age-related changes contribute to this? (Select all that apply) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing

A, B, C, D The ventilator bundle is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule

C, D, E Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.

When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply) a. Avoid drinking alcohol b. Eat more omega-3 fatty acids c. Exercise on a regular basis d. Maintain a healthy weight e. Stop smoking cigarettes