Study Guide 3 NUR-110

A female client presents to the health clinic for a routine physical examination. The nurse observes that the client's urine is bright yellow. Which question is most appropriate for the nurse to ask the client?

"Do you take multiple vitamin preparations?"

A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement?

"It is all right if I have a grilled cheese sandwich with American cheese."

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?

15-mm induration

A nurse is performing blood pressure screenings at a local health fair. While obtaining subjective assessment data from a patient with hypertension, the nurse learns that the patient has a family history of hypertension and she herself has high cholesterol and lipid levels. The patient says she smokes one pack of cigarettes daily and drinks "about a pack of beer" every day. The nurse notes what nonmodifiable risk factor for hypertension?

A family history of hypertension

The nurse is planning the care of a patient with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this patient's health problem is due to what?

Abnormalities in the structure and function RBCs

A nurse is caring for a client with left-sided heart failure. During the nurse's assessment, the client is wheezing, restless, tachycardic, and has severe apprehension. The clients reports that these symptoms came on suddenly. The nurse knows that these are symptoms of what condition?

Acute pulmonary edema

A school nurse is caring for a 10 year old girl who is having an asthma attack. What is the preferred intervention to alleviate the clients airflow obstruction?

Administer an inhaled beta adrenergic agonist

The nurse is performing a physical assessment on a patient suspected of having HF. The presence of what sound would signal the possibility of impending HF?

An S3 heart sound

A client has been experiencing increasing shortness of breath and fatigue. The health care provider has ordered a diagnostic test in order to determine what type of heart failure the client is having. What diagnostic test does the nurse anticipate being ordered?

An echocardiogram

The nurse is assessing a postoperative patient who had a percutaneous transluminal coronary angioplasty (PTCA). Which possible complications should the nurse monitor for? (Select all that apply.)

Arterial dissection Coronary artery vasospasm Abrupt closure of the artery

Which of the following conditions contributes to secondary hypertension?

Arterial vasoconstriction

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?

Assess the client's level of pain and administer prescribed analgesics.

A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan?

Avoiding tight-fitting socks

An 87-year-old patient has been hospitalized with pneumonia. Which nursing action would be a priority in this patient's plan of care?

Cautious hydration

A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority health education for this patient?

Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD.

The nurse is to administer morphine sulfate to a client with chest pain. What initial nursing action is required prior to administration?

Count the respiratory rate for bradypnea.

A nurse is educating a client with coronary artery disease about nitroglycerin administration. The nurse tells the client that nitroglycerin has what actions? Select all that apply.

Decreases ischemia Reduces myocardial oxygen consumption Dilates blood vessels Relieves pain

A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication?

Deep vein thrombosis

The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patient's diagnosis?

Distended neck veins

Which instruction would be included in a teaching plan for a client diagnosed with a UTI?

Drink liberal amount of fluids.

When assessing venous disease in a patient's lower extremities, the nurse knows that what test will most likely be ordered?

Duplex ultrasonography

The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Mich measure should the nurse implement to most decrease the patient's risk for developing PE?

Early Ambulation

The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the patient takes oral contraceptives. Consequently, the nurse's postoperative plan of care should include what intervention?

Early ambulation and leg exercises

The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump?

Echocardiogram

A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. What is the most appropriate intervention for this diagnosis?

Encourage the patient to engage in a moderate amount of exercise.

The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patient's sensorium and LOC. Why is the assessment of the patient's sensorium and LOC important in patients with HF?

HF ultimately affects oxygen transportation to the brain.

The nurse is creating a community teaching demonstration focusing on the cause of blood pressure. When completing the visual aid, which body structures represent the mechanism of blood pressure?

Heart and blood vessels

The nurse is describing normal RBC physiology to a patient who has a diagnosis of anemia. The nurse should explain that the RBCs consist primarily of which of the following?

Hemoglobin

Which factor contributes to UTI in older adults?

Immunocompromised

A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient?

In a high Fowler's position

A patient with a hematologic disorder asks the nurse how the body forms blood cells. The nurse should describe a process that takes place where?

In the bone Marrow

The nurse is providing education to a patient newly diagnosed with iron deficiency anemia. Which of the following would be a component of the education?

Include citrus fruits while taking the medication for this disorder.

A nurse is caring for a patient with COPD. The patients medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. What assessment parameters suggest a consequent improvement in a respiratory status: SATA

Increased expiratory flow rate Relief of dyspnea

A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patient's left leg is visibly swollen and reddened. What is the nurse's most appropriate action?

Inform the physician that the patient has signs and symptoms of VTE.

A patient has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the patient's consequent increase in RBC production, the nurse knows that the patient may need to increase her daily intake of what substance?

Iron

A patient comes to the clinic complaining of fatigue and the health interview is suggestive of pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that the patient will be diagnosed?

Iron deficiency anemia

The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the physician. What type of anemia is the nurse concerned the co-worker may have?

Iron deficiency anemia

The nurse is educating a patient diagnosed with angina pectoris about the difference between the pain of angina and a myocardial infarction (MI). How should the nurse describe the pain experienced during an MI? (Select all that apply.)

It is substernal in location. It is viselike and radiates to the shoulders and arms. It is sudden in onset and prolonged in duration.

What signs and symptoms does the nurse anticipate to find in a patient diagnosed with tuberculosis? Select all that apply.

Lethargy, Night sweats, Low-grade fever

A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely? Select all that apply.

Level of consciousness Arterial blood gases Vital signs

Which feature is the hallmark of systolic heart failure?

Low ejection fraction (EF)

The nurse is assessing a patient who comesn to the clinic complaining of feeling constantly tired and very weak. The patient also has a very sore tongue, and upon observing the patient's oral cavity, the nurse notices the tongue is beefy red. What type of anemiadoes the nurse know these symptomsindicate?

Megaloblastic anemia

You are caring for a 65 y/o male patient admitted 72 hours ago with pyloric stenosis. An NG tube is placed upon admission has been on low intermittent suction ever since. Upon review of the mornings blood work you notice the patient's potassium below reference range. You should recognize that as what imbalance?

Metabolic alkalosis

The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals: Ph 7.28, paco2 50, hco3 23. The nurse recognizes this as what?

Mixed acid base disorder: because! One can have respiratory acidosis and alkalosis at the same time.

The nurse is caring for a patient with a platelet count of <20,000/mm3. Which of the following precautions should the nurse take in providing care for this patient? (Select all that apply.)

Monitor for black tarry stools. Avoid blood draws when possible. Use soft toothbrush to clean the teeth.

Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF?

Monitor for hypotension

The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting?

Monitor her weight daily

A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the resident's feet, the nurse notes that she appears to have early evidence of gangrene on one of her great toes. The nurse knows that gangrene in the elderly is often the first sign of what?

PAD

The nurse is providing an education program for the nursing assistants in a long-term care facility in order to decrease the number of UTIs in the female population. What interventions should the nurse introduce in the program? Select all that apply.

Perform hand hygiene prior to patient care. Provide careful perineal care. Assist the patients with frequent toileting.

The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition?

Pneumothorax

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client?

Pulmonary congestion

The nurse is caring for a client newly diagnosed with secondary hypertension. Which of the following conditions contributes to the development of secondary hypertension?

Renal disease

A patient with a longstanding anxiety disorder presents to the ER. The triage nurse notes upon assessment that the patient is hyperventilating. What's the imbalance?

Respiratory alkalosis- because fast breathing decreased the co2 in the blood/ not enough time for gas exchange

A nurse is creating health promotion intervention focused on COPD. What complication should the nurse identiy as a complication?

Respiratory failure

According to the classification of hypertension diagnosed in the older adult, hypertension that can be attributed to an underlying cause is termed:

Secondary

A nurse is planning the care of a patient with emphysema who will soon be d/c. What teaching should the nurse prioritize in the plan of care?

Setting realistic short term and long term goals.

A patient with emphysema is experiencing SOB. To relieve the patients symptoms the nurse should assit her into what position?

Sitting upright, leaning forward slightly.

A nurse providing education about hypertension to a community group is discussing the high risk for cardiovascular complications. Which of the following are risk factors for cardiovascular problems in clients with hypertension? Choose all that apply.

Smoking Physical inactivity Diabetes mellitus

The nurse is seeing a client for the first time and has just checked the client's blood pressure. For what value would the nurse consider the client prehypertensive?

Systolic BP is between 120 and 130 mm Hg.

A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?

The development of left-sided heart failure

An adult patient has tested positive for TB. While providing patient teaching, what information should the nurse prioritize?

The importance of adhering closely to the prescribed medication regimen

Graduated compression stockings have been prescribed to treat a patient's venous insufficiency. What education should the nurse prioritize when introducing this intervention to the patient?

The importance of ensuring the stockings are applied evenly with no pressure points

The nurse is assessing an older adult patient with numerous health problems. What assessment datum indicates an increase in the patient's risk for heart failure (HF)?

The patient's age is greater than 65.

The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis?

Unequal peripheral pulses between extremities

A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patient's left foot. How should the nurse proceed with assessment?

Use Doppler ultrasound to identify the pulses.

An older adult is newly diagnosed with primary hypertension and has just been started on a betablocker. The nurse's health education should include which of the following?

Use of strategies to prevent falls stemming from postural hypotension

The prevention of VTE is an important part of the nursing care of high-risk patients. When providing patient teaching for these high-risk patients, the nurse should advise lifestyle changes, including which of the following? Select all that apply.

Weight loss Regular exercise Smoking cessation

Lifestyle modifications are recommended to prevent and manage hypertension. Select the modification that has been found to have the greatest effect in reducing blood pressure measurements.

Weight reduction

A nurses assessment reveals that a client with COPD may be experiencing bronchospasm. What assessment finding would suggest that the patient is experiencing bronchospasm?

Wheezes or diminished breath sounds on auscultation.

A client who has been diagnosed with Prinzmetal's angina will present with which symptom?

chest pain that occurs at rest and usually in the middle of the night

Frequently, what is the earliest symptom of left-sided heart failure?

dyspnea on exertion

A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured?

echocardiogram

Expected findings for a patient with emphysema

productive cough -hypoxemia- crackles/wheezes-rapid shallow breaths- use of accessory muscles - barrel chest - thin extremities, enlarged neck muscles - clubbing of fingers

A patient who is being treated for pneumonia starts complaining of sudden SOB. ABGS are drawn and present the following: ph 7.21, paco2 64 mm hg, hco3 24.

respiratory acidosis

A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the...

skin test doesn't differentiate between active and dormant tuberculosis infection