260- Exam 2
A clinic nurse is caring for a patient who has just been diagnosed with chronic obstructive pulmonary disease (COPD). The patient asks the nurse what he could have done to minimize the risk of contracting this disease. What would be the nurse's best answer? Select one: A. "The most important risk factor for COPD is cigarette smoking." B. "The most important risk factor for COPD is exposure to occupational toxins." C. "The most important risk factor for COPD is exposure to dust and pollen." D. "The most important risk factor for COPD is inadequate exercise."
A. "The most important risk factor for COPD is cigarette smoking." The most important risk factor for COPD is cigarette smoking. Lack of exercise and exposure to dust and pollen are not risk factors for COPD. Occupational risks are significant but are far exceeded by smoking.
A nurse is caring for a patient who has been hospitalized with an acute asthma exacerbation. What drugs should the nurse expect to be ordered for this patient to gain underlying control of persistent asthma? Select one: A. Anti-inflammatory drugs B. Rescue inhalers C. Antitussives D. Antibiotics
A. Anti-inflammatory drugs Because the underlying pathology of asthma is inflammation, control of persistent asthma is accomplished primarily with regular use of anti-inflammatory medications. Rescue inhalers, antibiotics, and antitussives do not aid in the first-line control of persistent asthma.
A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan? Select one: A. Avoiding tight-fitting socks. B. Sleep with legs in a dependent position. C. Limit activity whenever possible. D. Avoid the use of pressure stockings.
A. Avoiding tight-fitting socks. Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles; maintaining activities, such as walking, sleeping with legs elevated, and using pressure stockings. Not included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs dependent, and avoiding pressure stockings. Each of these actions exacerbates venous insufficiency.
A newly admitted older patient has severe edema in the lower extremities and no hair on the legs. What do these manifestations most likely indicate to the nurse? Select one: A. Circulatory problems related to age and a chronic illness B. A diet low in protein C. Frequent falls and injuries because of unsteady gain D. Exposure to the cold from a lack of heat
A. Circulatory problems related to age and a chronic illness The manifestations indicate ineffective tissue perfusion in the lower extremities. These manifestations do not indicate a diet low in protein, exposure to the cold, or frequent falls and injuries.
A patient presents to the walk-in clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the patient that angina is most often attributable to what cause? Select one: A. Coronary arteriosclerosis B. Decreased cardiac output C. Infarction of the myocardium D. Decreased cardiac contractility
A. Coronary arteriosclerosis In most cases, angina pectoris is due to arteriosclerosis. The disease is not a result of impaired cardiac output or contractility. Infarction may result from untreated angina, but it is not a cause of the disease.
Most of the older patients on a geriatric care area have some degree of pulmonary disease and ineffective respirations. Which intervention should the nurse include on these patients' care plans? Select one: A. Perform daily deep-breathing exercises. B. Enroll in yoga classes. C. Avoid exposure to people with infections. D. Keep the nasal passages patent.
A. Perform daily deep-breathing exercises. Deep-breathing exercises can help improve some age-related changes in lung capacity and are an activity that even nonambulatory patients can do. It is unknown if yoga classes would be appropriate for these patients. Keeping the nasal passages patent and avoiding exposure to those with infections would not immediately help the patients' ineffective respirations.
A nurse is developing a teaching plan for a patient with COPD. What should the nurse include as the most important area of teaching? Select one: A. Setting and accepting realistic short- and long-range goals B. Avoiding extremes of heat and cold C. Avoiding emotional disturbances and stressful situations D. Adopting a lifestyle of moderate activity
A. Setting and accepting realistic short- and long-range goals A major area of teaching involves setting and accepting realistic short-term and long-range goals. The other options should also be included in the teaching plan, but they are not areas that are as high a priority as setting and accepting realistic goals.
An older patient with a history of environmental exposure to chemicals complains of shortness of breath. Which symptom most likely indicates the patient has chronic obstructive pulmonary disease (COPD)? Select one: A. Sticky, translucent, grayish white sputum B. Greenish, thick sputum C. Red, frothy sputum D. Purulent and foul-smelling sputum
A. Sticky, translucent, grayish white sputum Tenacious, translucent, and grayish white sputum is associated with COPD. Purulent and foul-smelling sputum is associated with a lung abscess. Greenish, thick sputum is associated with a lung infection. Red, frothy sputum is associated with pulmonary edema or left-sided heart failure.
Family members bring a patient to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data? Select one: A. The symptoms indicate an acute coronary episode and should be treated as such. B. The symptoms indicate a pulmonary etiology rather than a cardiac etiology. C. The symptoms indicate angina and should be treated as such. D. Treatment should be determined pending the results of an exercise stress test.
A. The symptoms indicate an acute coronary episode and should be treated as such. Angina and MI have similar symptoms and are considered the same process, but are on different points along a continuum. That the patient's symptoms are unrelieved by rest suggests an acute coronary episode rather than angina. Pale cool skin and sudden onset are inconsistent with a pulmonary etiology. Treatment should be initiated immediately regardless of diagnosis.
A nurse is explaining to a patient with asthma what her new prescription for prednisone is used for. What would be the most accurate explanation that the nurse could give? Select one: A. To gain prompt control of inadequately controlled, persistent asthma B. To ensure long-term prevention of asthma exacerbations C. To prevent recurrent pulmonary infections D. To cure any systemic infection underlying asthma attacks
A. To gain prompt control of inadequately controlled, persistent asthma Prednisone is used for a short-term (3-10 days) "burst" to gain prompt control of inadequately controlled, persistent asthma. It is not used to treat infection or to prevent exacerbations in the long term.
A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the patient has a history of what health problem? Select one: A. CAD B. Arterial insufficiency C. Varicose veins D. Raynaud's phenomenon
B. Arterial insufficiency Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is caused by trauma. The toe is stubbed and then turns black. Raynaud's, CAD and varicose veins are not the usual causes of digital gangrene in the elderly.
A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would assessment of ankle-brachial index (ABI) be most clearly warranted? Select one: A. A patient who has peripheral edema secondary to chronic heart failure B. A patient with poorly controlled type 1 diabetes who is a smoker C. A patient who has community-acquired pneumonia and a history of COPD D. An older adult patient who has a diagnosis of unstable angina
B. A patient with poorly controlled type 1 diabetes who is a smoker Nurses should perform a baseline ABI on any patient with decreased pulses or any patient 50 years of age or older with a history of diabetes or smoking. The other answers do not apply.
An older patient who smokes half a pack of cigarettes daily and is diagnosed with COPD expresses regret about starting smoking over 50 years ago at a time when it was considered both fashionable and harmless. What can the nurse respond to this patient? Select one: A. "Even though it won't affect the course of your COPD, quitting smoking would probably make you feel better about yourself." B. "Even though you have smoked for a long time, there are still benefits to quitting smoking." C. "If you continue to smoke, any medical treatment for your COPD is likely to be ineffective." D. "Unfortunately the damage is now done and quitting smoking will likely have little effect on your future health."
B. "Even though you have smoked for a long time, there are still benefits to quitting smoking." There are health benefits to quitting smoking at any stage and doing so would likely aid in the treatment of the patient's COPD. Continuing to smoke, while detrimental, would not necessarily render all medical treatments for COPD ineffective. Quitting smoking could stop the progression of the patient's disease.
A patient who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day? Select one: A. Assess the patient for signs and symptoms of compartment syndrome every 2 hours. B. Assess pulse of affected extremity every 15 minutes at first. C. Palpate the affected leg for pain during every assessment. D. Perform Doppler evaluation once daily.
B. Assess pulse of affected extremity every 15 minutes at first. The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the patient's status remains stable. Doppler evaluations should be performed every 2 hours. Pain is regularly assessed, but palpation is not the preferred method of performing this assessment. Compartment syndrome results from the placement of a cast, not from vascular surgery.
A nurse is completing a focused respiratory assessment of a patient with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? Select one: A. Shallow respirations B. Bilateral wheezes C. Bradypnea D. Increased anterior-posterior (A-P) diameter
B. Bilateral wheezes The three most common symptoms of asthma are cough, dyspnea, and wheezing. There may be generalized wheezing (the sound of airflow through narrowed airways), first on expiration and then, possibly, during inspiration as well. Respirations are not usually slow and the child's A-P diameter does not normally change.
A nurse is developing the teaching portion of a care plan for a patient with COPD. What would be the most important component for the nurse to emphasize? Select one: A. Smoking up to one-half of a pack of cigarettes weekly is allowable. B. Chronic inhalation of indoor toxins can cause lung damage. C. Activities of daily living (ADLs) should be clustered in the early morning hours. D. Minor respiratory infections are considered to be self-limited and are not treated.
B. Chronic inhalation of indoor toxins can cause lung damage. Environmental risk factors for COPD include prolonged and intense exposure to occupational dusts and chemicals, indoor air pollution, and outdoor air pollution. Smoking cessation should be taught to all patients who are currently smoking. Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of the person with emphysema. ADLs should be paced throughout the day to permit patients to perform these without excessive distress.
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? Select one: A. The lack of exercise, which is the main cause of PAD. B. Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. C. The likelihood that heavy alcohol intake is a significant risk factor for PAD. D. Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.
B. Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. Tobacco is powerful vasoconstrictor; its use with PAD is highly detrimental, and patients are strongly advised to stop using tobacco. Sedentary lifestyle is also a risk factor, but smoking is likely a more significant risk factor that the nurse should address. Alcohol use is less likely to cause PAD, although it carries numerous health risks.
An older adult patient has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan? Select one: A. Use of supplementary oxygen to aid tissue oxygenation B. Compression stockings for life C. Daily use of normal saline compresses on the lower limbs D. Daily administration of prophylactic antibiotics
B. Compression stockings for life A diet that is high in protein, vitamins C and A, iron, and zinc is encouraged to promote healing and prevent future ulcers. Prophylactic antibiotics and saline compresses are not used to prevent ulcers. Oxygen supplementation does not prevent ulcer formation.
An asthma nurse educator is working with a group of adolescent asthma patients. What intervention is most likely to prevent asthma exacerbations among these patients? Select one: A. Teaching patients to utilize alternative therapies in asthma management B. Educating patients about recognizing and avoiding asthma triggers C. Ensuring that patients keep their immunizations up to date D. Encouraging patients to carry a corticosteroid rescue inhaler at all times
B. Educating patients about recognizing and avoiding asthma triggers Asthma exacerbations are best managed by early treatment and education, including the use of written action plans as part of any overall effort to educate patients about self-management techniques, especially those with moderate or severe persistent asthma or with a history of severe exacerbations. Corticosteroids are not used as rescue inhalers. Alternative therapies are not normally a high priority, though their use may be appropriate in some cases. Immunizations should be kept up to date, but this does not necessarily prevent asthma exacerbations.
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? Select one: A. Elevate his legs and arms above his heart when resting. B. Encourage the patient to engage in a moderate amount of exercise. C. Discourage walking in order to limit pain. D. Encourage extended periods of sitting or standing.
B. Encourage the patient to engage in a moderate amount of exercise. The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires interventions that focus on improving circulation. Encouraging the patient to engage in a moderate amount of exercise serves to improve circulation. Elevating his legs and arms above his heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting or standing would further compromise circulation. The nurse should encourage, not discourage, walking to increase circulation and decrease pain.
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? Select one: A. On the left side-lying position B. In a high Fowler's position C. In a flat, supine position D. In the Trendelenburg position
B. In a high Fowler's position Proper positioning can help reduce venous return to the heart. The patient is positioned upright. If the patient is unable to sit with the lower extremities dependent, the patient may be placed in an upright position in bed. The supine position and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, side-lying does not promote circulation.
A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? Select one: A. Metabolic alkalosis B. Respiratory acidosis C. Metabolic acidosis D. Respiratory alkalosis
B. Respiratory acidosis The pH is below 7.40, PaCO2 is greater than 40, and the HCO3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.
A patient with emphysema is experiencing shortness of breath. To relieve this patient's symptoms, the nurse should assist her into what position? Select one: A. Trendelenburg B. Sitting upright, leaning forward slightly C. Prone D. Low Fowler's, with the neck slightly hyperextended
B. Sitting upright, leaning forward slightly The typical posture of a person with COPD is to lean forward and use the accessory muscles of respiration to breathe. Low Fowler's positioning would be less likely to aid oxygenation. Prone or Trendelenburg positioning would exacerbate shortness of breath.
After completing an assessment of an older patient, which finding should the nurse attribute to a pathological process rather than age-related respiratory changes? Select one: A. Uses accessory muscles on expiration B. Slight wheeze on exhalation C. Posture is slightly kyphotic D. Mucous membranes drier than younger clients'
B. Slight wheeze on exhalation While some use of accessory muscles, kyphosis, and drying of mucous membranes occur as part of the aging process, a wheeze would not be considered a normal, age-related change and could indicate a pathological process.
An older male patient taking medication for hypertension asks what else can be done to reduce the blood pressure. What measures should the nurse recommend to the patient? Select one: A. Deep breathing and Buerger-Allen exercises B. Weight loss and a reduction in sodium intake C. Daily low-dose aspirin and one alcoholic drink daily D. A low-fat, low-cholesterol diet
B. Weight loss and a reduction in sodium intake While moderate alcohol intake, low-dose ASA, and a low-fat diet are conducive to cardiac health, weight loss and reduced sodium intake are more specific to the management of hypertension. Buerger-Allen exercises are used in the management of arteriosclerosis. Deep breathing is not a measure to specifically reduce the blood pressure.
A patient presents to the ED stating she was in a boating accident about 3 hours ago. Now the patient has complaints of headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the patient is restless and tachycardic with an elevated blood pressure. This patient may be in the early stages of what respiratory problem? Select one: A. Pleural effusion B. Pneumoconiosis C. Acute respiratory failure D. Pneumonia
C. Acute respiratory failure Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.
A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? Select one: A. Administration of prophylactic antibiotics B. Administration of antiretroviral medications to patients over age 65 C. Administration of pneumococcal vaccine to vulnerable individuals D. Obtaining culture and sensitivity swabs from all newly admitted patients
C. Administration of pneumococcal vaccine to vulnerable individuals Pneumococcal vaccination reduces the incidence of pneumonia, hospitalizations for cardiac conditions, and deaths in the general older adult population. A onetime vaccination of pneumococcal polysaccharide vaccine (PPSV) is recommended for all patients 65 years of age or older and those with chronic diseases. Antibiotics are not given on a preventative basis and antiretroviral medications do not affect the most common causative microorganisms. Culture and sensitivity testing by swabbing is not performed for pneumonia since the microorganisms are found in sputum.
A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patient's increased risk for what complication? Select one: A. Pulmonary embolism B. Acute respiratory distress syndrome (ARDS) C. Atelectasis D. Aspiration
C. Atelectasis A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.
A patient who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurse's most appropriate action? Select one: A. Document the patient's low urine output and monitor closely for the next several hours. B. Contact the dietitian and suggest the need for increased oral fluid intake. C. Contact the patient's physician and suggest assessment of fluid balance and renal function. D. Increase the infusion rate of the patient's IV fluid to prompt an increase in renal function.
C. Contact the patient's physician and suggest assessment of fluid balance and renal function. Nursing management includes accurate measurement of urine output. An output of less than 1 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse.
A nurse is teaching a patient with asthma about Azmacort, an inhaled corticosteroid. Which adverse effects should the nurse be sure to address in patient teaching? Select one: A. Nausea and vomiting B. Dyspnea and increased respiratory secretions C. Cough and oral thrush D. Fatigue and decreased level of consciousness
C. Cough and oral thrush Azmacort has possible adverse effects of cough, dysphonia, oral thrush (candidiasis), and headache. In high doses, systemic effects may occur (e.g., adrenal suppression, osteoporosis, skin thinning, and easy bruising). The other listed adverse effects are not associated with this drug.
A 60-year-old patient who participates in outdoor activities is diagnosed with angina. Which activity should the nurse instruct the patient to avoid to decrease the risk of anginal syndrome? Select one: A. Golfing B. Sitting in a spa C. Cross-country skiing D. Gardening
C. Cross-country skiing Anginal syndrome can be aggravated by cold wind, emotional stress, strenuous activity, anemia, and tachycardia. Cross-country skiing would be strenuous and could precipitate the development of anginal syndrome. Golfing, gardening, and sitting in a spa would not likely cause the development of anginal syndrome.
A patient with a diagnosis of HF is started on a beta-blocker. What is the nurse's priority role during gradual increases in the patient's dose? Select one: A. Educating the patient about the potential changes in LOC that may result from the drug B. Making adjustments to each day's dose based on the blood pressure trends C. Educating the patient that symptom relief may not occur for several weeks D. Stressing that symptom relief may take up to 4 months to occur
C. Educating the patient that symptom relief may not occur for several weeks An important nursing role during titration is educating the patient about the potential worsening of symptoms during the early phase of treatment and stressing that improvement may take several weeks. Relief does not take 4 months, however. The nurse monitors blood pressure, but changes are not made based on short-term assessment results. Beta-blockers rarely affect LOC.
An older patient with hypertension has been admitted to a nursing home to recover from minor orthopedic surgery. What should the nurse include in this patient's nursing care plan to improve tissue perfusion? Select one: A. Inspecting the patient's extremities daily for signs of altered tissue circulation B. Maintaining an adequate blood pressure level by monitoring vital signs and medications C. Encouraging the patient to ambulate several times each day D. Educating the patient about the importance of diet
C. Encouraging the patient to ambulate several times each day Consistent exercise would reduce the pooling of blood in the lower extremities and improve circulation. Diet teaching would not improve the patient's tissue perfusion. Inspecting the lower extremities and measuring blood pressure are assessment actions.
An older patient with a terminal illness is extremely thin and is prescribed to use oxygen via a face mask at home. Which is the priority nursing consideration to ensure the patient's oxygenation needs are met? Select one: A. Educate the family about risks of oxygen use. B. Observe the patient for signs of pneumonia. C. Ensure a tight seal around the face mask. D. Maintain the patency of the nasal passages.
C. Ensure a tight seal around the face mask. If the patient is emaciated, a face mask may leak. The proper administration is the first consideration and would supersede family education and potential pneumonia. Nasal passages need not necessarily remain patent with the use of a face mask.
An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that the vessel most commonly used as source for a CABG is what? Select one: A. Brachial artery B. Femoral artery C. Greater saphenous vein D. Brachial vein
C. Greater saphenous vein The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as frequently. The femoral artery, brachial artery, and brachial vein are never harvested.
A nurse has been asked to give a workshop on COPD for a local community group. The nurse emphasizes the importance of smoking cessation because smoking has what pathophysiologic effect? Select one: A. Collapses the alveoli in the lungs B. Shrinks the alveoli in the lungs C. Increases the amount of mucus production D. Destabilizes hemoglobin
C. Increases the amount of mucus production Smoking irritates the goblet cells and mucous glands, causing an increased accumulation of mucus, which, in turn, produces more irritation, infection, and damage to the lung.
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? Select one: A. Massage the patient's lower leg to temporarily restore venous return. B. Administer a PRN dose of subcutaneous heparin. C. Inform the physician that the patient has signs and symptoms of VTE. D. Mobilize the patient promptly to dislodge any thrombi in the patient's lower leg.
C. Inform the physician that the patient has signs and symptoms of VTE. VTE requires prompt medical follow-up. Heparin will not dissolve an established clot. Massaging the patient's leg and mobilizing the patient would be contraindicated because they would dislodge the clot, possibly resulting in a pulmonary embolism.
An adult patient is admitted to the ED with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions? Select one: A. Bed rest, albuterol nebulizer treatments, and oxygen B. Oxygen and beta-adrenergic blockers C. Morphine sulphate, oxygen, and bed rest D. Thrombolytics, oxygen administration, and nonsteroidal anti-inflammatories
C. Morphine sulphate, oxygen, and bed rest The patient with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine sulphate reduces preload and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate.
A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe? Select one: A. Older adults have less compliant lung tissue than younger adults. B. Older adults are not normally candidates for pneumococcal vaccination. C. Older adults often lack the classic signs and symptoms of pneumonia. D. Older adults often cannot tolerate the most common antibiotics used to treat pneumonia.
C. Older adults often lack the classic signs and symptoms of pneumonia. The diagnosis of pneumonia may be missed because the classic symptoms of cough, chest pain, sputum production, and fever may be absent or masked in older adult patients. Mortality from pneumonia in the elderly is not a result of limited antibiotic options or lower lung compliance. The pneumococcal vaccine is appropriate for older adults.
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? Select one: A. VTE B. Chronic venous insufficiency C. PAD (peripheral arterial disease) D. Raynaud's phenomenon
C. PAD (peripheral arterial disease) In elderly people, symptoms of PAD may be more pronounced than in younger people. In elderly patients who are inactive, gangrene may be the first sign of disease. Venous insufficiency does not normally manifest with gangrene. Similarly, VTE and Raynaud's phenomenon do not cause the ischemia that underlies gangrene.
A patient presents to the ED in distress and complaining of "crushing" chest pain. What is the nurse's priority for assessment? Select one: A. Rapid assessment of the patient's peripheral pulses B. Auscultation of the patient's point of maximal impulse (PMI) C. Prompt initiation of an ECG D. Palpation of the patient's cardiac apex
C. Prompt initiation of an ECG The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED. Each of the other listed assessments is valid, but ECG monitoring is the most time dependent priority.
A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance? Select one: A. CNS disturbances B. Respiratory acidosis C. Respiratory alkalosis D. Increased PaCO2
C. Respiratory alkalosis The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation. Acute respiratory acidosis occurs in emergency situations, such as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2. CNS disturbances are found in extreme hyponatremia and fluid overload.
A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patient's aneurysm? Select one: A. Cessation of pulsating in an aneurysm that has previously been pulsating visibly B. New onset of hemoptysis C. Sudden onset of severe back or abdominal pain D. Sudden increase in blood pressure and a decrease in heart rate
C. Sudden onset of severe back or abdominal pain Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Impending rupture is not typically signaled by increased blood pressure, bradycardia, cessation of pulsing, or hemoptysis.
An adult patient has tested positive for tuberculosis (TB). While providing patient teaching, what information should the nurse prioritize? Select one: A. The need to work closely with the occupational and physical therapists B. The fact that the disease is a lifelong, chronic condition that will affect ADLs C. The importance of adhering closely to the prescribed medication regimen D. The fact that TB is self-limiting, but can take up to 2 years to resolve
C. The importance of adhering closely to the prescribed medication regimen Successful treatment of TB is highly dependent on careful adherence to the medication regimen. The disease is not self-limiting; occupational and physical therapy are not necessarily indicated. TB is curable.
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? Select one: A. The need to wear the stockings on a "one day on, one day off" schedule B. The importance of wearing the stockings around the clock to ensure maximum benefit C. The importance of ensuring the stockings are applied evenly with no pressure points D. The need to take anticoagulants concurrent with using compression stockings
C. The importance of ensuring the stockings are applied evenly with no pressure points Any type of stocking can inadvertently become a tourniquet if applied incorrectly (i.e., rolled tightly at the top). In such instances, the stockings produce rather than prevent stasis. For ambulatory patients, graduated compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning. They are used daily, not on alternating days. Anticoagulants are not always indicated in patients who are using compression stockings.
After measuring an 80-year-old patient's blood pressure, the nurse realizes that it is within acceptable range. Which is an acceptable blood pressure range for this patient? Select one: A. Usually under 140 mm Hg systolic and 80 mm Hg diastolic B. Usually under 130 mm Hg systolic and 90 mm Hg diastolic C. Usually under 140 mm Hg systolic and 90 mm Hg diastolic D. Usually under 130 mm Hg systolic and 80 mm Hg diastolic
C. Usually under 140 mm Hg systolic and 90 mm Hg diastolic The acceptable range of blood pressure for older adults is usually under 140 mm Hg systolic and 90 mm Hg diastolic.
A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD? Select one: A. Lung cancer B. Cystic fibrosis C. Hemothorax D. Respiratory failure
D. Respiratory failure Complications of COPD include respiratory failure, pneumothorax, atelectasis, pneumonia, and pulmonary hypertension (corpulmonale). Lung cancer, cystic fibrosis, and hemothorax are not common complications.
A patient's severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the patient's statements suggests a need for further education? Select one: A. "I've heard that this drug is particularly good at preventing asthma attacks during exercise." B. "I know that these drugs can sometimes make my heart beat faster." C. "I've heard that this drug sometimes gets less effective over time." D. "I'll make sure to use this each time I feel an asthma attack coming on."
D. "I'll make sure to use this each time I feel an asthma attack coming on." LABAs are not used for management of acute asthma symptoms. Tachycardia is a potential adverse effect and decreased protection against exercise-induced bronchospasm may occur with regular use.
A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation following an MI. The nurse's plan of care calls for the patient to walk for 10 minutes 3 times a day. The patient questions the relationship between walking and heart function. How should the nurse best reply? Select one: A. "Walking helps your heart adjust to your new arteries and helps build your self-esteem." B. Walking increases your heart rate and blood pressure. Therefore your heart is under less stress." C. "The arteries in your legs constrict when you walk and allow the blood to move faster and with more pressure on the tissue." D. "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart."
D. "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart." Veins, unlike arteries, are equipped with valves that allow blood to move against the force of gravity. The legs have one-way bicuspid valves that prevent blood from seeping backward as it moves forward by the muscles in our legs pressing on the veins as we walk and increasing venous return. Leg arteries do constrict when walking, which allows the blood to move faster and with more pressure on the tissue, but the greater concern is increasing the flow of venous blood to the heart. Walking increases, not decreases, the heart' pumping ability, which increases heart rate and blood pressure and the hearts ability to manage stress. Walking does help the heart adjust to new arteries and may enhance self-esteem, but the patient had an MI—there are no "new arteries."
A patient with thoracic trauma is admitted to the ICU. The nurse notes the patient's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? Select one: A. A feeding tube B. An endotracheal tube C. A chest tube D. A tracheostomy
D. A tracheostomy In severe cases in which there is widespread subcutaneous emphysema, a tracheostomy is indicated if airway patency is threatened by pressure of the trapped air on the trachea. The other listed tubes would neither resolve the subcutaneous emphysema nor the consequent airway constriction.
A patient presents to the ED complaining of increasing shortness of breath. The nurse assessing the patient notes a history of left-sided HF. The patient is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem? Select one: A. Pneumonia B. Cardiogenic shock C. Right-sided heart failure D. Acute pulmonary edema
D. Acute pulmonary edema Because of decreased contractility and increased fluid volume and pressure in patients with HF, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema and signs and symptoms described. In right-sided heart failure, the patient exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the patient would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia.
A patient with dementia has difficulty swallowing, and frequently coughs when eating. Recently, the patient has developed a nonproductive cough with a temperature of 99°F. The nurse is concerned that this patient is at risk for developing which health problem? Select one: A. Chronic bronchitis B. Lung cancer C. Chronic obstructive lung disease D. Aspirational pneumonia
D. Aspirational pneumonia Aspiration of foreign material can cause a lung abscess, which is a risk in older people with decreased pharyngeal reflexes. Difficulty swallowing and coughing are not typical manifestations of chronic bronchitis, lung cancer, or chronic obstructive lung disease.
A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU? Select one: A. Obtain information about family history of heart disease. B. Determine if the patient smokes. C. Auscultate lung fields. D. Begin ECG monitoring.
D. Begin ECG monitoring. The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored; life-threatening arrhythmias are the leading cause of death in the first hours after an MI. Obtaining information about family history of heart disease and whether the patient smokes are not immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung fields are auscultated after oxygenation and pain control needs are met.
A patient with HF has met with his primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment? Select one: A. Assessment for nausea B. Oxygen saturation C. Level of consciousness (LOC) D. Blood pressure
D. Blood pressure Patients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must be monitored in patients with HF, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not normally cause nausea.
An 87-year-old patient has been hospitalized with pneumonia. Which nursing action would be a priority in this patient's plan of care? Select one: A. Administration of probiotic supplements B. Nasogastric intubation C. Bedrest D. Cautious hydration
D. Cautious hydration Supportive treatment of pneumonia in the elderly includes hydration (with caution and with frequent assessment because of the risk of fluid overload in the elderly); supplemental oxygen therapy; and assistance with deep breathing, coughing, frequent position changes, and early ambulation. Mobility is not normally discouraged and an NG tube is not necessary in most cases. Probiotics may or may not be prescribed for the patient.
An older patient with a history of anginal syndrome and congestive heart failure is admitted to the Cardiac Care Unit with a myocardial infarction. Which assessment finding should the nurse report to the health care provider? Select one: A. Increase in respiratory rate B. Dyspnea when getting out of bed to sit in a chair C. Early morning fatigue D. Decrease in blood pressure and increase in temperature
D. Decrease in blood pressure and increase in temperature Vital signs must be checked regularly. A temperature elevation can reflect an infection or another myocardial infarction. A drop in blood pressure can cause insufficient circulation. Early morning fatigue is to be expected after experiencing a myocardial infarction. An increased respiratory rate would not be reportable unless the patient has a drop in oxygen saturation. Dyspnea with position change would be expected immediately after experiencing a myocardial infarction.
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? Select one: A. Raynaud's disease B. Aoritis C. Thoracic aortic aneurysm D. Deep vein thrombosis
D. Deep vein thrombosis Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchow's triad, are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. In this woman's case, she has venous stasis from immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aoritis is unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or mobility issues. Raynaud's disease is a disorder that involves spasms of blood vessels and, again, no direct connection to HF, PAD, or mobility issues.
An admitting nurse is assessing a patient with COPD. The nurse auscultates diminished breath sounds, which signify changes in the airway. These changes indicate to the nurse to monitor the patient for what? Select one: A. Bradypnea and pursed lip breathing B. Sepsis and pneumothorax C. Kyphosis and clubbing of the fingers D. Dyspnea and hypoxemia
D. Dyspnea and hypoxemia These changes in the airway require that the nurse monitor the patient for dyspnea and hypoxemia. Kyphosis is a musculoskeletal problem. Sepsis and pneumothorax are atypical complications. Tachypnea is much more likely than bradypnea. Pursed lip breathing can relieve dyspnea.
How should the nurse best position a patient who has leg ulcers that are venous in origin? Select one: A. Keep the patient's knees bent to 45-degree angle and supported with pillows. B. Dangle the patient's legs over the side of the bed. C. Keep the patient's legs flat and straight. D. Elevate the patient's lower extremities.
D. Elevate the patient's lower extremities. Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Dangling the patient's legs and applying pillows may further compromise venous return.
A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patient's lower extremities? Select one: A. Perform gentle massage of the patient's lower legs, as tolerated. B. Perform passive range-of-motion exercises once per shift. C. Closely monitor the patient's serum albumin and prealbumin levels. D. Ensure that the patient's heels are protected and supported.
D. Ensure that the patient's heels are protected and supported. If the patient is on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations, since the heels are among the most vulnerable body regions. Monitoring blood work does not directly prevent skin breakdown, even though albumin is related to wound healing. Massage is not normally indicated and may exacerbate skin breakdown. Passive range- of-motion exercises do not directly reduce the risk of skin breakdown.
A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do? Select one: A. Increase activity. B. Call the nurse for oral suctioning, as needed. C. Lie in a low Fowler's or supine position. D. Increase oral fluids unless contraindicated.
D. Increase oral fluids unless contraindicated. The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The patient should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.
A nurse is caring for a young adult patient whose medical history includes an alpha1-antitrypsin deficiency. This deficiency predisposes the patient to what health problem? Select one: A. Cystic fibrosis (CF) B. Empyema C. Pulmonary edema D. Lobular emphysema
D. Lobular emphysema A host risk factor for COPD is a deficiency of alpha1-antitrypsin, an enzyme inhibitor that protects the lung parenchyma from injury. This deficiency predisposes young patients to rapid development of lobular emphysema even in the absence of smoking. This deficiency does not influence the patient's risk of pulmonary edema, CF, or empyema.
An older patient is recovering from hip replacement surgery. Which risk factor would most likely affect tissue perfusion in this older patient? Select one: A. The effects of anesthesia after a surgical procedure B. A history of anemia affected by additional blood loss from the surgery C. History of hypotension D. Prolonged immobility after surgery
D. Prolonged immobility after surgery The risk factor that will most likely affect tissue perfusion in this patient is prolonged immobility after surgery. Hypotension will not negatively impact this patient's tissue perfusion. The effects of anesthesia and a history of anemia are also not likely to affect this patient's tissue perfusion.
An older patient develops rapid, shallow respirations, with retraction of the respiratory muscles. What will the nurse do first to improve this patient's ineffective breathing pattern? Select one: A. Keep the nasal passages patent B. Prevent a respiratory infection C. Administer oxygen D. Raise the bed at least 30°
D. Raise the bed at least 30° Although any of these interventions may be appropriate at one point or another, raising the bed is the most immediate, effective intervention. The nurse will need to receive an order from the physician for oxygen. Preventing infection and keeping nasal passages patent are not going to help the patient who is experiencing respiratory distress.
An older adult patient with HF is being discharged home on an ACE inhibitor and a loop diuretic. The patient's most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this patient's subsequent care, what nursing diagnosis should be identified? Select one: A. Risk for fluid volume excess related to medication regimen B. Risk for ineffective breathing pattern related to hypoxia C. Risk for ineffective tissue perfusion related to dysrhythmia D. Risk for falls related to hypotension
D. Risk for falls related to hypotension The combination of low BP, diuretic use, and ACE inhibitor use constitute a risk for falls. There is no evidence, or heightened risk, of dysrhythmia. The patient's medications create a risk for fluid deficit, not fluid excess. Hypoxia is a risk for all patients with HF, but this is not in evidence for this patient at this time.
A student nurse is developing a teaching plan for an adult patient with asthma. Which teaching point should have the highest priority in the plan of care that the student is developing? Select one: A. Avoid goose-down pillows. B. Gradually increase levels of physical exertion. C. Change filters on heaters and air conditioners frequently. D. Take prescribed medications as scheduled.
D. Take prescribed medications as scheduled. Although all of the measures are appropriate for a client with asthma, taking prescribed medications on time is the most important measure in preventing asthma attacks.
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? Select one: A. Apply a tourniquet for 3 to 5 minutes and then reassess. B. Elevate the extremity and attempt to palpate the pulses. C. Have the primary care provider order a CT. D. Use Doppler ultrasound to identify the pulses.
D. Use Doppler ultrasound to identify the pulses. When pulses cannot be reliably palpated, a hand-held continuous wave (CW) Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels. CT is not normally warranted and the application of a tourniquet poses health risks and will not aid assessment. Elevating the extremity would make palpation more difficult.
A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurse's preceptor is going over the patient's past lab reports with the new nurse. The nurse takes note that the patient's PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurse's best response? Select one: A. Oxygen will increase the patient's intracranial pressure and create confusion. B. Oxygen may cause the patient to hyperventilate and become acidotic. C. The patient's calcium will rise dramatically due to pituitary stimulation. D. Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.
D. Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. When PaCO2 chronically exceeds 50 mm Hg, it creates insensitivity to CO2 in the respiratory medulla, and the use of oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. No information indicates the patient's calcium will rise dramatically due to pituitary stimulation. No feedback system that oxygen stimulates would create an increase in the patient's intracranial pressure and create confusion. Increasing the oxygen would not stimulate the patient to hyperventilate and become acidotic; rather, it would cause hypoventilation and acidosis.
An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. What should the nurse suggest as a proactive preventative measure for varicose veins? Select one: A. Wear snug-fitting ankle socks to decrease edema. B. Sit with crossed legs for a few minutes each hour to promote relaxation. C. Elevate the legs when tired. D. Walk for several minutes every hour to promote circulation.
D. Walk for several minutes every hour to promote circulation. A proactive approach to preventing varicose veins would be to walk for several minutes every hour to promote circulation. Sitting with crossed legs may promote relaxation, but it is contraindicated for patients with, or at risk for, varicose veins. Elevating the legs only helps blood passively return to the heart and does not help maintain the competency of the valves in the veins. Wearing tight ankle socks is contraindicated for patients with, or at risk for, varicose veins; socks that are below the muscles of the calf do not promote venous return, the socks simply capture the blood and promote venous stasis.
A nurse's assessment reveals that a client with COPD may be experiencing bronchospasm. What assessment finding would suggest that the patient is experiencing bronchospasm? Select one: A. Fine or coarse crackles on auscultation B. Slow, deliberate respirations C. Reduced respiratory rate or lethargy D. Wheezes or diminished breath sounds on auscultation
D. Wheezes or diminished breath sounds on auscultation Wheezing and diminished breath sounds are consistent with bronchospasm. Crackles are usually attributable to other respiratory or cardiac pathologies. Bronchospasm usually results in rapid, inefficient breathing and agitation.
