260 week 6-10
Which clinical manifestation occurs when the vertebral artery is affected by a stroke? -Global aphasia -Contralateral paralysis -Stupor -Dysphagia
Dysphagia
The nurse is providing care to a pregnant client with a blood pressure of 180/100 mmHg at 18 weeks gestation. Which diagnosis does the nurse anticipate for this client? -Gestational hypertension -Chronic hypertension -Preeclampsia -Eclampsia
Chronic hypertension
While caring for a client recovering from an appendectomy, the nurse monitors urine output, intravenous fluid intake, and the amount of nasogastric drainage. Which nursing diagnosis is the nurse using to guide this client's care? -Risk for infection -Alteration in perfusion and oxygenation -Acute pain -Risk for deficient fluid volume
-Risk for deficient fluid volume
Plethysmography
any technique for measuring changes in the volume of blood in a part of the body
A nurse is planning client teaching for a client with hypertension. The client's cholesterol is elevated. What instructions by the nurse would help the client lower cholesterol levels? -Eat a diet low in saturated fat -Exercise occasionally for 15 to 30 minutes per sessi -Practice smoking cessation -Participate in stress reduction
Eat a diet low in saturated fat
What occurs in the pathophysiology of emphysema? (Select all that apply.) -Enlargement of the alveoli -Decrease in cilia function -Fluid buildup in the lungs -Elastic recoil of the lungs is lost. -Excessive mucus is produced
Enlargement of the alveoli Elastic recoil of the lungs is lost.
A nurse is caring for a client with inflammatory bowel disease and is planning for the most appropriate client interventions. Which nursing diagnosis best supports the interventions needed for the client with inflammatory bowel disease? (Select all that apply.) -Risk for injury -Risk for deficient fluid volume -Constipation -Acute confusion -Diarrhea
-Risk for deficient fluid volume -Constipation -Diarrhea
Which muscles of respiration are considered accessory muscles? (Select all that apply.) -Rectus femoris -Scalene -Sternohyoid -Sternocleidomastoid -Trapezius
-Scalene -Sternocleidomastoid -Trapezius
Eighteen month old Jeremy Young is brought to the emergency department by his mother. After seeing Jeremy, the nurse suspects Jeremy has bronchiolitis. What manifestation did Jeremy demonstrate for the nurse to come to this conclusion? -Diarrhea -Bruising -Wheezing -Cool skin
Wheezing
The nurse is interviewing and educating a client about anatomy and knows that the ribs and muscles surround the thorax, or the chest. What explanation by the nurse would describe the primary purpose of the ribs in the chest? -To protect the lungs from external injury -To push the lungs during deflation -To aid in inspiration -To aid in exhalation
-To protect the lungs from external injury
Hemoptysis
coughing up blood
The nurse is preparing a plan of care for an infant diagnosed with acute bronchiolitis due to respiratory syncytial virus (RSV). Which nursing diagnosis should the nurse select to guide this infant's care? -Potential for tissue perfusion changes -Impaired pain response -Reduced activity tolerance -Alteration in cardiac output
Reduced activity tolerance
A client with a history of DVT reports a sudden onset of severe pain in the pelvis. Which diagnostic test should the nurse expect to be prescribed for this client? -Magnetic resonance imaging -Ascending contrast venography -Duplex venous ultrasonography -Plethysmography
Magnetic resonance imaging
The nurse is admitting a client with ulcerative colitis who is scheduled for surgery. The client tells the nurse that he is having his bowel removed and will have a temporary ostomy for 2 to 3 months. Which upcoming surgical procedure is the client describing? -Gastric resection -Pyloroplasty -Strictureplasty -Total colectomy ileal pouch-anal anastomosis (IPAA)
-Total colectomy ileal pouch-anal anastomosis (IPAA)
The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who needs an artificial airway to assist in maintaining an open airway. Which airway can the nurse anticipate being placed forlong-term management? -Oropharyngeal -Tracheostomy -Endotracheal -Nasopharyngeal
-Tracheostomy
The nurse is caring for a client with a pneumothorax. Based on the client's history, which is the most likely cause for this alteration in oxygenation? -Trauma -Obesity -Asthma -Pneumonia
-Trauma
A client is experiencing chest pain. What aggravating factors for this client should the nurse assess? (Select all that apply.) -How many minutes does the chest pain last? -What have you done that relieves the chest pain? -Is the chest pain continuous or episodic? -Does the chest pain change with breathing? -Does the chest pain change with activity?
-Does the chest pain change with breathing? -Does the chest pain change with activity?
Where is the most common site for peptic ulcers to develop? -Large intestine -Stomach -Esophagus -Duodenum
-Duodenum
A community health nurse is educating a group of adults on the prevention of pulmonary embolism (PE). Which statement will the nurse include in the teaching regarding the best way to decrease the risk of developing PE? -"It is best to work out daily." -"It is best not to work in a sedentary job." -"It is best not to have a family history of heart disease." -"It is best to stop smoking."
"It is best to stop smoking."
You are assisting in the treatment of Mr. Wendell for secondary hypertension. During your assessment of him, he tells you that he smokes a pack of cigarettes per day and has two to three 12-oz cans of beer to relax after work each day. What is your best response when teaching Mr. Wendell about how to improve his hypertensive condition? -"Stop smoking and limit alcohol intake to one drink per day." -"Reduce your smoking and drink no more than 8 to 12 oz of beer per day." -"Cut your smoking and alcohol consumption in half." -"Stop smoking and drink no more than 24 to 30 oz of beer per day."
"Stop smoking and limit alcohol intake to one drink per day."
Which clinical manifestations occur with asthma? (Select all that apply.) -Dyspnea -Retractions -Anxiety -Wheezing -Bradycardia
-Dyspnea -Retractions -Anxiety -Wheezing
The nurse is caring for an adult client with asthma. Which clinical manifestations of asthma should the nurse expect to see? (Select all that apply.) -Dyspnea -Wheezing -Cough -Retractions -Bradycardia
-Dyspnea -Wheezing -Cough -Retractions
The nurse is providing care to a client admitted to the coronary care unit for a suspected heart attack. Which diagnostic tests does the nurse anticipate to confirm the diagnosis? (Select all that apply.) -ECG -CBC -WBC -CPK -CK-MB
-ECG -CPK -CK-MB
A 16-year-old female client is brought to the emergency department experiencing severe right lower quadrant abdominal pain. In addition to appendicitis, which other health problems will the nurse also assess for during the examination? (Select all that apply.) -Kidney stone -Ectopic pregnancy -Mittelschmerz -Fecalith -Pelvic inflammatory disease
-Ectopic pregnancy -Mittelschmerz -Pelvic inflammatory disease
What are common manifestations of heart failure? (Select all that apply.) -Edema -Paroxysmal nocturnal dyspnea -Dyspnea at rest -Nocturia -Weight loss
-Edema -Paroxysmal nocturnal dyspnea -Dyspnea at rest -Nocturia
An adult client returns from the postanesthesia care unit (PACU) following a laparoscopic appendectomy. The nurse checks the postoperative notes and determines which factor is most important with regard to the client's immediate oxygenation status? -Amount of narcotics the client received over the last 4 hr -Amount of drainage on the surgical dressings in the last 1 hr -Amount of intravenous fluid infused over the last 2 hr -Amount of urine output over the past 4 hr
-Amount of narcotics the client received over the last 4 hr
Which action helps prevent development of a DVT? (Select all that apply.) -Avoiding prolonged sitting -Avoiding tight-fitting clothing or stockings -Avoiding crossing the legs -Avoiding extreme exercise -Avoiding prolonged standing
-Avoiding prolonged sitting -Avoiding tight-fitting clothing or stockings -Avoiding crossing the legs -Avoiding prolonged standing
What is assessed during the physical examination of a client with a DVT? (Select all that apply.) -Edema of the affected extremity -Redness of the affected extremity -Muscle atrophy of the affected extremity -Warmth on palpation -Body temperature
-Edema of the affected extremity -Redness of the affected extremity -Warmth on palpation -Body temperature
The nurse is caring for a client receiving tube feedings. Which intervention can decrease the risk of this client developing acute respiratory distress syndrome (ARDS)? -Suggest that the client become NPO -Administer prophylactic antibiotics per order -Elevate the head of the bed during feedings -Order an x-ray to verify placement of the tube
-Elevate the head of the bed during feedings
Which nursing interventions will the nurse implement to promote tissue perfusion for the client with peripheral vascular disease (PVD)? (Select all that apply.) -Encourage exercise -Encourage frequent position change -Keep lower extremities warm -Elevate lower extremities -Assess peripheral pulses
-Encourage exercise -Encourage frequent position change -Keep lower extremities warm -Assess peripheral pulses
Why are pregnant clients prone to developing supine hypotension? -Insufficient red blood cells in proportion to volume of plasma -Increase in blood flow to the developing fetus -Enlarging uterus pressing on the vena cava -Pooling of blood in the lower extremities
-Enlarging uterus pressing on the vena cava
The nurse is caring for a client with a thoracic catheter, also known as a chest tube. Which interventions are appropriate for this client? (Select all that apply.) -Ensuring oxygen is available -Monitoring for air leaks -Reporting hyperresonance with percussion -Assessing for pain -Prescribing prn pain medications
-Ensuring oxygen is available -Monitoring for air leaks -Assessing for pain
The nurse is caring for a client who is receiving oxygen. Which intervention is appropriate by the nurse? -Increasing the flow if the client requests -Ensuring the client is comfortable with the manner of administration -Suctioning upper airways each shift -Assessing the client for anxiety
-Ensuring the client is comfortable with the manner of administration
A nurse is caring for a client with nephritis who also has ascites due to excess fluid volume. Which action by the nurse is the best way to monitor the client's degree of ascites? -Monitor blood pressure -Measure CVP -Measure abdominal girth -Monitor intake and output
-Measure abdominal girth
While waiting for morning report, the nurse is called to help in the room of a client with an alteration in perfusion. Which actions can the nurse perform independently? (Select all that apply.) -Measure urine output -Administer a dose of a nitrate -Explain why the client is on a no-added-salt diet -Measure peripheral blood pressure -Assess radial pulse
-Measure urine output -Explain why the client is on a no-added-salt diet -Measure peripheral blood pressure -Assess radial pulse
Which nursing interventions are included in the care of a client with acute respiratory distress syndrome (ARDS)? (Select all that apply.) -Treating with suction as needed -Prescribing surfactant therapy -Obtaining sputum culture -Maintaining head of the bed at less than 30 degrees -Positioning the client in a prone position for 60 minutes five times a day
-Treating with suction as needed -Obtaining sputum culture
A client with cardiovascular disease has a new onset of lethargy. Assessment data includes a blood pH of 7.31 and a respiratory rate of 8 breaths per minute. What should the nurse do to help this client? (Select all that apply.) -Measure urine output -Provide rest periods between activities -Review medications for analgesics provided -Raise the head of the bed -Assess for jugular vein distention
-Measure urine output -Review medications for analgesics provided
The nurse is caring for a client with asthma who is having difficulty breathing while lying supine, can only talk in phrases without experiencing shortness of breath, and has a moderately elevated respiratory rate. Based on these assessment findings, what is the severity of this client's asthma attack? -Minimal -Mild -Moderate -Severe
-Mild
The nurse is planning care for a client in the early stages of ulcerative colitis. The nurse understands that which part of the colon is initially affected by ulcerative colitis? -Rectosigmoid area -Ileocecal junction -Duodenum -Transverse colon
-Rectosigmoid area
Which heart murmurs are intensified with inspiration? (Select all that apply.) -Tricuspid stenosis -Aortic regurgitation -Tricuspid regurgitation -Pulmonic regurgitation -Pulmonary stenosis
-Tricuspid stenosis -Tricuspid regurgitation -Pulmonic regurgitation -Pulmonary stenosis
An older adult is using an inhaled corticosteroid for long-term management of persistent asthma. Which rationale is correct for using steroids in clients with asthma? -Act as an expectorant -Promote bronchodilation -Reduce inflammation -Prevent the development of respiratory infections
-Reduce inflammation
The nurse is preparing teaching materials for the parents of a 7-year-old child newly diagnosed with a severe allergy to dust. What should the nurse include in this teaching? -Remove stuffed toys from the home. -Avoid exposure to all animals and pets. -Ensure all rooms in the home are carpeted. -Place plants on high shelves in the home.
-Remove stuffed toys from the home.
An 8-year-old child is scheduled for an invasive diagnostic procedure. What should the nurse do to prepare this child for the test? (Select all that apply.) - Teach the parents about the test. -Remind the child that only grownups get this test. -Teach the child about the test. -Discuss the use of anesthesia with the healthcare provider. -Encourage the parents to attend during the test.
- Teach the parents about the test. -Teach the child about the test. -Discuss the use of anesthesia with the healthcare provider. -Encourage the parents to attend during the test.
While conducting a health history, the nurse determines that a client is at risk for developing an inflammatory disorder. What did the nurse most likely assess during the health history? (Select all that apply.) - Treated for peptic ulcer disease within the last year. -Treated with antispasmodics for back strain 3 months ago. - Received surgery for carpal tunnel syndrome 2 years ago. -Hospitalized with gallstones 6 months ago. -Experiences allergic rhinitis every spring and fall.
- Treated for peptic ulcer disease within the last year. -Hospitalized with gallstones 6 months ago. -Experiences allergic rhinitis every spring and fall.
Which nursing diagnosis is used to guide the care for a client with a DVT? (Select all that apply.) -Ineffective oxygenation -Alterations in comfort -Impaired tissue perfusion -Potential for ineffective protection -Increased risk for impaired physical mobility
-Alterations in comfort -Impaired tissue perfusion -Potential for ineffective protection -Increased risk for impaired physical mobility
Mr. Cosgrove has developed acute respiratory distress syndrome (ARDS) as a complication of overall body sepsis. He has sustained alveolar collapse and respiratory acidosis is developing. What event in the pathophysiology of ARDS would you expect next if Mr. Cosgrove receives no respiratory support? -Respiratory failure -Loss of surfactant -Fluid enters the alveoli -Formation of hyaline membranes
-Respiratory failure
A 30-year-old female client is seen in the clinic for a wellness checkup. The client states that her mother had a stroke recently. The client asks the nurse about risk factors for stroke. Which risk factors would the nurse consider pertinent for this particular client? (Select all that apply.) -Sedentary lifestyle -Oral contraceptive use -Menopause -Insomnia -Family history of stroke
-Sedentary lifestyle -Oral contraceptive use -Family history of stroke
The nurse is identifying goals of care with a client seeking treatment for appendicitis. Which outcomes are appropriate for the nurse to include in the plan of care? (Select all that apply.) -Abdominal pain will be relieved with pain medication. -Questions about surgical procedure will be addressed. -The abdominal wound will heal without infection. -Perfusion status will improve after surgery. -Fluid and electrolyte balance will be maintained.
-Abdominal pain will be relieved with pain medication. -Questions about surgical procedure will be addressed. -The abdominal wound will heal without infection. -Fluid and electrolyte balance will be maintained.
Which risk factors contribute to the development of appendicitis? (Select all that apply.) -Age less than 4 years -Adolescent male -Low-fiber diet -High-carbohydrate diet -Caucasian race
-Adolescent male -Low-fiber diet -High-carbohydrate diet
Which are nonmodifiable risk factors for the development of cardiac disorders? (Select all that apply.) -Age -Obesity -Smoking -Race -Gender
-Age -Race -Gender
Ms. Campos is a 38-year old woman who has a chronic cough but does not show symptoms of wheezing or dyspnea. She has seen many healthcare providers but has never been diagnosed with asthma. Her new healthcare provider suspects that Ms. Campos has asthma. What other symptom would help confirm that Ms. Campos has asthma? -Nausea -Weight loss -Sneezing -Airway inflammation
-Airway inflammation
A nurse is caring for a client with Goodpasture syndrome who recently had plasmapheresis for treatment of this condition. The nurse notes petechiae and bruising to the client's abdomen and face. Which potential complication of plasmapheresis does the nurse suspect? -Alteration of fluid volume -Alteration of immunity -Alteration of skin integrity -Alteration of coagulation
-Alteration of coagulation
A nurse is caring for a client with congestive heart failure (CHF) who has recently been diagnosed with peptic ulcer disease (PUD). The client takes digoxin to manage symptoms associated with CHF. The healthcare provider has ordered antacids for the client to help heal the gastric mucosa as a result of PUD. What is true regarding antacids and digoxin? -Antacids absorb digoxin's therapeutic effect. -Antacids cancel all therapeutic effects of digoxin. -Antacids interfere with the absorption of digoxin. -Antacids do not affect digoxin.
-Antacids interfere with the absorption of digoxin
The nurse is caring for a client is admitted for a burst appendix. Which information is appropriate for the nurse to provide to this client? (Select all that apply.) -Antibiotic medication will be provided before and after the surgery. -A laparoscopic appendectomy will be performed. -Intravenous fluids will be provided. -Pain medication will be provided after the surgery. -A laparotomy will be performed.
-Antibiotic medication will be provided before and after the surgery. -Intravenous fluids will be provided. -Pain medication will be provided after the surgery. -A laparotomy will be performed.
A client is admitted for cholelithiasis. The client is not a surgical candidate at this time. Which pharmacologic treatments can be used for this client with cholelithiasis? (Select all that apply.) -Antibiotics -Ursodiol -Chenodiol -Cholecystectomy -Cholestyramine
-Antibiotics -Ursodiol -Chenodiol -Cholestyramine
A client with asthma is taking an inhaler that blocks parasympathetic input to bronchial smooth muscles. Which class of medication is this client taking for asthma control? -Adrenergic stimulant -Leukotriene modifier -Methylxanthine -Anticholinergic agent
-Anticholinergic agent
You are performing a physical assessment of Mrs. Gupta, a70-year-old woman who is being admitted to the hospital for acute respiratory distress syndrome (ARDS). Mrs. Gupta is confined to bed because of her illness. Which medication do you anticipate will be prescribed by the healthcareprovider? -Inhaled nitric oxide therapy -Surfactant therapy -Corticosteroid therapy -Anticoagulant therapy
-Anticoagulant therapy
The nurse is preparing teaching material for a client newly diagnosed with coronary artery disease. What should the nurse include when explaining the disease process to the client? (Select all that apply.) -Aortic pressure controls the flow of blood through these vessels. -It is a high-pressure system needed to move oxygenated blood to body tissues. -The coronary vessels supply oxygen and nutrients to the heart muscle. -It is a low-pressure system that begins with the right side of the heart. -Heart rate controls the flow of blood through these vessels.
-Aortic pressure controls the flow of blood through these vessels. -The coronary vessels supply oxygen and nutrients to the heart muscle. -Heart rate controls the flow of blood through these vessels.
The nurse is caring for a postoperative client who has limited mobility. Which assessment finding should the nurse report as a possible sign of a pending DVT? (Select all that apply.) -Area of redness along a left lower leg vein -Swelling of the left lower leg -Muscle twitching of the left thigh -Pale skin color of the left lower leg -Aching of the left calf
-Area of redness along a left lower leg vein -Swelling of the left lower leg -Pale skin color of the left lower leg -Aching of the left calf
Which is the most common inflammatory disorder in the United States? -Appendicitis -Arthritis -Ulcerative colitis -Nephritis
-Arthritis
The nurse is planning care for a client with limited knee function due to arthritis. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) -Assess pain level and provide medication as prescribed. -Encourage rest of the affected joint. -Provide antipyretics as prescribed. -Provide antiarthritis medications as prescribed. -Encourage participation in physical therapy as prescribed.
-Assess pain level and provide medication as prescribed. -Encourage rest of the affected joint. -Provide antiarthritis medications as prescribed. -Encourage participation in physical therapy as prescribed.
Which are skills used to provide care to a client with an alteration in perfusion? (Select all that apply.) -Assess peripheral pulses -Evaluate laboratory values after fluid administration -Interpret electrocardiogram tracing -Apply elastic compression stockings -Measure peripheral blood pressure
-Assess peripheral pulses -Interpret electrocardiogram tracing -Apply elastic compression stockings -Measure peripheral blood pressure
A client with acute cholecystitis is experiencing nausea and vomiting. Which nursing actions address this client's nutritional status? (Select all that apply.) -Assessing height and weight -Administering antiemetics per order -Counseling regarding low-fat menu choices -Reviewing serum electrolytes -Counseling on options for medical vs. surgical management
-Assessing height and weight -Administering antiemetics per order -Counseling regarding low-fat menu choices -Reviewing serum electrolytes
What can be done to ensure comfort during the physical assessment of the cardiovascular system? (Select all that apply.) -Assist with position changes -Warm the stethoscope -Reduce environmental noise -Use standard precautions -Ensure adequate draping
-Assist with position changes -Warm the stethoscope -Ensure adequate draping
A nurse is providing care to a client diagnosed with heart failure. Which interventions should the nurse implement when monitoring the client's fluid volume? (Select all that apply.) -Allow for rest periods. -Auscultate lung sounds every 4 hours. -Weigh the client daily. -Monitor intake and output. -Record hourly urine outputs.
-Auscultate lung sounds every 4 hours. -Weigh the client daily. -Monitor intake and output. -Record hourly urine outputs.
The nurse is providing care to a client with acute respiratory distress syndrome (ARDS). Which interventions can the nurse perform independently with this client? (Select all that apply.) -Prescribing analgesia for pain -Ordering a Foley catheter to monitor urine output -Auscultating heart and lung sounds -Maintaining the head of the bed at 30 degrees -Recommending a prone position to facilitate oxygenation
-Auscultating heart and lung sounds -Maintaining the head of the bed at 30 degrees -Recommending a prone position to facilitate oxygenation
A nurse is participating in a free community health clinic. Which clients will the nurse identify as being at risk for compromised oxygenation? (Select all that apply.) -A 56-year-old male who has been working at a textile factory -A 64-year-old female with osteoporosis and limited mobility -A 28-year-old male who smokes with a 10-pack/year history -A 70-year-old female who eats a well-balanced diet and exercises daily -A 46-year-old female with a history of anxiety attacks
-A 56-year-old male who has been working at a textile factory -A 64-year-old female with osteoporosis and limited mobility -A 28-year-old male who smokes with a 10-pack/year history -A 46-year-old female with a history of anxiety attacks
The nurse is caring for a client diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which clinical findings would indicate that the client is experiencing emphysema? (Select all that apply.) -Cough with copious amounts of sputum -Barrel chest -Use of accessory muscles when breathing -Diminished breath sounds -Hypercapnia noted within laboratory results
-Barrel chest -Use of accessory muscles when breathing -Diminished breath sounds
A nurse is caring for a client with peptic ulcer disease (PUD) who asks the nurse, open double quoteI don't understand how I can help to prevent my ulcers from recurring.close double quote What is the nurse's best response? (Select all that apply.) -Eliminate all alcohol intake. -Be cautious with your intake of over-the-counter pain medications. -Stop smoking. -Eliminate all high-fat foods from your diet. -Reduce your stress as much as possible.
-Be cautious with your intake of over-the-counter pain medications. -Stop smoking. -Reduce your stress as much as possible.
You and Mrs. Cochran are discussing how some common types of asthma medications work. Which is her best description of beclomethasone (Beconase)? -Beconase is a bronchodilator that is chemically just like coffee. -Beconase is one of those medications that block that rest-and-digest response. -Beconase prevents the mast cells in my lungs from releasing histamine and causing more inflammation. -Beconase is the one I inhale that prevents my lungs from becoming inflamed.
-Beconase is the one I inhale that prevents my lungs from becoming inflamed.
When does the onset of ulcerative colitis most commonly occur? -Between the ages of 5 and 15 years -Between the ages of 30 and 60 years -Between the ages of 15 and 30 years -Between the ages of 25 and 55 years
-Between the ages of 15 and 30 years
The nurse is questioning a client with Crohn disease about the presence of current symptoms. Which symptoms would the nurse find in the client? (Select all that apply.) -Blood in the stool -Left lower quadrant abdominal pain relieved by defecation -Persistent diarrhea -Malaise -Fissures, ulcers, fistulas, and abscesses of the anorectal area
-Blood in the stool -Persistent diarrhea -Malaise -Fissures, ulcers, fistulas, and abscesses of the anorectal area
The nurse observes unlicensed assistive personnel measuring a client's blood pressure and is concerned that the reading is erroneously high. Which factors could have resulted in an erroneously high reading? (Select all that apply.) -Blood pressure was assessed while the client was eating breakfast. -Blood pressure cuff was wrapped too loosely. -Client's arm was above the level of the heart. -Blood pressure cuff was too wide. -Client's arm was unsupported.
-Blood pressure was assessed while the client was eating breakfast. -Blood pressure cuff was wrapped too loosely. -Client's arm was unsupported.
At the completion of a health history and physical assessment, the nurse is concerned that a middle-aged adult client is at risk for developing cardiovascular disease. What did the nurse most likely assess in this client? (Select all that apply.) -Fasting blood glucose 86 mg/dL -Plays racquet ball 4 times a week for 1 hour -Blood pressure 158/96 mmHg -Smokes 1 pack per day of cigarettes -Body mass index 31.4
-Blood pressure 158/96 mmHg -Smokes 1 pack per day of cigarettes -Body mass index 31.4
The nurse notes that a client is prescribed a dietary consult as part of treatment for inflammation. What should the nurse expect to assess in this client? -Reduction in pedal pulses -Body mass index 42 -Blood pressure 148/90 mmHg -Cool and mottled extremities
-Body mass index 42
During a home visit, the community health nurse becomes concerned that a 2-year-old child is at risk for contracting respiratory syncytial virus (RSV). Which observations would lead the nurse to this conclusion? (Select all that apply.) -Both parents unemployed -Both parents smoke cigarettes -Absence of soap at the kitchen sink -Toddler shares drinking cup with older brother -Toddler wearing clean but rumpled pants and shirt
-Both parents unemployed -Both parents smoke cigarettes -Absence of soap at the kitchen sink -Toddler shares drinking cup with older brother
A nurse is planning a seminar about chronic obstructive pulmonary disease (COPD). Which descriptions of the disease would the nurse include in the presentation? (Select all that apply. -COPD is a respiratory disorder that has components of chronic bronchitis and emphysema. -COPD is characterized by periodic exacerbations. -After exacerbations, the lung tissue returns to normal. -COPD exacerbations cause dyspnea and sputum production. -COPD is a mismatch between inhalation and expiration.
-COPD is a respiratory disorder that has components of chronic bronchitis and emphysema. -COPD is characterized by periodic exacerbations. -COPD exacerbations cause dyspnea and sputum production.
After completing an assessment, the nurse determines that a client with cardiovascular disease would benefit from consultations with a physical therapist, dietitian, and psychologist. Which factors support the nurse's findings? (Select all that apply.) -Client smokes 1 to 2 packs of cigarettes per day. -Client is an employee of the Internal Revenue Service. -Client sits at a desk for 10 hours each day. -Client sleeps 7 to 8 hours each night. -Client eats fast food for breakfast and lunch.
-Client smokes 1 to 2 packs of cigarettes per day. -Client is an employee of the Internal Revenue Service. -Client sits at a desk for 10 hours each day. -Client eats fast food for breakfast and lunch.
Which is the sodium limit for a client diagnosed with heart failure? -3.5d-4 g/day -2.5d-3 g/day -0.5-1 g/day -1.5-2 g/day
1.5-2 g/day
Dorothea Johnson is an 80-year-old woman who lives in a two-story townhouse with her husband Torrence. They have been married for 40 years and have no children. Mr. Johnson is a high school graduate, but she is not. Although both came from large families, they have no relatives in the area. The couple is on a fixed income and has little savings. Mrs. Johnson is a retired hair dresser; her husband recently retired as a sergeant on the police force. They are very active in their local church. Mrs. Johnson has a history of a cerebrovascular accident (CVA) two years ago that left her with right-sided weakness. She uses a cane to help her balance when walking. Mrs. Johnson's daily medications include one 2.5 mg tablet of warfarin (Coumadin), one multivitamin tablet, and one 40 mg tablet of propranolol (Inderal). As the parish nurse making a home visit, you notice several new healing bruises on Mrs. Johnson's arms and legs. When you question her, Mr. Johnson answers for her, stating that his wife is careless and frequently stumbles when she walks. He does not seem concerned. The purpose of your visit is to review the results of Mrs. Johnson's recent bone density test with her. It shows she has moderate osteoporosis. She hands you a bottle of over-the-counter vitamin and mineral pills marketed for seniors, which she says she takes once a day. You check the bottle to determine if the pills contain which necessary components related to her osteoporosis? -Vitamin C -Vitamin B -Vitamin A -Calcium -Vitamin D
-Calcium -Vitamin D
The nurse is preparing to conduct a physical examination on a client experiencing vague abdominal pain. What should the nurse include in this assessment? (Select all that apply.) -Presence of blood in the stool -Characteristics of bowel sounds -Current body temperature -Contour of the abdomen -Presence of abdominal pain on palpation
-Characteristics of bowel sounds -Current body temperature -Contour of the abdomen -Presence of abdominal pain on palpation
What diagnostic tests are appropriate to diagnose a client with chronic obstructive pulmonary disease (COPD)? (Select all that apply.) -Sweat test -Chest x-ray -Ventilationdashperfusion testing -Arterial blood gases -CBC with differential
-Chest x-ray -Ventilationdashperfusion testing -Arterial blood gases
Which symptoms of ARDS appear within 24 to 48 hours after the initial insult? (Select all that apply.) -Chest x-ray clear of infiltrates -Rapid breathing -Shortness of breath -Arterial blood gases vary from normal limits. -Fluid imbalance
-Chest x-ray clear of infiltrates -Rapid breathing -Shortness of breath
The mother of a 3-year-old child newly diagnosed with an allergy says that she has the same allergy as the child but the child seems to have worse symptoms. What should the nurse explain to the mother? -Adults have faster metabolisms than children. -Children have more chemicals that encourage inflammation. -Adults have more chemicals that encourage inflammation. -Children have more chemicals that block inflammation.
-Children have more chemicals that encourage inflammation.
An obese, Native American female is admitted for right upper quadrant pain present for the past 12 hours. A right upper quadrant ultrasound shows inflammation of the gallbladder. What is the most likely diagnosis for this client? -Choledocholithiasis -Cholecystitis -Cholelithiasis -Biliary colic
-Cholecystitis
Which medication used in the treatment of gallbladder disorders is also used for severe jaundice? -Cholestyramine (Questran) -Chenodiol (Chenix) -Ursodiol (Actigall) -Opioid analgesics
-Cholestyramine (Questran)
A client is newly diagnosed with asthma and needs information regarding possible asthma triggers. The nurse is preparing to teach the client to prevent asthma triggers. What information is appropriate for the nurse to educate the client to avoid? (Select all that apply.) -Cigarette smoke -Tile floors in the house -Indoor pets -Stuffed animals -Mattress covers
-Cigarette smoke -Indoor pets -Stuffed animals
The nurse is evaluating teaching provided to a client with chronic appendicitis. Which observation indicates that teaching has been effective? -Client walks for 30 minutes three times a week -Client meets with family or friends at least once a week -Client engages in quiet activity 1 hour before going to sleep -Client eats fruit with breakfast and a salad for lunch
-Client eats fruit with breakfast and a salad for lunch
The nurse is evaluating a client recovering at home after an emergency appendectomy. Which observations indicate that self-care has been effective? (Select all that apply.) -Client performs abdominal wound care appropriately -Client requests a prescription for more pain medication -Client snacks on pretzels and club soda during the visit -Client plans to recover at home until cleared by the surgeon -Client uses a pillow to splint incision before coughing
-Client performs abdominal wound care appropriately -Client plans to recover at home until cleared by the surgeon -Client uses a pillow to splint incision before coughing
The home care nurse is visiting a client recovering from an acute inflammation. Which observations indicate that client teaching has been effective? (Select all that apply.) -Client props left ankle on a pillow. -Client puts weight on right knee while reaching for dishes in cabinet. -Client has a cup of warm tea while reading the afternoon mail. -Client uses the knee to close silverware drawer in the kitchen. -Client applies ice to the right wrist for 10 minutes.
-Client props left ankle on a pillow. -Client has a cup of warm tea while reading the afternoon mail. -Client applies ice to the right wrist for 10 minutes.
A nurse is planning care for a client with inflammatory bowel disease. What goal or outcome is the best choice for this client? -Client's skin excoriation has not worsened. -Client's symptoms of infection have not worsened. -Client lost less than 5% of pre-illness body weight. -Client recognized the early signs of a flare up.
-Client recognized the early signs of a flare up.
The nurse plans to assess a client for inflammation. Which questions should the nurse include when interviewing this client? (Select all that apply.) -Do you take vitamins? -Did you receive the annual influenza vaccination? -What surgeries have you had? -How much exercise do you get each day? -Are you experiencing any pain?
-Do you take vitamins? -What surgeries have you had? -Are you experiencing any pain?
The nurse is planning care for a client with a DVT of the right calf. What should the nurse include in this client's plan of care? (Select all that apply.) -Coaching to perform deep breathing and coughing every 2 hours -Applying warm, moist heat to the affected area every 6 hours -Assisting to a sitting position with the legs dependent every 4 hours -Encouraging range-of-motion exercises every 2 to 4 hours -Measuring the calf and thigh diameter of the right leg every shift
-Coaching to perform deep breathing and coughing every 2 hours -Applying warm, moist heat to the affected area every 6 hours -Encouraging range-of-motion exercises every 2 to 4 hours -Measuring the calf and thigh diameter of the right leg every shift
Alicia Meritt, a 22-year-old woman with complaints of fatigue and persistent diarrhea, is suspected of having Crohn disease and is scheduled to have a colonoscopy. Which finding would Alicia's nurse expect to see from the colonoscopy if Alicia has Crohn disease? -Red, edematous, and friable tissue -Continuous inflammatory lesions of bowel -Cobblestone appearance of bowel -Inflammation that begins at the crypts of Lieberkühn in the distal large intestine and rectum
-Cobblestone appearance of bowel
A nurse is performing a nursing assessment on a client with peripheral vascular disease (PVD). Which findings will the nurse anticipate during the health history portion of the nursing assessment? (Select all that apply.) -Complaints of pain -Current medications -Presence of skin discoloration -Current diet -History of coronary artery disease (CAD)
-Complaints of pain -Current medications -Current diet -History of coronary artery disease (CAD)
During a physical assessment, the nurse becomes concerned that 75-year-old Hattie Jackson is experiencing acute appendicitis. Which assessment finding supports thisdiagnosis? -Confusion -2 cm mass in right lower abdominal quadrant -Pain with abduction of the left hip -Hyperactive bowel sounds
-Confusion
The nurse is assessing an older client with acute respiratory distress syndrome (ARDS). Which assessment findings indicate early signs of hypoxemia for this client? (Select all that apply.) -Confusion -Dyspnea -Agitation -Tachypnea -Anxiety
-Confusion -Agitation -Anxiety
The nurse is caring for a client with suspected acute glomerulonephritis. Which clinical manifestations support this suspicion? (Select all that apply.) -Crackles auscultated in lungs -Microscopic hematuria -Weight loss -Tea-colored urine -Low blood pressure
-Crackles auscultated in lungs -Microscopic hematuria -Tea-colored urine
What will be included in the health history of the client with irritable bowel disease? -Weight -Vital signs -Current medications -General appearance
-Current medications
Which manifestations occur with progressive respiratory distress for a client with acute respiratory distress syndrome (ARDS)? (Select all that apply.) -Cyanosis -Increased pulse oximetry -Decreased respiratory rate -Use of accessory muscles of respiration -Changes in mental status
-Cyanosis -Use of accessory muscles of respiration -Changes in mental status
A client is admitted to a medical floor with acute postinfection glomerulonephritis. Which medication will the nurse administer in an effort to reduce the inflammation caused by this condition? -Prednisone -Cytoxan -Hydralazine -Lisinopril
-Cytoxan
Which are manifestations of dehydration in a child with bronchiolitis? (Select all that apply.) -Delayed capillary refill -Weak peripheral pulses -Decreased urine output -Intercostal muscle retractions -Dry sticky mucous membranes
-Delayed capillary refill -Weak peripheral pulses -Decreased urine output -Dry sticky mucous membranes
Mrs. Johnson is reluctant to discuss the cause of her bruises. Which feelings or conditions would make her hesitant to confide in you? Select all that apply. -Confusion -Amnesia -Denial -Fear -Shame
-Denial -Fear -Shame
A nurse is providing education about heart failure to a community group. Which risk factors should the nurse include in the presentation? (Select all that apply.) -Diabetes mellitus -Coronary heart disease -Pituitary adenoma -Hypertension -Sleep apnea
-Diabetes mellitus -Coronary heart disease -Hyperension -Sleep apnea
A nurse is planning care for a client who is going to be admitted to the nurse's unit. The client has a diagnosis of peptic ulcer disease (PUD) and is complaining of nausea, heartburn, and epigastric pain. What nursing intervention will the nurse plan to implement? -Insert a nasogastric tube upon client admission. -Allow client to have bathroom privileges. -Listen to client's bowel sounds every shift. -Discourage the client from eating a nighttime snack.
-Discourage the client from eating a nighttime snack.
The nurse is caring for a client admitted with exacerbation of chronic obstructive pulmonary disease(COPD). The client is exhibiting symptoms of chronic bronchitis. Which symptoms did the nurse discover during the assessment process? (Select all that apply.) -Distended neck veins -Diminished breath sounds -Barrel chest -Cough with sputum production -Wheezing
-Distended neck veins -Cough with sputum production -Wheezing
A nurse is providing discharge orders for a client with peptic ulcer disease (PUD). What statement will the nurse include regarding client diet and lifestyle modifications for the prevention of PUD? -Restrict your diet to nonfat and sugar-free foods. -Do not skip any meals. -Be sure to eat a bland diet to avoid a flare-up of PUD. -You must eliminate intake of all alcohol.
-Do not skip any meals.
The nurse is caring for Shanelle Hamilton, a 35-year-old African American female being treated for exacerbation of systemic lupus erythematosus. What should the nurse teach Ms. Hamilton about the prescribed medication dexamethasone? -Do not stop taking this medication. -Notify the healthcare provider if bruising or nosebleeds occur. -Remember to get the live flu vaccination in the autumn. -Take on an empty stomach.
-Do not stop taking this medication.
A client telephones the health clinic with complaints of vague abdominal pain. The client has not been able to eat for a day and is nauseated. What advice should the nurse provide to thisclient? -Rest in bed and drink warm fluids -Seek immediate medical attention -Take an over-the-counter laxative -Take a warm shower and apply a heating pad to the abdomen
-Seek immediate medical attention
The nurse is discussing the incidence of inflammatory bowel disease with a group of nursing students. Which information would the nurse include in the discussion? (Select all that apply.) -Environmental factors can contribute to the etiology of chronic inflammatory bowel disease. -The peak incidence of the disease is in adolescence and young adulthood. -The disease is often linked to heredity. -Chronic inflammatory bowel disease does not affect older adults. -The disease occurs more frequently in the United States and northern European nations.
-Environmental factors can contribute to the etiology of chronic inflammatory bowel disease. -The peak incidence of the disease is in adolescence and young adulthood. -The disease is often linked to heredity. -The disease occurs more frequently in the United States and northern European nations.
Which diagnostic test is a general indicator of inflammation and may be elevated in acute postinfection glomerulonephritis and in lupus nephritis? -BUN -Antistreptolysin O (ASO) titer -Erythrocyte sedimentation rate (ESR) -Creatinine clearance
-Erythrocyte sedimentation rate (ESR)
Which structures are contained within the mediastinum? (Select all that apply.) -Esophagus -Trachea -Lungs -Pleural membranes -Heart
-Esophagus -Trachea -Heart
Which symptom is associated with the classification of moderate persistent asthma? -Client is asymptomatic between attacks. -Attacks occur more than twice a week but less than daily. -Exacerbations occur more than twice a week and can last for days. -Client has limited physical activity.
-Exacerbations occur more than twice a week and can last for days.
A community health nurse is educating a group of adults about the risk factors associated with peripheral vascular disease (PVD) and chronic venous insufficiency (CVI). Which factors will the nurse include as those factors that increase the risk for developing CVI or PVD? (Select all that apply.) -Male gender -Excess body weight -Age 45 or older -Physical inactivity -Increased cholesterol levels
-Excess body weight -Physical inactivity -Increased cholesterol levels
Which factors are present in the formation of gallstones? (Select all that apply.) -Excess cholesterol -Abnormal bile composition -Inflammation of the gallbladder -Biliary stasis -Rapid weight gain
-Excess cholesterol -Abnormal bile composition -Inflammation of the gallbladder -Biliary stasis
A middle-aged obese woman presents with right upper quadrant abdominal pain present for the past several hours. The nurse suspects that the client is at risk for the formation of gallstones. Which risk factors will the nurse assess this client for during the health history? (Select all that apply.) -Excess cholesterol -Inflammation of the gallbladder -Abnormal bile composition -Biliary colic -Biliary stasis
-Excess cholesterol -Inflammation of the gallbladder -Abnormal bile composition -Biliary stasis
A client is admitted with cholecystitis and is scheduled for surgery in the morning. The client asks about risk factors for developing cholecystitis. Which risk factors for developing cholecystitis would the nurse indicate to the client? (Select all that apply.) -Family history of gallstones -Male gender -Hyperlipidemia -Ethnicity -Obesity
-Family history of gallstones -Hyperlipidemia -Ethnicity -Obesity
Which are nonmodifiable risk factors for the development of asthma? (Select all that apply.) -Female age 16 years -Asian American culture -African American race -Positive family history -Male age 4 years
-Female age 16 years -African American race -Male age 4 years
How is appendicitis classified? (Select all that apply.) -Gangrenous -Infected -Inflamed -Perforated -Simple
-Gangrenous -Perforated -Simple
What is true regarding the diagnostic testing used for peptic ulcer disease (PUD)? -Gastroscopy allows visualization of the esophageal, gastric, and duodenal mucosa, and direct inspection of ulcers. -The upper GI series requires sedation. -In Zollinger-Ellison syndrome, gastric acid levels are decreased. -The gastric analysis can detect 80%-90% of peptic ulcers via x-ray.
-Gastroscopy allows visualization of the esophageal, gastric, and duodenal mucosa, and direct inspection of ulcers.
You continue to assess Mr. Goodings health history. He reports he is more fatigued than usual but states he has also been working more due to the tax season. He has also been waking up with headaches and reports occasional dizziness when he gets up out of bed. He says, I have been checking my blood pressure over the past couple months. I noticed it was running a little high, but I was not too concerned because I have not had any symptoms of high blood pressure. Which signs or symptoms that Mr. Gooding has reported could be indicative of high blood pressure? Select all that apply. -Headaches -Blurred vision -Hypertension never has any symptoms -Confusion -Dizziness
-Headaches -Blurred vision -Dizziness
The nurse is providing care to a client with uncontrolled hypertension. Based on this diagnosis, which heath problems is the client at risk for developing? (Select all that apply.) -Heart failure -Liver failure -Stroke -Diabetes mellitus -Coronary artery disease
-Heart failure -Stroke -Coronary artery disease
The nurse is teaching the parents of a 3-year-old child with respiratory syncytial virus (RSV) on ways to help the child recover quickly from the disorder. What should the nurse include in this teaching? (Select all that apply.) -Help the child to blow the nose to clear the airway -Provide frequent small meals throughout the day -Limit visits by other friends until the infection clears -Wash hands thoroughly after caring for the child -Permit the child to rest and nap throughout the day
-Help the child to blow the nose to clear the airway -Provide frequent small meals throughout the day -Wash hands thoroughly after caring for the child -Permit the child to rest and nap throughout the day
A nurse is caring for Taraj Singh, a 5-year-old child who was recently diagnosed with strep throat and treated. However, a week after Taraj's strep throat diagnosis, Taraj began complaining of a severe headache and Taraj's mother noticed Taraj had a swollen face. Taraj's healthcare provider has diagnosed Taraj with acute postinfection glomerulonephritis. Which additional manifestation will Taraj's nurse expect to find upon physical assessment? -Glucosuria -Muscle spasms -ECG abnormalities -Hematuria
-Hematuria
A nurse is preparing educational materials for a community health fair concerning stroke. What information would the nurse include about the causes of hemorrhagic stroke? (Select all that apply.) -Hemorrhagic stroke can be caused by a ruptured aneurysm in the brain. -Hemorrhagic stroke can be caused by damage to the blood-brain barrier -Hemorrhagic stroke can be caused by rupture of a fragile arterial vessel in the brain. -Hemorrhagic stroke can be caused by an atherosclerotic plaque breaking off in the artery. -Hemorrhagic stroke can be caused by traumatic injury to the brain, such as a fall.
-Hemorrhagic stroke can be caused by a ruptured aneurysm in the brain. -Hemorrhagic stroke can be caused by rupture of a fragile arterial vessel in the brain. -Hemorrhagic stroke can be caused by traumatic injury to the brain, such as a fall.
Which pharmacologic therapy is used in the treatment of peptic ulcer disease (PUD) for reducing gastric acid content? -Sucralfate -Bismuth compounds -Antacids -Histamine2-receptor blockers
-Histamine2-receptor blockers
A nurse is performing a nursing assessment on a client with a pulmonary embolism (PE). Which assessments will the nurse anticipate during the health history portion of the nursing assessment? (Select all that apply.) -Degree of edema -History of DVT -Current medications -Recent surgeries -Quality of apical pulse
-History of DVT -Current medications -Recent surgeries
A nurse is caring for Maria Lopez, a 68-year-old female who presents to the hospital in a hypertensive crisis. Ms. Lopez's healthcare provider has ruled out a neurological cause for her symptoms and now suspects that Ms. Lopez may be suffering from nephritis. Ms. Lopez's nurse is performing a focused exam and is now performing Ms. Lopez's health history intake. Which factor would the nurse suspect as being related to the possible diagnosis of nephritis? -Weight loss of 10 pounds over last 2 months -Upper back or shoulder pain -History of a nonhealing skin infection -Muscle wasting or flaccidity
-History of a nonhealing skin infection
A nurse is caring for Jeret Sudiki, a 72-year-old man who has been diagnosed with a pulmonary embolism after presenting to the emergency department with sudden shortness of breath. Jeret's nurse is anticipating that the health care provider will order fibrinolytic therapy in the collaborative treatment of Jeret's condition. Which manifestation or past medical history is a contraindication of this therapy for Jeret? -History of COPD -History of intracranial bleeding -Blood pressure of 140/84 -Blood sugar of 200 mg/dL
-History of intracranial bleeding
Mr. Gooding returns to the clinic after 2 months. You previously educated him on lifestyle modification to manage his primary hypertension. He has been keeping a log of his blood pressure readings. You notice his blood pressure has ranged from 138/86 to 152/98 mmHg. His blood pressure today is 142/82 mmHg in the left arm. Which medications do you anticipate the health care provider may prescribe to treat his primary hypertension? Select all that apply. -Hydrochlorathiazide (Hydrodiuril) -Vasotec (Enalapril) -Amitriptyline (Elavil) -Metoprolol tartrate (Lopressor) -No medications are necessary at this time.
-Hydrochlorathiazide (Hydrodiuril) -Vasotec (Enalapril) -Metoprolol tartrate (Lopressor)
The intensive care nurse is caring for a client diagnosed with status asthmaticus who is currently not receiving medical treatment. What is this client at risk for developing? (Select all that apply.) -Hypercapnia -Hyperresonance -Alkalosis -Anxiety -Hyporeflexia
-Hypercapnia -Hyperresonance -Anxiety
The nurse in the emergency department is assessing an adult client with emphysema. What symptoms of emphysema would not be obvious from inspection and direct observation by the nurse? -Pursed-lip breathing and clubbing of fingers -Shortness of breath -Barrel chest -Hyperresonance sounds from the lungs
-Hyperresonance sounds from the lungs
The nurse is caring for a client diagnosed with sepsis. Which clinical finding indicates the client may be experiencing acute respiratory distress syndrome (ARDS)? -Fever -Bradycardia -Cough -Hypoxemia
-Hypoxemia
The nurse is evaluating teaching provided to a client with chronic inflammation. Which client statement indicates that teaching has been successful? -I ignore the pain until I can't stand it anymore. -I think it would be best if I just died right now. -I lay in bed most days. -I limit doing things that aggravate the pain.
-I limit doing things that aggravate the pain.
You work on the medicaldashsurgical unit in a large urban hospital. Alfreda Cochran is a 66-year-old African American female who has just been admitted to the unit from the emergency department (ED). As you review Mrs. Cochrans chart, you learn that she was brought to the hospital on an ambulance during an asthma attack. Prior to calling for an ambulance, she had been cleaning a small bathroom in her home with several different cleaning products. She has a history of asthma and was having difficulty catching her breath. She was stabilized in the ED and admitted to your unit. She is currently wearing oxygen at 3 L/min and her oxygen saturation level is 95%. She weighs 182 pounds and is 52 tall. She has an intravenous line infusing NS into her right forearm. At home, she uses a leukotriene modifier and beclothmethasone (Beconase) to help control her asthma symptoms. Her vital signs are T 98.8°F, P 94 bpm, R 24/min, and BP 142/86 mmHg.You come to Mrs. Cochrans room. You find her lying quietly in bed. As you speak with Mrs. Cochran, you identify several risk factors for the development of asthma and triggers for an asthma attack based on which of her statements? Select all that apply. -I live in a big apartment building downtown. -I just do not eat enough fruits and vegetables. -My sister came for a visit last week, and she smoked in my apartment because she said it was too cold to go outside. -I caught a cold from my grandson about 2 weeks ago. -Ive been so lonely since my husband passed away, so I got myself a little dog.
-I live in a big apartment building downtown. -My sister came for a visit last week, and she smoked in my apartment because she said it was too cold to go outside. -I caught a cold from my grandson about 2 weeks ago. -Ive been so lonely since my husband passed away, so I got myself a little dog.
Which diagnostic test evaluates obstructed bile in the biliary duct? -Serum bilirubin -Serum amylase -WBC count -Serum lipase
-Serum bilirubin
You are speaking to Mrs. Cochran about some lifestyle changes that she can make to help prevent the occurrence of future asthma attacks. Which statement by Mrs. Cochran indicates that further education is necessary? -I talked to a real estate agent about looking for a home that is out in the country. -I told my sister that if she comes to stay with me again, she is going to have to smoke outside. -I sure cant wait to get back to my apartment so I can pet my dog. -My daughter bought me some disposable masks to wear in case I need to go out in the cold.
-I sure cant wait to get back to my apartment so I can pet my dog.
Mrs. Cochrans health care provider has requested that you teach her how to use a peak expiratory flow rate (PEFR) meter to monitor her asthma following discharge. She has never used a PEFR before and asks, What the heck is that supposed to do? You educate her about the use of a PEFR meter. Which statements by Mrs. Cochran indicate that she has an adequate understanding about the use of PEFR meter? -I need to use it once a week at first, and later once a month. -I use the meter to monitor how well the air is flowing out of my lungs. -These things sound so expensive, Im not sure Ill be able to afford all of my medications. -When I see yellow on the meter after I use it, that means that my asthma is under control.
-I use the meter to monitor how well the air is flowing out of my lungs.
Which is a risk factor for development of a DVT? (Select all that apply.) -Immobilization -Hormone therapy -Lung cancer -Diabetes mellitus -Hypercholesterolemia
-Immobilization -Hormone therapy -Lung cancer
The nurse is planning care for a client with acute glomerulonephritis. Which problem is priority for the nurse to address when caring for this client? -Impaired skin integrity -Fatigue -Impaired nutrition -Impaired fluid balance
-Impaired fluid balance
The nurse is planning care for a client with inflammatory bowel disease. What problem is priority for the nurse to address when caring for this client? -Impaired nutrition -Impaired skin integrity -Fatigue -Impaired fluid balance
-Impaired fluid balance
A client was recently admitted with a gallbladder disorder. The nurse is preparing to teach health promotion activities. Which topics are appropriate to include in the teaching session? (Select all that apply.) -Importance of a low-cholesterol diet -Role of a high-cholesterol diet on gallstone formation -Role of hypolipidemia on gallstone formation -Importance of a high-fiber diet -Dangers of rapid weight loss
-Importance of a low-cholesterol diet -Role of a high-cholesterol diet on gallstone formation -Importance of a high-fiber diet -Dangers of rapid weight loss
The nurse is providing discharge instructions for a client with peptic ulcer disease (PUD). What will the nurse include in teaching? -Importance of rest if client feels dizzy -Importance of using over-the-counter analgesics for mild pain -Importance of continuing treatment until symptoms of PUD subside -Importance of stress management techniques
-Importance of stress management techniques
A nurse is caring for a client with a possible diagnosis of glomerulonephritis. Which laboratory values would the nurse pay particular attention to when monitoring for manifestations of this condition? (Select all that apply.) -Increased BUN -Decreased urine creatinine -Decreased ESR -Increased serum creatinine -Positive ASO titer
-Increased BUN -Decreased urine creatinine -Increased serum creatinine -Positive ASO titer
The nurse is planning care for a client with acute respiratory distress syndrome (ARDS). What nursing diagnosis is the priority for the nurse to initiate? -Anticipatory grieving -Acute pain -Deficient knowledge -Ineffective airway clearance
-Ineffective airway clearance
The nurse is caring for an older adult client diagnosed with nephritis and congestive heart failure (CHF). Which clinical finding may be present in this client, which is not a typical finding in the client with nephritis? -Flank pain -Purulent sputum -Infiltrates on chest x-ray -Midabdominal
-Infiltrates on chest x-ray
A nurse is providing education to the parent of a 6-year-old client diagnosed with asthma. Which statement by the parent regarding pathophysiology indicates understanding of the education? -There is decreased capillary permeability leading to mucosal edema. -There is decreased mucus production, which leads to narrowed airways leading to symptoms. -Inflammatory mediators cause the symptoms my child is experiencing. -Bronchodilation is causing symptoms for my child.
-Inflammatory mediators cause the symptoms my child is experiencing.
Which pharmacologic therapy used in the treatment of inflammatory bowel diseases suppresses tumor necrosis factor (TNF) to reduce inflammation? -Infliximab (Remicade) -Olsalazine (Dipentum) -Metronidazole (Flagyl) -Methylprednisolone (Solu-Medrol)
-Infliximab (Remicade)
Eli Schwartz is a 15-year-old boy who was recently diagnosed with ulcerative colitis and is admitted to the hospital with severe diarrhea. Which nursing intervention would Eli's nurse provide for Eli? -Infuse intravenous fluids as prescribed -Avoid anti-inflammatory medications -Avoid placing any kind of cream on the perianal region -Weigh every other day
-Infuse intravenous fluids as prescribed
Which effects has cigarette smoking been known to cause? (Select all that apply.) -Atrophy of mucus-secreting glands -Inhibited function of alveolar macrophages -Enhanced ciliary movement -Constriction of smooth muscle -Destruction of airways
-Inhibited function of alveolar macrophages -Constriction of smooth muscle -Destruction of airways
Which items will the nurse include in the physical examination portion of the nursing assessment for a client diagnosed with heart failure? (Select all that apply. -Inspecting for jugular vein distention -Inspecting for edema -Reviewing current medications -Taking vital signs -Palpating peripheral pulses
-Inspecting for jugular vein distention -Inspecting for edema -Taking vital signs -Palpating peripheral pulses
A client is experiencing acute respiratory distress syndrome (ARDS). The client's spouse asks the nurse what caused ARDS. The nurse bases the response on which etiologies of indirect injury to the lungs? (Select all that apply.) -Fat embolism -Systemic sepsis -Multiple blood transfusions -Pancreatitis -Smoke inhalation
-Systemic sepsis -Multiple blood transfusions -Pancreatitis
A client was seen in the emergency department with an initial complaint of abdominal pain and was admitted to an in-patient unit earlier in the day. The client is now in surgery having her gallbladder removed. Which topics will be included in the client's discharge education? (Select all that apply.) -Instruct on surgical incision care -Instruct on pain control measures -Instruct on prescribed activity level -Instruct on a high-fat diet -Teach manifestations of postoperative complications
-Instruct on surgical incision care -Instruct on pain control measures -Instruct on prescribed activity level -Teach manifestations of postoperative complications
Which independent nursing intervention is most appropriate for a client experiencing tachypnea? -Repositioning the head of the bed to less than 30 degrees -Instructing the client to complete breathing exercises -Administering oxygen -Suctioning the upper airway
-Instructing the client to complete breathing exercises
While reviewing laboratory results, the nurse notes that one client has an elevated C-reactive protein level. What should the nurse identify as a priority for this client? -Interventions to rule out the diagnosis of liver failure -Teaching to reduce aggravation of inflammation after discharge -Actions to reduce localized inflammation -Administration of medications to reduce symptoms of inflammation
-Interventions to rule out the diagnosis of liver failure
The nurse is preparing to provide newly prescribed anti-inflammatory medication to a 33-year-old female client with systemic lupus erythematosus. What should the nurse ask this client before providing the medication? -How many hours of sleep do you get each night? -Do you need to drive or operate electronic machinery? -Is it possible that you are pregnant? -Does your health insurance have a pharmacy plan?
-Is it possible that you are pregnant?
What is true regarding sulfasalazine (Azulfidine) prescribed for clients with inflammatory bowel disease? (Select all that apply.) -The client should reduce intake of sodium when taking this. -The main side effect is appetite stimulation. -It blocks the production of prostaglandin to reduce inflammation. -The client should use sunscreen when taking this. -It reduces the amount of stools per day to maintain fluid balance.
-It blocks the production of prostaglandin to reduce inflammation. -The client should use sunscreen when taking this.
A nurse is caring for a client with peptic ulcer disease (PUD) who is taking a proton pump inhibitor (PPI) for the treatment of PUD. Prior to administering this medication, what does the nurse need to know about a PPI? (Select all that apply.) -It inhibits histamine binding to the receptors on the gastric parietal cells to reduce acid secretion. -It stimulates gastric mucosal defenses. -It may be used in combination with two antibiotics to eliminate H. pylori. -It stimulates secretion of mucus, bicarbonate, and prostaglandin. -It inhibits an acid-secreting enzyme to reduce gastric acid content.
-It may be used in combination with two antibiotics to eliminate H. pylori. -It inhibits an acid-secreting enzyme to reduce gastric acid content.
Which statement is true regarding Goodpasture syndrome? -It is a result of systemic lupus erythematosus (SLE). -It is caused by an infection. -It may cause glucosuria (glucose in the urine). -It may cause hemoptysis (bloody sputum).
-It may cause hemoptysis (bloody sputum).
Which conditions cause secondary hypertension? (Select all that apply.) -Lupus -Kidney disease -Diabetes -Asthma -Pregnancy
-Kidney disease -Diabetes -Pregnancy
Which diagnostic test used in the collaborative care of nephritis uses nuclear medicine to visualize the kidney? -Kidney scan -KUB -Renal biopsy -Renal ultrasound
-Kidney scan
The health care provider asks you to educate Mr. Gooding on lifestyle modifications including the (Dietary Approaches to Stop Hypertension) DASH diet. Mr. Gooding looks at you and states Oh good! I believe Im already eating the DASH diet. I do not have much time to eat lunch at work, so I have to eat quickly. I have been eating at the buffet near my office every day. What will you include when educating Mr. Gooding on the DASH diet? Select all that apply. -Limit sodium and fat intake. -Limit calories to 2500 per day. -Eat lean meat (fish, poultry). -Eat 7 to 8 servings of whole grains, 2 to 3 servings of low fat milk, and 4 to 5 servings of fruits and vegetables daily. -Do not eat fat or drink alcoholic beverages.
-Limit sodium and fat intake.y. -Eat lean meat (fish, poultry). -Eat 7 to 8 servings of whole grains, 2 to 3 servings of low fat milk, and 4 to 5 servings of fruits and vegetables daily.
Which nutritional modifications are therapeutic for clients experiencing an episode of cholecystitis? (Select all that apply.) -Limiting food intake -Low-fiber, low-residue diet -Nasogastric tube insertion -Low-fat diet -High-protein diet
-Limiting food intake -Nasogastric tube insertion -Low-fat diet
A client is newly diagnosed with acute postinfection glomerulonephritis. Which medication will the nurse administer to manage the protein loss associated with nephrotic syndrome? -Prednisone (Deltasone) -Hydralazine (Apresoline) -Cyclophosphamide (Cytoxan) -Lisinopril (Zestril)
-Lisinopril (Zestril)
The results of diagnostic tests indicate that a client with coronary artery disease has cardiomyopathy. Which clinical manifestations should the nurse expect to assess in this client? (Select all that apply.) -Lower extremity edema -Fatigue -Shortness of breath when walking -Nosebleeds -Morning headache
-Lower extremity edema -Fatigue -Shortness of breath when walking
Which test is used to diagnose a DVT? (Select all that apply.) -Magnetic resonance imaging -Magnetic resonance angiography -Duplex venous ultrasonography -Plethysmography -Color-flow Doppler ultrasound
-Magnetic resonance imaging -Duplex venous ultrasonography -Plethysmography
A nurse is caring for a client with acute glomerulonephritis. When planning care for this client, which interventions take primary focus? (Select all that apply.) -Maintain skin integrity -Promote nutritional balance -Prevent infection -Maintain fluid balance -Promote adequate sleep pattern
-Maintain skin integrity -Promote nutritional balance -Prevent infection -Maintain fluid balance
The nurse is planning care for a client with ulcerative colitis. Which characteristics associated with ulcerative colitis will the nurse recognize? (Select all that apply.) -Mild to moderate symptoms are present. -Attacks last 1 to 3 months. -The onset is usually insidious. -It affects the mucosa and submucosa of the small intestine. -A secondary peak of ulcerative colitis occurs between the ages of 40 and 50 years.
-Mild to moderate symptoms are present. -Attacks last 1 to 3 months. -The onset is usually insidious.
A nurse is caring for a client with inflammatory bowel disease. When planning care for this client, which interventions take primary focus? (Select all that apply.) -Monitor weight -Encourage deep breathing and coughing -Maintain skin integrity -Promote nutritional balance -Maintain fluid balance
-Monitor weight -Maintain skin integrity -Promote nutritional balance -Maintain fluid balance
Which nursing actions are appropriate to reduce the risk of infection for a hospitalized client recovering from a laparoscopic cholecystectomy? (Select all that apply.) -Monitoring vital signs, including temperature, every 4 hours -Assisting client to deep breathe and cough or use incentive spirometers every 1 to 2 hours while awake -Placing the patient in Fowler position -Assessing abdomen every 4 hours as indicated postsurgery -Administering antibiotics as prescribed
-Monitoring vital signs, including temperature, every 4 hours -Assisting client to deep breathe and cough or use incentive spirometers every 1 to 2 hours while awake -Assessing abdomen every 4 hours as indicated postsurgery -Administering antibiotics as prescribed
The nurse is reviewing the blood test results conducted on Carmen Pataglia, a 68-year-old female with rheumatoid arthritis. On which laboratory value should the nurse focus to determine the presence of chronic inflammation in Ms.Pataglia? -Lymphocytes 30% -Neutrophils 40% -Monocytes 10% -Basophils 0.6%
-Monocytes 10%
What is true regarding duodenal ulcers? (Select all that apply.) -More common in individuals who eat poorly -More common in individuals who smoke -Typically develop between the ages of 30 and 55 -Typically develop between the ages of 55 and 70 -More common in men than in women
-More common in individuals who smoke -Typically develop between the ages of 30 and 55 -More common in men than in women
You are concerned about the bruises on Mrs. Johnson's arms and legs. What possible causes would you want to consider when completing your assessment of Mrs. Johnson? Select all that apply. -Mrs. Johnson's propranolol (Inderal) might be increasing her clotting time above the target range. -Mrs. Johnson could have orthostatic hypotension. -Mrs. Johnson could be in a domestic violence situation. -Mrs. Johnson could be falling often.
-Mrs. Johnson could have orthostatic hypotension. -Mrs. Johnson could be in a domestic violence situation. -Mrs. Johnson could be falling often.
Which health problems can develop from coronary artery disease? (Select all that apply.) -Hypertension -Myocardial infarction -Hyperlipidemia -Angina -Coronary artery spasms
-Myocardial infarction -Angina -Coronary artery spasms
The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who needs an artificial airway to assist in maintaining an open airway. Which airway will the nurse plan to reposition every 8 hours while providing care? -Nasopharyngeal -Tracheostomy -Oropharyngeal -Endotracheal
-Nasopharyngeal
The mother of a 10-year-old client is pleased to hear that the child's blood work for inflammation was negative but asks why the child continues to have symptoms. Which response by the nurse is the most appropriate? -Normal results are common in children with inflammation. -The child is experiencing a mild case of inflammation. -The level of inflammation has subsided. -Blood tests are not useful to diagnose the presence of inflammation.
-Normal results are common in children with inflammation.
A nurse is caring for a client newly diagnosed with heart failure. The client is placed on venous pressure monitoring. Which information about the heart function does venous pressure monitoring provide? (Select all that apply.) -Normal range, 2 to 6 mmHg -Left ventricular and cardiac functioning -Right heart filling pressures -Fluid status -Direct and continuous arterial blood pressures
-Normal range, 2 to 6 mmHg -Right heart filling pressures -Fluid status
Kevin Gooding, a 42-year-old accountant, comes into the clinic for a physical examination. He reports he feels fine but says, I feel more tired than I usually do. With the upcoming tax season, he reports he has been working longer hours and has had a few more headaches than usual. He admits he has not been eating a well balanced diet. With his busy work schedule, Mr. Gooding has had to eat out more than usual and has not been exercising. He reports he would like to quit smoking, but he has been unsuccessful in the past. He currently smokes 1 pack per day.You are the nurse conducting Mr. Goodings initial assessment at the health care providers office. Mr. Gooding has olive skin, hazel eyes, and curly black hair. On the health history Mr. Gooding completed, he lists his race/ethnicity as African American. You obtain his height and weight: 5 feet 10 inches, 214 pounds. Mr. Gooding is surprised by his weight. You note on the chart he has gained 20 pounds compared to his last visit one year ago. Based on your initial assessment, Mr. Gooding has which modifiable risk factors associated with primary hypertension? -African American male -Obesity and sedentary lifestyle -Smoking 1 pack per day -Eating fast food -Stress
-Obesity and sedentary lifestyle -Smoking 1 pack per day -Eating fast food -Stress
The nurse is planning care for a client who has been prescribed bed rest after abdominal surgery. Which action by the nurse helps to prevent development of a DVT in this client? (Select all that apply.) -Limiting fluids and restricting caloric intake -Reviewing ankle extension and flexion exercises -Placing a pillow under the client's knees -Teaching the proper way to cross the legs -Elevating the client's feet with the knees slightly bent
-Reviewing ankle extension and flexion exercises -Elevating the client's feet with the knees slightly bent
You repeat the blood pressure in Mr. Goodings left arm and get 152/104 mmHg as compared to 145/98 mmHg in his right arm. After documenting the blood pressure reading, Mr. Gooding asks you why you took the blood pressure in both arms. What is your best response? -The arm with the lower blood pressure more accurately reflects your blood pressure and should always be used to check your blood pressure. -Our doctor is very thorough and it is his policy to check it in both arms. -Obtaining the blood pressure in both arms helps to determine if one arm is higher; that arm will most accurately reflect your blood pressure. -The cuff may be too small, and I want to compare it to the reading in the left arm to make sure it is the same.
-Obtaining the blood pressure in both arms helps to determine if one arm is higher; that arm will most accurately reflect your blood pressure.
A nurse on the medical-surgical unit is providing care for a client with new onset stroke. The nurse notes the client is having difficulty with eating and swallowing. Which members of the rehabilitative team will the nurse consult with regarding this issue? (Select all that apply.) -Case manager -Occupational therapist -Dietician -Speech therapist -Physical therapist
-Occupational therapist -Speech therapist
The nurse is planning a care conference for a client recently diagnosed with chronic obstructive pulmonary disease (COPD). Which team members should the nurse invite to the care conference for this client? (Select all that apply.) -Occupational therapist -Nutritionist -Respiratory therapist -Physical therapist -Billing specialist
-Occupational therapist -Nutritionist -Respiratory therapist -Physical therapist
The nurse is caring for a client with chronic inflammatory bowel disease who is prescribed antibiotics to treat the condition. The client reports an allergy to sulfa. Which medication orders will the nurse question? (Select all that apply.) -Ciprofloxacin (Cipro) -Olsalazine (Dipentum) -Sulfasalazine (Azulfidine) -Mesalamine (Asacol, Rowasa) -Clarithromycin (Biaxin)
-Olsalazine (Dipentum) -Sulfasalazine (Azulfidine) -Mesalamine (Asacol, Rowasa)
The nurse is concerned that a 9-month-old child being treated for bronchiolitis caused by respiratory syncytial virus (RSV) is developing respiratory distress. Which assessment findings support this concern? (Select all that apply.) -Onset of expiratory grunting -Visible intercostal retractions with ventilations -Femoral pulse weak and 120 beats per minute -Respiratory rate increased from 30 to 48 a minute -Systolic blood pressure 10 mmHg less than previous measurement
-Onset of expiratory grunting -Visible intercostal retractions with ventilations -Respiratory rate increased from 30 to 48 a minute
Which nonpharmacologic therapy is appropriate for a child with respiratory syncytial virus (RSV)? -Suctioning the airway every hour -Organizing care to allow for rest -Taking the child to the playroom to socialize -Providing three full meals each day
-Organizing care to allow for rest
Which breathing difficulty is associated with body position? -Hypoxia -Apnea -Tachypnea -Orthopnea
-Orthopnea
The nurse is performing a respiratory assessment on a young adult. What findings are considered alterations of oxygenation? (Select all that apply.) -Orthopnea -Dyspnea -Tachypnea -Eupnea -Retractions
-Orthopnea -Dyspnea -Tachypnea -Retractions
A client is newly admitted with chest tubes. Which type of intervention is the priority when providing nursing care to this client? -Inputs -Pressure supports -Outputs -Fluid supports
-Outputs
A community health nurse is planning to teach a group of clients about the etiology, risk factors, and prevention of nephritis. Which group of clients would best benefit from this education? (Select all that apply.) -Parents of children with sickle cell disease -Pregnant female clients -Male clients with prostate cancer -Clients with congestive heart failure -Clients with diabetes
-Parents of children with sickle cell disease -Clients with congestive heart failure -Clients with diabetes
Manny Domingo, a 45-year-old gardener is being treated for severe inflammation of the right lower leg. Why should the nurse teach Manny infection control techniques prior to being discharged? -The body will perceive normal tissue as being foreign. -Pathogens could cause the inflammatory process to become worse. -Temporary or long-term impairment of function can occur. -An abnormal inflammatory response can cause airway obstruction.
-Pathogens could cause the inflammatory process to become worse.
An 8-year-old child is admitted in the emergency room for asthma. The nurse would expect which of the following diagnostic and lab tests to be ordered? (Select all that apply.) -Peak expiratory flow -Pulse oximetry -Allergy skin testing -Arterial blood gas -Spirometry
-Peak expiratory flow -Pulse oximetry -Allergy skin testing -Arterial blood gas
The nurse is assessing an adult client who is complaining of chest congestion and cough. What skill(s) would the nurse expect to use to specifically assess for chest congestion? -Auscultation -Percussion and auscultation -Inspection -Palpation and percussion
-Percussion and auscultation
A nurse is caring for William Sanders, a 65-year-old male with a history of peptic ulcer disease (PUD), who presents to the emergency department via ambulance gurney. Mr. Sanders called first responders to his house when he developed severe upper abdominal pain that radiated to his right shoulder. Mr. Sanders's heart rate is 114 and blood pressure is 90/55. Mr. Sanders's nurse notes that his skin is cool and clammy, his abdomen is hard, and no bowel sounds can be auscultated. What complication associated with PUD does the nurse suspect that Mr. Sanders has? -Gastric outlet obstruction -Perforation -Hemorrhage -Zollinger-Ellison syndrome
-Perforation
Which medication is only used to treat severe case of respiratory syncytial virus (RSV)? -Racemic epinephrine -Ribivarin -Prednisone -Aceteminophen
-Ribivarin
During an assessment, the nurse becomes concerned that a client is experiencing early signs of acute appendicitis. Which assessment finding causes this concern? -Left lower quadrant abdominal pain aggravated by bending the left leg -Right lower quadrant abdominal pain aggravated by coughing -Mid-lower abdominal pain aggravated by palpating over the bladder -Mid-epigastric abdominal pain aggravated by bending forward
-Right lower quadrant abdominal pain aggravated by coughing
A nurse manager is teaching a group of staff nurses about the complications related to peptic ulcer disease (PUD). What statement regarding peritonitis will the nurse manager include in the teaching? -Chemical peritonitis occurs between 6 and 12 hours after perforation, when the acids from the stomach or duodenum create an inflammatory response. -Bacterial peritonitis happens immediately after perforation as bacteria proliferate in the peritoneal cavity. -Peritonitis occurs due to the obstruction of the pyloric region of the stomach and duodenum. The increased pressure from the obstruction leads to peritonitis. -Peritonitis occurs when the ulcer penetrates through the mucosal wall, causing gastric or duodenal contents to enter the peritoneum.
-Peritonitis occurs when the ulcer penetrates through the mucosal wall, causing gastric or duodenal contents to enter the peritoneum.
Which are complementary behavioral or mind-body therapies used to help some clients with hypertension reduce blood pressure? (Select all that apply.) -Physical exercise -Angiotensin II receptor blockers (ARBs) -Tai chi -Yoga -Memory games
-Physical exercise -Tai chi -Yoga
When planning care for a client experiencing an asthma attack, the nurse needs to address the client's shortness of breath. Which nursing intervention is most appropriate for this client? -Assess level of anxiety -Use relaxation techniques -Place head of bed in a Fowler position -Reduce external stimuli
-Place head of bed in a Fowler position
Which independent intervention is a priority for a client who is experiencing dyspnea? -Weigh the client daily in the morning -Place the client in high- Fowler position -Order oxygen 2 to 4 L per nasal cannula -Turn the client once a shift
-Place the client in high- Fowler position
What independent action by the nurse will enhance oxygenation for a client diagnosed with acute respiratory distress syndrome (ARDS)? -Elevating the head of the bed to 30 degrees -Restricting fluid intake each shift -Placing in a prone position several times each day -Administering oxygen
-Placing in a prone position several times each day
The nurse is caring for a client diagnosed with acute respiratory distress syndrome (ARDS) who requires mechanical ventilation. Which ventilator mode will promote pressure throughout the respiratorycycle? -Positive end-expiratory pressure (PEEP) -Tidal volume -Sensitivity -Flow rate
-Positive end-expiratory pressure (PEEP)
What are risk factors for the development of bronchiolitis? (Select all that apply.) -Age 4 or older -Premature birth -Attends daycare -Chronic lung disease -Cigarette smoke exposure
-Premature birth -Attends daycare -Chronic lung disease -Cigarette smoke exposure
A client with severe arthritis of the right hip is scheduled for total hip replacement surgery. What is the first action that the nurse should take at this time? -Discuss the length of rehabilitation. -Ensure a bed is available for the client after surgery. -Prepare needed preoperative teaching. -Determine who will help the client at home after surgery.
-Prepare needed preoperative teaching.
While eating a peanut butter sandwich as a bedtime snack, the nurse observes a client begin to wheeze and complain of dizziness. What should the nurse do first? -Provide an antihistamine. -Lower the head of the bed. -Prepare to administer epinephrine. -Notify anesthesia for intubation.
-Prepare to administer epinephrine.
A nurse is preparing to obtain a health history from a client with peptic ulcer disease (PUD). Which factors should the nurse include in this portion of the nursing assessment? (Select all that apply.) -History of a high-fat diet -Presence of nausea and vomiting -History of chronic use of NSAIDs -Complaints of heartburn -History of smoking
-Presence of nausea and vomiting -History of chronic use of NSAIDs -Complaints of heartburn -History of smoking
The nurse is caring for a client who has chronic inflammatory bowel disease. The client tells the nurse the she is taking nutritional supplements that help reduce the inflammation. Which supplements are used in the treatment of chronic inflammatory bowel disease? -Energy drinks -Vitamin K tablets -Probiotics -Glucose tablets
-Probiotics
What will prevent the spread of infection when a child with respiratory syncytial virus (RSV) is admitted to a care area? -Perform frequent handwashing -Cover the child's face with a mask -Prohibit contact between clients with and without RSV -Admit to the intensive care unit
-Prohibit contact between clients with and without RSV
A nurse is caring for a client with nephritis and wishes to assist the client in maintaining nutritional balance. Which interventions best support the client's nutritional balance? (Select all that apply.) -Provide a diet with large portions of meat and dairy -Provide opportunity for family to bring food from home -Provide large portions of food across the life span -Provide a diet with no added salt -Provide a diet low in protein
-Provide opportunity for family to bring food from home -Provide a diet with no added salt -Provide a diet low in protein
The nurse is discussing diagnostic tests for COPD. Which diagnostic tests will assist in evaluating the extent and current progression of the disease? (Select all that apply.) -Pulmonary function tests -Ventilation-perfusion testing -Arterial blood gas analysis -CBC with differential -Serum alpha-1 antitrypsin
-Pulmonary function tests -Ventilation-perfusion testing -Arterial blood gas analysis
The nurse is caring for a client admitted with a possible myocardial infarction (MI). Which assessment findings are consistent with this diagnosis? (Select all that apply.) -Q wave changes -ST segment depression -Anxiety -Vomiting -Tachypnea
-Q wave changes -Anxiety -Vomiting -Tachypnea
Why does anaphylaxis occur? -Rapid release of inflammatory mediators -Damaged tissues are replacement by other cells -Release of heparin and histamine -No answer text provided.
-Rapid release of inflammatory mediators
What is one of the risk factors for gallbladder disease? -Rapid weight loss -Hypolipidemia -Male gender -Hypocalcemia
-Rapid weight loss
Which clinical manifestation is expected with acute appendicitis? -High fever -Rebound tenderness -Pain relieved with ambulation -Reduced pain after vomiting
-Rebound tenderness
A nurse is reviewing diagnostic tests for a client newly diagnosed with heart failure. The nurse is concerned that the client is experiencing renal issues in addition to the heart failure. Which diagnostic tests would the nurse focus on to help determine renal function? (Select all that apply.) -Chest x-ray -Serum creatinine -B-type natriuretic peptide(BNP) -Blood urea nitrogen (BUN) -Urinalysis
-Serum creatinine -Blood urea nitrogen (BUN) -Urinalysis
A pediatric client who has asthma is brought to the emergency room. He is unable to speak, has shortness of breath, and has diminished breath sounds. Based on the assessment findings, what type of asthma exacerbation is the client experiencing? -Minimal -Moderate -Severe -Mild
-Severe
A client with asthma reports, "I cannot catch my breath with the most simple of tasks, and I find the only thing I can do is sit in a chair most days." Based on these symptoms, what classification of asthma is this client experiencing? -Moderate persistent -Severe persistent -Mild intermittent -Mild persistent
-Severe persistent
Brian, a student nurse, is shadowing you today. The two of you are sitting in the nurses station discussing what should be included in Mrs. Cochrans discharge instructions. Which statements by the student nurse indicate that he requires further education about asthma management? -It would be great if she would start exercising, but it would be best for her to do it indoors. -Shes definitely going to need an influenza vaccine every five years. -Some of the medications that asthmatic clients take shouldnt be taken with herbal preparations. -Asthma clients fare better when they are able to effectively manage their stress.
-Shes definitely going to need an influenza vaccine every five years.
Mrs. Cochrans health care provider has ordered for her to continue on her home medications while she is hospitalized. Mrs. Cochrans blood was drawn this morning to monitor her theophylline level, and you have performed a head-to-toe assessment. Which findings are most consistent with the development of theophylline toxicity? Select all that apply. -She states, My stomach really hurts. -Theophylline level is 22 mcg/mL. -She states, While Ive been in the hospital, Ive become so constipated. -She states, I feel so jumpy and I cant sleep at night. -Apical pulse is 58 beats per minute.
-She states, My stomach really hurts. -Theophylline level is 22 mcg/mL. -She states, I feel so jumpy and I cant sleep at night.
During a home visit, the nurse is concerned that a client is experiencing an acute inflammation. What did the nurse assess in this client? (Select all that apply.) -Skin area hot to touch -Skin area swollen -Pain level 7 on a scale from 1 to 10 -Skin area reddened -Pink and red wound tissue
-Skin area hot to touch -Skin area swollen -Pain level 7 on a scale from 1 to 10 -Skin area reddened
The nurse is assessing an 8-year-old client during a well-child visit at a clinic. Which anatomical differences does the nurse expect to finding during the assessment process? (Select all that apply.) -Smaller nasopharynx -Atrophy of the tonsils -Small mouth with large tongue -Larynx and glottis lower in the neck -Soft tracheal cartilage
-Smaller nasopharynx -Small mouth with large tongue -Soft tracheal cartilage
As you educate Mr. Gooding regarding his newly diagnosed hypertension, which referrals may be necessary? Select all that apply. -No additional referrals are needed. He just needs to follow-up with the health care provider. -Smoking cessation program -Physical therapy -Dietician for dietary teaching -Weight management program
-Smoking cessation program -Dietician for dietary teaching -Weight management program
The nurse is caring for a client with a history of respiratory issues. Which lifestyle factor indicates a priority need for instruction? -Age -Sexual orientation -Smoking history -Weight
-Smoking history
The nurse identifies the potential for impaired gas exchange as a potential problem for 68-year-old Jorge Dominiquez, who is recovering from an appendectomy. Which intervention should the nurse select to support this client's oxygenation needs? -Replacing nasogastric drainage with intravenous fluids -Providing pain medication as prescribed -Splinting the incision when coughing -Assessing bowel sounds before changing the dressing
-Splinting the incision when coughing
Which pathological factors, or parts of the Virchow triad, are associated with thrombophlebitis? (Select all that apply.) -Stasis of blood -Increased blood coagulability -Lysis -Vessel damage -Embolism
-Stasis of blood -Increased blood coagulability -Vessel damage
Danae Jacobs is a 35-year-old woman with a history of Crohn disease, which manifested itself when she was 21 years old. For the last 2 years, she has been on numerous antibiotics and steroids with less than desirable effects. After a recent colonoscopy, the surgeon has told Danae that strictures have formed in her bowel and he suggested surgery. What surgery does Danae's nurse anticipate Danae needing? -Strictureplasty -Sigmoidoscopy -Bowel resection -Total colectomy ileal pouch-anal anastomosis (IPAA)
-Strictureplasty
The nurse is monitoring a client receiving several different medications for the treatment of acute respiratory distress syndrome (ARDS). Which medication administered to the client prevents atelectasis? (Select all that apply.) -Confusion -Surfactant -Prednisone -Heparin
-Surfactant
Which type of medication is used to help maintain open alveoli in clients with acute respiratory distress syndrome (ARDS)? -Inhaled nitric oxide -NSAIDs -Corticosteroids -Surfactant therapy
-Surfactant therapy
Which are signs of inflammation? (Select all that apply.) -Swelling -Paresthesias -Paralysis -Pain -Redness
-Swelling -Pain -Redness
What are the characteristics of chronic glomerulonephritis? (Select all that apply.) -Symmetrical decrease in the size of the kidneys -Gradual decline in renal function -Surfaces of the kidneys become soft and boggy -Entire nephrons are eventually lost -Slow, progressive destruction of the glomeruli
-Symmetrical decrease in the size of the kidneys -Gradual decline in renal function -Entire nephrons are eventually lost -Slow, progressive destruction of the glomeruli
The nurse is caring for a client with inflammatory bowel disease who is being treated with corticosteroids. Which information would the nurse provide for the client about the medications? (Select all that apply.) -Take medication consistently and do not stop abruptly -Reduce intake of foods high in sodium -It may cause low blood pressure. -Take with food or at mealtimes -Expect weight loss
-Take medication consistently and do not stop abruptly -Reduce intake of foods high in sodium -Take with food or at mealtimes
The nurse is caring for a client who is diagnosed with bronchitis and wants to know the function of the bronchi. Which response by the nurse is the most appropriate? -The bronchi contain the heart, trachea, esophagus, and the great vessels. -The bronchi warm and moisten air as it moves through the respiratory tract to the alveoli in the lungs. -The bronchi capture debris and help to sweep the debris toward the mouth for removal when coughing. -The bronchi help to keep the lungs inflated.
-The bronchi warm and moisten air as it moves through the respiratory tract to the alveoli in the lungs.
While conducting an assessment, the nurse determines that a client is at risk for developing a DVT. What did the nurse assess to make this conclusion? (Select all that apply.) -The client controls type 2 diabetes mellitus with dietary intake and exercise. -The client experienced a myocardial infarction 2 years ago. -The client has a history of atrial fibrillation. -The client is taking over-the-counter medication for arthritis. -The client is being treated for bladder cancer.
-The client experienced a myocardial infarction 2 years ago. -The client has a history of atrial fibrillation. -The client is being treated for bladder cancer.
A nurse is planning care for a client with peptic ulcer disease (PUD) who presents with intractable nausea and vomiting and epigastric pain. What is an appropriate outcome for this client? -The client will maintain adequate fluid volume. -The client will have minimal bleeding. -The client will report pain as 5 or less on standard pain scale. -The client will maintain a urine output of at least 0.1 mL/kg/hr.
-The client will maintain adequate fluid volume.
The nurse is planning care for a client diagnosed with asthma. Which expected outcome is appropriate for this client? -The client will experience short-term control of exacerbations. -The client will maintain oxygen saturations at 85%. -The client will verbalize triggers for asthma attacks. -The client will explain proper use of the prescribed nebulizer.
-The client will verbalize triggers for asthma attacks.
A client is admitted with a diagnosis of acute cholecystitis. The nurse understands that acute cholecystitis occurs after which opening is obstructed with a gallstone? -The common bile duct -The ampulla of Vater -The small intestine -The cystic duct
-The cystic duct
A nurse is describing the pathophysiology of heart failure to a client. Which changes caused by compensatory mechanisms in the development of heart failure should the nurse describe? (Select all that apply.) -Increased cardiac output causes the aortic baroreceptors to stimulate the sympathetic nervous system. -The kidneys release renin to retain sodium and water in an attempt to maintain cardiac output. -Atrial natriuretic peptide is released by the cardiac cells to help delay cardiac decompensation. -Hypertension causes the cardiac muscles to overstretch and cause temporarily increased cardiac output. -The ventricles in the heart remodel and develop hypertrophy because of the chronic increase in fluid volume.
-The kidneys release renin to retain sodium and water in an attempt to maintain cardiac output. -Atrial natriuretic peptide is released by the cardiac cells to help delay cardiac decompensation. -Hypertension causes the cardiac muscles to overstretch and cause temporarily increased cardiac output. -The ventricles in the heart remodel and develop hypertrophy because of the chronic increase in fluid volume.
A nurse is caring for a client with peptic ulcer disease (PUD). The client tells the nurse, "I don't understand why I have pain in the middle of the night. It's like my pain starts 2-3 hours after I eat, not right away. Why does this happen?" What is the nurse's best response? -The food that you ate for dinner likely contained too much fat, causing pain. -The food in your stomach takes longer to digest at night, which causes pain. -The acid in your stomach is increased at night, causing pain. -The pain occurs when your stomach is empty.
-The pain occurs when your stomach is empty.
A client being treated for a leg wound says that it must be improving because of the milky white discharge. What should the nurse explain to the client about the wound drainage? -This type of drainage is only seen in healing wounds. -This type of drainage is seen with an infection. -This exudate means blood vessels have been ruptured. -This drainage means you have a mild inflammation.
-This type of drainage is seen with an infection.
A nurse is caring for a client with chronic venous insufficiency (CVI) who has a past medical history of thrombophlebitis. Why is a client with a history of thrombophlebitis at greater risk for developing CVI? -Thrombophlebitis may damage valves of deep veins. -Thrombophlebitis may increase nitric oxide concentration, which damages veins. -Thrombophlebitis may alter coagulation that damages deep veins. -Thrombophlebitis may create a toxin that damages veins.
-Thrombophlebitis may damage valves of deep veins.
A client presents to the emergency department with right upper quadrant abdominal pain, suspicious for cholelithiasis. The client asks the nurse why so many tests are being ordered. The nurse bases the response on which rationales? (Select all that apply.) -To diagnose the disorder -To identify possible complications -To determine the location of gallstones -To prevent recurrence -To determine if gallstones are present
-To diagnose the disorder -To identify possible complications -To determine the location of gallstones -To determine if gallstones are present
What is the purpose of pulmonary function tests when diagnosing asthma? -To evaluate oxygenation, carbon dioxide elimination, and acid-base status -To confirm an asthma diagnosis -To evaluate the degree of airway obstruction -To identify specific allergens if an allergic trigger is suspected
-To evaluate the degree of airway obstruction
A nurse is assessing a client with heart failure. The nurse is concerned the client is experiencing poor tissue perfusion based on which assessment findings? (Select all that apply.) -Urinary output is 20 mL/hr for the past 2 hours. -Level of consciousness is decreasing. -Oxygen saturation is 93% on room air. -Capillary refill time is increasing. -Blood pressure is 126/72 mmHg.
-Urinary output is 20 mL/hr for the past 2 hours. -Level of consciousness is decreasing. -Capillary refill time is increasing.
You teach a client with hypertension about lifestyle changes that may help control the disorder. Which dietary changes should you include in the teaching? (Select all that apply.) -Limit fat intake to saturated types of fat -Eliminate cholesterol from diet -Use salt substitutes -Switch to low-fat dairy products -Eat 4-5 servings of fruits and vegetables each day
-Use salt substitutes -Switch to low-fat dairy products -Eat 4-5 servings of fruits and vegetables each day
While conducting a physical assessment, the nurse hears an additional heart sound immediately after the second sound. How should the nurse document this assessment finding? -Ventricular gallop -Atrial gallop -Diastolic murmur -Friction rub
-Ventricular gallop
What is the most common location of arterial plaque? -Vessel bifurcation -Vessel valves -Femoral artery -Pulmonary artery
-Vessel bifurcation
The nurse educator is teaching a group of students about acute respiratory distress syndrome (ARDS). Which etiology is related to infection and is appropriate for the educator to include in the teachingsession? -Near drowning -Burn injury -Viral pneumonia -Lung contusion
-Viral pneumonia
Mrs. Reyes is a 53-year-old woman who has just had a cholecystectomy with T-tube placement. She is 12 hours postsurgery. She is in semi-Fowler position and is NPO with a nasogastric (NG) tube in place after surgery. Her T-tube is connected to a sterile container. Orders include routine vital signs and pain medications per protocol, or as tolerated, minimal ice chips, and measuring T-tube drainage. You are completing ahead-to-toe assessment. Which assessment finding would require notification of the healthcare provider? -Small amounts of NG drainage -Pain is reported as being 6 on a 10-point scale. -Mrs. Reyes has tolerated ice chips well. -Vomiting after administration of ordered antiemetic
-Vomiting after administration of ordered antiemetic
After reviewing data collected during a cardiovascular assessment, the nurse determines that an older client is demonstrating normal signs of aging. Which did the nurse assess to come to this conclusion? (Select all that apply.) -Weak popliteal pulses bilaterallyvvvvv -Blood pressure dropping from a sitting to a standing position -Dependent edema of both feet when sitting for several hours -Elevated systolic blood pressure -Heart murmur heard in early diastole
-Weak popliteal pulses bilaterallyvvvvv -Blood pressure dropping from a sitting to a standing position -Dependent edema of both feet when sitting for several hours -Elevated systolic blood pressure
Mrs. Cochran tells you, I remember they told me in the ambulance that I was having a full-blown asthma attack! Later, you review the information in her chart from when she was seen in the emergency department. Which of the following assessment findings documented by the health care provider is LEAST associated with ensuing respiratory failure? -Her oxygen saturation level has fallen from 89% to 74% since arriving in the emergency department. -She was anxious upon arrival, but has become increasingly lethargic. -Wheezing has become progressively more audible. -Her cough has become ineffective.
-Wheezing has become progressively more audible.
The nurse is planning the education for a client being prepared for a coronary angiogram. What is appropriate information for the nurse to include? (Select all that apply.) -Will require the use of radiography -Allows ambulation within an hour of the procedure -Pressure is applied to the insertion site -Can eat after the procedure -Requires the insertion of a catheter
-Will require the use of radiography -Pressure is applied to the insertion site -Can eat after the procedure -Requires the insertion of a catheter
A client who exercises 30 minutes every day and maintains a normal body weight develops primary hypertension. The client asks how this could have happened. Which findings in the client's health history will the nurse include in the response to the client? (Select all that apply.) -Working as an air traffic controller -High magnesium intake -Insulin resistance -Family history of hypertension -Age: 62 years
-Working as an air traffic controller -Insulin resistance -Family history of hypertension -Age: 62 years
Miss Lopez is a fit and healthy 28-year-old hairdresser who lost her father to emphysema. She has been working in Washington, D.C. for 8 years and has come in for a consultation due to a cough that has lasted several months. Which item is most likely to be a factor in her chronic condition? -Workplace exposure to chemicals -Recent flu vaccine -Lives in rural environment -Early parental death from emphysema
-Workplace exposure to chemicals
Mrs. Clemons, a 65-year-old woman, is being treated for chronic obstructive pulmonary disease (COPD). Which medication classification do you anticipate will be prescribed for this client? -Anticholinergic -Xanthine -Inhaled corticosteroid -Beta agonist
-Xanthine
The health care provider orders benazepril (Lotensin) for Mr. Gooding. What teaching should you provide to Mr. Gooding regarding this medication? -Take this medication in the morning with breakfast each day. -There are no side effects when taking benazepril (Lotensin). -You will need to report any leg swelling or persistent cough to your doctor, and change your position slowly to prevent dizziness. -This medication will slow your heart rate. You will need to check your pulse and blood pressure before you take it.
-You will need to report any leg swelling or persistent cough to your doctor, and change your position slowly to prevent dizziness.
A nurse is caring for a client who has recently been diagnosed with peptic ulcer disease (PUD). The client asks the nurse, "My doctor told me I might have bacteria that is causing my ulcers. How will I know if I do?" What is the nurse's best response? -Your healthcare provider may order a breath test to determine the presence of H. pylori. -Your healthcare provider may order a test to analyze your stomach contents. -Your healthcare provider may order a skin test to determine the presence of H. pylori. -Your healthcare provider may order an x-ray with contrast to visualize the H. pylori bacteria.
-Your healthcare provider may order a breath test to determine the presence of H. pylori.
A nurse is planning care for Peter Carroll, a 55-year-old man who was recently diagnosed with peptic ulcer disease (PUD). Peter is hospitalized after several days of nausea and vomiting in addition to complaining of epigastric pain. When planning care for Mr. Carroll, which nursing diagnosis takes priority? -risk for impaired skin integrity -imbalanced nutrition: less than body requirements -disturbed sleep pattern -risk of deficient fluid volume
-risk of deficient fluid volume
A home health nurse is caring for a client with peripheral vascular disease (PVD). When educating the client regarding foot and leg care, which statements will the nurse include? (Select all that apply.) -"Buy shoes in the morning, when feet are largest." -"When swimming, ensure the water is cool, not warm." -"Apply moisturizing cream to feet and legs daily." -"Dry between your toes after showering." -"Avoid using powder on your feet."
-"Apply moisturizing cream to feet and legs daily." -"Dry between your toes after showering."
The mother of 4-year-old Kerry Washington asks why the nurse is concerned about the client's breathing after she was stung by a bee. Which response by the nurse is the most appropriate? -"Bee stings can cause a release of inflammatory substances that can lead to airway obstruction." -"The larynx is in the posterior position in children which can become swollen after a bee sting." -"Children have a longer epiglottis which can become easily obstructed after a bee sting." -"The longer and wider trachea in children can cause excess mucous to accumulate after a bee sting."
-"Bee stings can cause a release of inflammatory substances that can lead to airway obstruction."
A 58-year-old client who has a strong family history of coronary artery disease asks the nurse, "How can I decrease my chances of developing problems with my arteries?" Which response by the nurse is appropriate? (Select all that apply.) -"Diets high in fruits, vegetables and unsaturated fatty acids appear to have a protective effect on the arteries." -"As long as your cholesterol is normal, your arteries will remain clear." -"You can reduce your risk by making some changes in your lifestyle such as moderate exercise." -"Keeping your blood pressure within normal levels will decrease the risk of injury to your arteries." -"With your age and family history, there is little you can do besides take medication to prevent coronary artery disease."
-"Diets high in fruits, vegetables and unsaturated fatty acids appear to have a protective effect on the arteries." -"You can reduce your risk by making some changes in your lifestyle such as moderate exercise." -"Keeping your blood pressure within normal levels will decrease the risk of injury to your arteries."
A nurse is evaluating teaching for a client who has recently experienced a hypertensive crisis. Which statements by the client indicate understanding of the instructions? (Select all that apply.) -"I will exercise 3 days a week." -"I need to restrict my alcohol intake to no more than 20 oz of beer a day." -"I will set a schedule to remind me to take my medications each day." -"I must stop smoking." -"I will increase fruits and vegetables in my diet."
-"I need to restrict my alcohol intake to no more than 20 oz of beer a day." -"I will set a schedule to remind me to take my medications each day." -"I must stop smoking." -"I will increase fruits and vegetables in my diet."
The nurse instructs a client with hypercholesterolemia on the medication lovastatin. Which client statement indicates that teaching has been effective? -"I should take this medication at bedtime so I won't get dizzy." -"I should not drink any alcohol while taking this medication." -"I should expect to have muscle cramps and pain while taking this medication." -"I need to weigh myself every day while taking this medication."
-"I should not drink any alcohol while taking this medication."
The nurse is teaching a client about coronary artery disease. Which responses by the client reflect an understanding of coronary artery disease? (Select all that apply.) -"It affects more than 13 million people in the United States." -"Plaque impairs the ability of a vessel to dilate in response to increased oxygen demands." -"The increased levels of high-density lipoproteins (HDLs) decrease the risk of atherosclerosis." -"Damage to the linings of my arteries can cause clots and blockage." -"It decreases quality of life but does not increase a client's risk of death."
-"It affects more than 13 million people in the United States." -"Plaque impairs the ability of a vessel to dilate in response to increased oxygen demands." -"The increased levels of high-density lipoproteins (HDLs) decrease the risk of atherosclerosis." -"Damage to the linings of my arteries can cause clots and blockage."
The nurse is educating a client with COPD about pulmonary exercises. Which statement would the nurse include? -"It is important to rest between exercises to prevent low oxygen levels and fatigue." -"These exercises are more effective if they are done in the low-Fowler position." -"Pulmonary exercises are more effective while oxygen is in place." -"These exercises will only need to be done as needed."
-"It is important to rest between exercises to prevent low oxygen levels and fatigue."
The mother of 7-year-old Peyton Henderson is upset because the child has not been given any medication for abdominal pain caused by acute appendicitis. Which explanation about the administration of pain medication is most appropriate? -"Pain medication will mask the change in pain if the appendix ruptures." -"Pain from appendicitis is not real and does not need to be treated." -"There is no medication available to reduce the pain caused by appendicitis." -"Preventing the child from moving the legs will eliminate the abdominal pain."
-"Pain medication will mask the change in pain if the appendix ruptures."
A nurse is caring for a client suspected of having a pulmonary embolism. The client's health care provider has ordered the client to have a pulmonary angiogram. Which statements will the nurse include in teaching the client about this procedure? (Select all that apply.) -"Part of this procedure involves inhaling a gas that measures ventilation." -"Part of this procedure uses radioisotopes to help diagnose pulmonary embolism." -"Part of this procedure involves the placement of an IV." -"Part of this procedure involves contrast injected into the pulmonary arteries." -"Part of this procedure involves the use of x-ray."
-"Part of this procedure involves the placement of an IV." -"Part of this procedure involves contrast injected into the pulmonary arteries." -"Part of this procedure involves the use of x-ray."
The nurse educator is teaching a group of students about the respiratory system. Which statement by the student indicates appropriate understanding of the role of the pleural membranes? -"The pleural membranes contain the heart." -"The pleural membranes warm and moisten air." -"The pleural membranes permit gas exchange." -"The pleural membranes help to keep the lungs inflated."
-"The pleural membranes help to keep the lungs inflated."
Mrs. Darby is a 26-year-old woman who is seeing the healthcare provider because of severe upper right quadrant and right shoulder pain lasting for "hours at a time." The healthcare provider indicates she believes it might be gallbladder disease but needs to complete some tests. Mrs. Darby states, "That can't be. I'm too young. That's a disease of old people." What is your best response? -"It's because you are pregnant." -"There are many risk factors for gallbladder disease." -"Don't worry. We'll get to the bottom of it." -"It is. You must be that exception to the rule."
-"There are many risk factors for gallbladder disease."
A nurse is caring for Mohammed Hassad, a 34-year-old man who has a 20-pack-year history of smoking and works as an construction worker. Recently, Mohammed has been complaining of hungerlike pain in his upper abdomen that occurs in the middle of the night but seems to subside once he eats. Mr. Hassad's healthcare provider has ordered an upper GI series to aid in diagnosing his condition. What instruction will Mr. Hassad's nurse provide to Mohammed regarding this diagnostic test? -"This procedure is a type of x-ray that uses contrast." -"This procedure is a type of biopsy." -"This procedure requires sedation." -"This procedure requires an IV."
-"This procedure is a type of x-ray that uses contrast."
A nurse is caring for Samuel McMurray, a 68-year-old man with rapidly progressive glomerulonephritis (RPGN). Mr. McMurray's past medical history includes diabetes mellitus and hypertension. His current blood pressure is 142/92 and his nurse notes 3+ pedal edema to both of Mr. McMurray's legs. Mr. McMurray's healthcare provider has ordered antihypertensive and immunosuppressive medications, as well as plasmapheresis. Mr. McMurray asks his nurse, "What is plasmapheresis?" Which response by the nurse is the most appropriate? -"This therapy removes damaging antibodies from your blood." -"It is a therapy that is done only once to rid your body of harmful toxins." -"This therapy is also called plasma infusion therapy." -"This therapy removes the plasma from your blood, washes it, and tests it."
-"This therapy removes damaging antibodies from your blood."
A home health nurse is caring for 60-year-old Nancy Yee, who was discharged from the hospital yesterday after being diagnosed with a pulmonary embolism (PE). In addition to reporting any worsening shortness of breath, what instruction will Nancy's nurse give Nancy? -"Bruising is common if it happens again in the next week." -"Bloody sputum is common if it happens again in the next week." -"Use a soft-bristled toothbrush when brushing your teeth." -"Take aspirin if you develop minor pain."
-"Use a soft-bristled toothbrush when brushing your teeth."
The nurse is caring for a client who has been diagnosed with a common duct obstruction. The healthcare provider has ordered blood tests to determine if the client has pancreatitis. The client asks, "I thought my gallbladder was bad, why are we testing for problems with my pancreas?" Which response by the nurse is the most appropriate? -"This is the only way for us to determine if your gallbladder is affected." -"Since you are bleeding internally we need to monitor your hemoglobin and hematocrit." -"Your condition can lead to pancreatitis. That is why we are monitoring your serum amylase and lipase levels." -"The tests will allow us to see if you have gallstones."
-"Your condition can lead to pancreatitis. That is why we are monitoring your serum amylase and lipase levels."
The nurse is caring for four clients on the medical-surgical unit. Which clients will the nurse recognize as having the greatest risk of deep vein thrombosis (DVT) or pulmonary embolism (PE)? (Select all that apply.) -19-year-old pregnant female with gestational diabetes -65-year-old male recovering from an MI -55-year-old female scheduled for a hysterectomy -32-year-old female with an asthma exacerbation. -24-year-old male in traction device after femur fracture
-19-year-old pregnant female with gestational diabetes -65-year-old male recovering from an MI -55-year-old female scheduled for a hysterectomy -24-year-old male in traction device after femur fracture
You decide to perform and document a fall risk assessment. What factors increase Mrs. Johnson's risk for falls? Select all that apply. -Being female -Post-stroke unsteady gait -Warfarin (Coumadin) -Previous history of falls -Propranolol (Inderal)
-Post-stroke unsteady gait -Previous history of falls
When caring for a client with heart failure, the nurse will notify the healthcare provider when urine output is less than how many mL/hour? -40 -60 -50 -30
30
Cardiac output is determined by the amount of blood that pumps through the ventricles in what time frame? -15 seconds -30 seconds -45 seconds -60 seconds
60 seconds
What is a normal systolic blood pressure for a 4-year-old child? -64 mmHg -104 mmHg -88 mmHg -96 mmHg
88 mmHg
A nurse is planning to present information on primary hypertension at a local community center. Which adult population would the nurse consider as being most likely to benefit, based on higher prevalence of primary hypertension? -Men of Asian descent -White men -Women of Hispanic descent -African American women
African American women
Syncope
fainting
The results of an abdominal ultrasound were inconclusive for a client experiencing vague right lower quadrant abdominal pain. Which diagnostic test will the nurse prepare the client for at this time? -Paracentesis -Upper gastrointestinal study -Myelogram -Abdominal x-raysvvv
Abdominal x-raysvvv
Mr. George Henry is a 70-year-old African American man with a history of hypertension and smoking. He has recently experienced a TIA and is scheduled for a carotid endarterectomy in 2 weeks. In discussing the upcoming surgery with Mr. Henry, which explanation would you use to describe the procedure? -A carotid endarterectomy shoots pulses of water through the artery to widen the blood vessel. -A carotid endarterectomy reroutes blood flow through cerebral tissue. -A carotid endarterectomy removes atherosclerotic plaque from the carotid arteries. -A carotid endarterectomy uses a stent to enlarge the diameter of the carotid artery.
A carotid endarterectomy removes atherosclerotic plaque from the carotid arteries.
When providing a temporary pacemaker to a patient, you should observe what on the ECG to determine if the pacemaker has capture? -A normal sinus rhythm noted on the monitor -A pacer spike every 3 seconds -A pacer spike followed by a QRS complex -PVC's every three to four beats
A pacer spike followed by a QRS complex
The nurse is educating a client newly diagnosed with hypertension on appropriate dietary choices. Which action by the client, regarding dietary choices, indicates the need for further instruction? -Decreasing fats and oils -Drinking one alcoholic beverage every evening -Consuming low-fat milk and dairy products -Adding salt to most foods
Adding salt to most foods
Mae Jones, an 83-year-old woman with a history of hypertension, is admitted with reports of dyspnea on exertion. When you perform a physical assessment on Ms. Jones, you auscultate S3 and S4 heart sounds over her left sternal border and fine crackles over the bottom half of her lung fields. Her breathing is labored, and her oxygen saturation is 88% while breathing room air. Which intervention would you include for Ms. Jones's nursing plan of care? -Encourage liberal fluid intake. -Administer oxygen as prescribed. -Instruct her to stop taking diuretics. -Give foods high in sodium.
Administer oxygen as prescribed.
Which intervention is appropriate for a client who is having trouble breathing following a stroke? -Administer oxygen per order -Actively engage the client in social dialogue during mealtimes -Implement passive range of motion exercises -Provide liquids of the prescribed consistency
Administer oxygen per order
A nurse is preparing discharge teaching for a client newly diagnosed with heart failure. Which information should the nurse include in this teaching? -Restrict sodium intake to 3 g/day. -Allow rest periods throughout the day. -Eat three large meals daily. -Strenuous exercise is encouraged as manifestations improve.
Allow rest periods throughout the day.
A student nurse is educating a client on the newly prescribed medication for chronic obstructive pulmonary disease (COPD). Which statement made by the student nurse is incorrect? -An enzyme replacement will be administered daily by mouth. -"Steroids are given to help with breathing and to increase exercise tolerance." -"An antibiotic will be given to prevent upper respiratory infections." -"You will be given a short-acting metered-dose inhaler to open your airways."
An enzyme replacement will be administered daily by mouth.
A nurse is caring for 28-year-old Samantha Martinez, who is 34 weeks pregnant with her first child. Samantha presents to the emergency department complaining of a sudden cough, and states, "I just can't seem to catch my breath." Samantha's healthcare provider suspects Samantha has a pulmonary embolism (PE). What additional manifestation will Samantha's nurse recognize as a manifestation of PE? -Flattened neck veins -Widening QRS complex on ECG -Bradycardia -Anxiety
Anxiety
The nurse is planning care for Lillian Greenwald, a 5-year old-client recovering from injuries sustained during a motor vehicle crash. What should the nurse do first? -Assess blood pressure -Change abdominal wound dressing -Provide intramuscular medication -Nasotracheal suction for a sputum culture
Assess blood pressure
A nurse on the rehabilitation unit is providing care for a client who recently experienced a stroke. What intervention would the nurse use to promote mobility for this client? -Encourage fluid intake up to 2,000 mL per day -Help the client to the bathroom every 2 hours -Assist with range of motion exercises -Administer oxygen per order
Assist with range of motion exercises
While measuring vital signs, the nurse discovers that a client's radial pulse rate is 70 and irregular. What should the nurse suspect is occurring with this client's heart? -Heart muscle fiber tension at the end of diastole is damaged. -Cardiac muscle fibers are losing the ability to shorten. -Cardiac cells in the right atrium are damaged. -The heart is not able to respond to changing demands.
Cardiac cells in the right atrium are damaged.
Akecheta Chapawee, a 78-year-old client from the Sioux tribe, is prescribed the adrenergic antagonist metoprolol for hypertension. What should the nurse teach the client about this medication? -Change positions slowly -Measure weight every day -Avoid alcohol with this medication -Report visual disturbances
Change positions slowly
You notice that your patient monitor is showing asystole; what is your first coarse of action? -Nothing asystole is a normal rhythm -Check the patient -Start CPR -Defibrillation at 200J
Check the patient
Betty Norman is an overweight, 57-year-old woman who works at the local diner and takes frequent smoking breaks. Mrs. Norman comes to the primary care provider for an annual physical examination. On assessment, her blood pressure is 180/96 mmHg. Which diagnostic test do you anticipate will be ordered for Mrs. Norman prior to initiating treatment? -Cholesterol panel -CT scan -Renal function tests -Intravenous pyelogram
Cholesterol panel
You are developing a nursing care plan for Mr. Gooding. Which of the following is the priority nursing diagnosis? -Client has ineffective health maintenance. -Client has imbalanced nutrition. -Client has a knowledge deficit. -Client is at risk for noncompliance.
Client has a knowledge deficit.
You are completing pre-procedure teaching on a client scheduled for an emergent angiogram. Which assessment finding is most important to report to the primary care provider? -Client is expressing concern over the impending procedure. -Client had an angiogram 7 years ago. -Client is allergic to shellfish. -Client has eaten within the last 30 minutes.
Client is allergic to shellfish.
A nurse who is working with clients who have had surgery needs to be aware that certain procedures increase the client's risk of developing a pulmonary embolism (PE). Which client would the nurse recognize as being at highest risk of PE? -Client who is postoperative from a renal stent placement -Client who is postoperative from a pneumonectomy -Client who is postoperative from a total hip repair -Client who is postoperative from a bowel resection
Client who is postoperative from a total hip repair
Which medication may be prescribed to prevent a stroke in a client who experiences transient ischemic attacks (TIAs)? -Enoxaparin (Lovenox) -Warfarin (Coumadin) -Docusate sodium (Colace) -Clopidogrel (Plavix)
Clopidogrel (Plavix)
What aspect is not assessed during the physical exam of the nursing assessment of a client with peripheral vascular disease (PVD)? -Skin temperature -Capillary refill -Complaints of pain -Vital signs
Complaints of pain
The nurse is caring for a client who is suspected of having a pulmonary embolism (PE). Which is the most common manifestation of PE that the nurse will recognize upon assessment? -Syncope -Hemoptysis -Cough -Cyanosis
Cough
During a health history interview, the nurse is concerned that a client is experiencing signs of a developing DVT. Which information should cause this concern? -Total hip replacement 5 years ago -Current calf pain with walking -Osteoarthritis of both wrists -History of hypertension
Current calf pain with walking
Mrs. Corelli is hospitalized for an exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment item can the nurse obtain from Mrs. Corelli's husband when completing the admission assessment? -Percussion tone -Peripheral pulses -Breath sounds -Current medications
Current medications
Which dietary modification should be implemented for a client with hypertension? -Decreased sodium -Increased saturated fats -Increased alcohol consumption to 2 oz per day -Decreased low-fat dairy products
Decreased sodium
What is the most common cause of chronic venous insufficiency (CVI)? -Congestive heart failure -Scleroderma -Varicose veins -Deep vein thrombosis
Deep vein thrombosis
A nurse is performing an assessment on a client with peripheral vascular disease (PVD). The nurse notes that the client's blood pressure is 142/86 mmHg. What additional manifestation, unique to PVD, will the nurse find upon physical examination of the nursing assessment of this client? -Dilated blood vessels in the eye -Delayed capillary refill in the lower extremities -Wheezing upon auscultation of the lungsv -Decreased sensation of the upper extremities
Delayed capillary refill in the lower extremities
The QRS complex on an ECG tracing indicates what? -Re-polarization of the Atria -Depolarization of the Ventricles -Re-polarization of the Ventricles -Depolarization of the Atria
Depolarization of the Ventricles
The nurse is assessing a client during a routine check-up. The client is concerned that he is at risk for stroke. Which item will the nurse include in the health history to determine the client's risk? -Monitor skin integrity -Auscultate breath sounds -Determine a history of smoking -Assess the level of consciousness
Determine a history of smoking
Madge Buccheri, a 65-year-old client with heart disease, is prescribed to have pulse pressure calculations completed every 4 hours. What should the nurse do to make this calculation? -Auscultate the heartbeat for 15 seconds and multiply by 4 -Multiply the stroke volume by the heart rate -Determine the difference between the most recent systolic and diastolic pressures -Divide the stroke volume by the end-diastolic volume
Determine the difference between the most recent systolic and diastolic pressures
Which is a risk factor for stroke? -Diabetes mellitus -Insomnia -Hypotension -Training to run a half marathon
Diabetes mellitus
A 3-year-old child is admitted in December with severe bronchiolitis. Which question should the nurse include when reviewing the child's health history with the parents? -When did the child begin to walk without help? -How much fluid does the child drink each day? -Did the child have an annual influenza vaccination? -At what age was the child potty trained?
Did the child have an annual influenza vaccination?
A nurse is providing care for a client with heart failure. The client has weakened ventricular contractions and deceased cardiac output. The nurse anticipates an order for which medication to improve contractility? -Loop diuretics -Alpha-blockers -Digitalis glycosides -Nitrates
Digitalis glycosides
The nurse is caring for a client newly diagnosed with heart failure. Which medication order does the nurse anticipate receiving from the healthcare provider? -Benzodiazepine -Diuretic -Proton pump inhibitor -Selective serotonin reuptake inhibitor
Diuretic
A nurse is caring for 72-year-old Selena Delgado, a client who has been admitted with severe claudication secondary to peripheral vascular disease (PVD). Due to the client's manifestations, Selena's healthcare provider has ordered an angiogram procedure. After Selena's healthcare provider has obtained informed consent from Selena, which assessment question will Selena's nurse ask as a priority prior to Selena's angiogram procedure? -Do you have any embedded metal shrapnel or artificial implants? -Do you have chronic liver problems? -Do you have an allergy to contrast dye? -Do you have an allergy to barium?
Do you have an allergy to contrast dye?
A client is admitted to the emergency department (ED) with diagnosis of stroke caused by thrombus that began at least 5 hours earlier. The healthcare provider orders intravenous heparin. The client's family member asks the nurse why the healthcare provider did not order a "clot buster" such as tPA. What is the most accurate response by the nurse? -Drugs that break up clots, such as tPA, must be given within 3 hours of symptoms onset because of serious side effects. -Heparin is given initially followed by an infusion of drugs such as tPA to finish breaking up the clot. -Heparin is the best drug on the market to break up clots that are causing stroke. -Heparin is given initially to start breaking up the clot followed by warfarin (Coumadin) to prevent further clotting.
Drugs that break up clots, such as tPA, must be given within 3 hours of symptoms onset because of serious side effects.
The nurse is performing a physical assessment of a client diagnosed with chronic obstructive pulmonary disease (COPD). Which assessment finding does the nurse expect for this client? -Eupnea -Edema -Decreased sputum production -Increased activity tolerance
Edema
A nurse is planning care for a client with peripheral vascular disease (PVD) who is scheduled to have revascularization surgery to improve circulation to the lower extremities. Which independent nursing intervention will the nurse implement to promote client tissue perfusion? -Warm lower extremities using heating pad -Elevate lower extremities above the heart -Encourage regular exercise -Administer medication as ordered
Encourage regular exercise
Which asthma attack trigger is characterized by loss of heat or water from the bronchial surface? -Emotional stress -Agents in the workplace -Environmental pollutants -Exercise
Exercise
Ms. Fortune has been diagnosed with narrowing of the coronary arteries. What would be the appropriate, conservative initial treatment for this condition? -Exercise 3 times a week for 30 minutes -Eat a diet with a minimum of 20% fat -Take statins as prescribed -Cut smoking by half the amount
Exercise 3 times a week for 30 minutes
A nurse is planning care for a client with a pulmonary embolism (PE) who is scheduled to have a vena caval filter placed. What independent nursing intervention will the nurse implement to decrease theclient's feelings of anxiety? -Administering antianxiety medications as ordered -Placing client away from the nurses' station to provide privacy -Discouraging visitors to maintain a therapeutic environment -Explaining all procedures and therapies ordered
Explaining all procedures and therapies ordered
The nurse is developing a plan of care for a client with coronary artery disease. Which mechanism contributes to a decreased blood flow to the client's coronary arteries? -Injury to arterial walls from increased arterial pressures -Decreased platelet aggregation -Increased vasodilation of the arteries -Fat and fibrin deposits on the arterial walls
Fat and fibrin deposits on the arterial walls
Where is the stethoscope placed to assess an apical pulse in an adult client? -Fifth intercostal space mid-clavicular line -Second intercostal space left sternal border -Second intercostal space right sternal border -Third intercostal space right sternal border
Fifth intercostal space mid-clavicular line
A nurse is caring for a client with peripheral vascular disease (PVD) who asks the nurse, "Is there anything other than medication to help slow this disease?" What is the nurse's best response? -Aromatherapy has been shown to slow the progression of PVD. -Yoga has been shown to slow the progression of PVD. -Garlic supplements have been shown to slow the progression of PVD. -A diet high in protein has been shown to slow the progression of PVD.
Garlic supplements have been shown to slow the progression of PVD.
A nurse is assessing a client with peripheral vascular disease (PVD). Which clinical manifestation will the nurse expect to find on assessment? -Pallor in lower extremities when in the dependent position -Hairless lower extremities -Spoon-shaped toenails -Dark red color to extremities when elevated
Hairless lower extremities
How is the concept of perfusion related to the concept of cognition? -Carbon dioxide is retained. -Hypoxemia can affect the mental state. -Perfusion of body tissues is decreased. -Blood flow is altered and cannot meet body needs.
Hypoxemia can affect the mental state.
Which nursing diagnosis is appropriate for a client with hypertension? -Chronic pain -Impaired mobility -Risk for dry eye -Imbalanced nutrition
Imbalanced nutrition
Mrs. Angela Hernandez is a 49-year-old woman who experienced an ischemic stroke in the right anterior cerebral artery. She displays weakness in her left leg and a sensory deficit. Which additional manifestation would you anticipate finding after a stroke at this cerebral location? -Homonymous hemianopia -Inability to make decisions -Problems with gait -Dysphagia
Inability to make decisions
Mrs. Kim, a 58-year-old client, is hospitalized with symptoms of DVT. The latest test results indicate stasis of blood, and the healthcare provider suspects that Mrs. Kim has developed venous thrombi. What other pathological factor should the nurse use to determine whether Mrs. Kim has a DVT? -Increased blood pressure -Increased blood coagulability -Tissue hypoxia -Tissue anoxia
Increased blood coagulability
The nurse is developing a plan of care for a client with coronary artery disease. Which mechanism does not contribute to decreased blood flow to the client's coronary arteries? -Increased platelet aggregation -Fat and fibrin deposits on the arterial walls -Spasms of normal or already narrowed arterial vessels -Increased vasodilation of the arteries
Increased vasodilation of the arteries
A nurse on the rehabilitation unit is planning discharge teaching for a client who is 6 weeks post-stroke. The client currently requires some assistance for mobility and is also able to self-feed with some assistance. The family plans to take the client home. What would the nurse include in discharge teaching for this client and family? -Instruct the family to install grab bars next to the toilet. -Instruct the family members to encourage the client to adhere to the existing family routine. -Tell the client and family the client will return to original level of mobility over the next year. -Tell the client and family that the client should not need to continue the inpatient therapy plan of care.
Instruct the family to install grab bars next to the toilet.
Ms. Wolfe, who has coronary artery disease, is leaving the hospital to go home. Which aspect of home care is most important for her to focus on? -Follow-up care -Lifestyle changes -Return to normal activity -Safety concerns
Lifestyle changes
Which term is defined as the average pressure in the arteries throughout the cardiac cycle? -Mean arterial pressure -Diastolic blood pressure -Systolic blood pressure -Pulse pressure
Mean arterial pressure
A highly stressed client is newly diagnosed with hypertension. What nonpharmacologic treatment option would best help the client maintain normal blood pressure? -Meditation -Competitive sports -High-potassium diet -Aerobic exercise 3 days a week
Meditation
A nurse is performing an assessment on a client with a pulmonary embolism (PE). The nurse notes that the client has jugular vein distention (JVD). Which independent nursing intervention will help maintain the client's cardiac output (CO)? -Administering vasoactive medications to improve CO as ordered -Monitoring for left heart failure -Assessing for such normal findings as S3 heart tone -Monitoring cardiac rhythm
Monitoring cardiac rhythm
The school nurse teaches a group of daycare teachers on the manifestations of respiratory syncytial virus (RSV). Which teacher's statement indicates that additional instruction is required? -Vomiting and diarrhea need to be investigated. -Rapid breathing is not normal and needs to be checked out. -Most babies are irritable when they miss their mothers. -I have to report any child that has a change in eating pattern.
Most babies are irritable when they miss their mothers.
Mrs. Bertha Marcowitz is preparing to go home following her recent stroke. The nurse is evaluating the nursing plan of care to determine if Mrs. Marcowitz has accomplished her goals. Which behavior demonstrated by Mrs. Marcowitz would indicate accomplishment of her nursing care plan goals? -Mrs. Marcowitz has experienced minimal complications from reduced mobility and dysphagia. -Mrs. Marcowitz is participating in her range of motion exercises each day. -Mrs. Marcowitz is sipping water with her meals to help her swallow. -Mrs. Marcowitz's family is at her bedside daily, crying and asking if Mrs. Marcowitz will be okay.
Mrs. Marcowitz has experienced minimal complications from reduced mobility and dysphagia.
A client was recently diagnosed with acute heart failure. The nurse anticipates that which cardiac disorder led to this diagnosis? -Cardiomyopathy -Coronary heart disease -Valvular disease -Myocardial infarction
Myocardial infarction
The client with a history of atherosclerosis has chest pain that is unrelated to activity, unpredictable, and often occurs while at rest. The client reports the pain has been becoming more frequent and severe, rating the current pain as 9 on a scale of 1 to 10. You recognize that the client is at severe risk of which disorder? -Myocardial infarction -Stable angina -Prinzmetal angina -Coronary artery disease
Myocardial infarction
A nurse is caring for a client with pulmonary embolism (PE) who presented to the emergency department complaining of cough and shortness of breath. The nurse is reviewing the client's recent electrocardiogram (ECG). Which finding is consistent with PE? -Nonspecific T-wave changes -Atrial fibrillation (A-fib) -Premature ventricular contractions (PVCs) -Bradycardia
Nonspecific T-wave changes
While assessing peripheral pulses in a 2-week-old infant, the nurse is unable to palpate the radial and pedal pulses. What action should the nurse take? -Prepare the infant for emergency cardiac catheterization -Notify the health care provider immediately -Insert a venous access device for intravenous cardiac medications -Nothing because this is a normal finding
Nothing because this is a normal finding
Six-year-old Kerry Teng has been diagnosed with bronchiolitis. What will the nurse include when assessing Kerry? -Observe for labored respirations -Observe for signs of obstruction -Assess for seizures -Monitor closely for lengthening of paroxysms
Observe for labored respirations
A nurse is providing care for a client with pulmonary edema subsequent to heart failure. Which finding indicates that the interventions implemented have resolved the gas exchange problem? -Client's respirations are 26 breaths/min with intercostal retractions. -Oxygen saturation is 94% with oxygen supplementation. -Lung sounds indicate bilateral crackles and a cough productive of frothy, pink sputum. -Client is restless and sitting upright to breathe.
Oxygen saturation is 94% with oxygen supplementation.
Which is a preventive measure for bronchiolitis? -Immunization -Palivizumab -Antibiotic therapy -Sputum culture
Palivizumab
Which pharmacologic therapy is used to decrease blood viscosity and improve red blood cell (RBC) flexibility in clients with peripheral vascular disease (PVD)? -Aspirin -Clopidogrel (Plavix) -Pentoxifylline (Trental) -Cilostazol (Pletal)
Pentoxifylline (Trental)
By spending more time discussing Mrs. Johnson's relationship with her husband, you are able to eliminate domestic violence as a concern. Although the results of her assessment for orthostatic hypotension indicate she may be experiencing adverse effects from the propranolol (Inderal), you also want to determine if Mrs. Johnson's clotting time is above her target range. You make a note to ask her health care provider to order the relevant lab test. The test results combined with your documentation of today's visit should provide Mrs. Johnson's health care provider with sufficient information for her medication review. Because Mrs. Johnson will need to go to the clinic to have her blood drawn, you let her know that she can schedule that testing to coincide with attending a post-stroke self-help group. She is delighted to know about that social opportunity. What is a central belief of self-help groups? -A self-help group has the same purpose and process as a therapy group. -A twelve-step approach is used by participants in all self-help groups. -Members of self-help groups undergo extensive selection interviews, prior to attendance. -People who have particular social or health problems understand each other in a special way.
People who have particular social or health problems understand each other in a special way.
The nurse is explaining the phases of cardiac rehabilitation to a client being prepared for discharge. What is a goal of phase 1 for the client? -Performs own bathing routine -Increases exercise at home -Improves psychosocial status -Decreases anxiety
Performs own bathing routine
You are reviewing Mrs. Cochrans discharge instructions. She asks, So which of these drugs is the one that I should use if Im having an asthma attack? Which is the appropriate medication to use only during an asthma attack? -Budesenide (Pulmicort) -Montelukast (Singulair) -Theophylline (Theo-Dur) -Pirbuterol (Maxair)
Pirbuterol (Maxair)
The nurse suspects that Herbert Johnson, a 68-year-old African-American client with heart disease, is experiencing problems with the transport of respiratory gases to the tissues. Which action should the nurse take to help Mr. Johnson? -Place in high-Fowler position and coach to take deep breaths -Assess pain level using a pain scale and measure blood pressure -Maintain on bed rest and assess jugular vein distention -Observe pupils and level of consciousness
Place in high-Fowler position and coach to take deep breaths
A nurse is planning care for a client with a pulmonary embolism (PE) who is hospitalized and requires supplemental oxygen in order to maintain adequate oxygenation. What independent nursing intervention will the nurse implement to help the client's condition? -Place the client's lower extremities in the dependent position -Place the client in the supine position -Encourage frequent range-of-motion (ROM) activities -Elevate the client's lower extremities
Place the client's lower extremities in the dependent position
The nurse is planning a presentation about hypertension during a community health fair. Which modifiable risk factor will the nurse include in the presentation? -Potassium intake -Gender -Age -Race
Potassium intake
Ms. Gordon has chronic obstructive pulmonary disease (COPD) and is experiencing respiratory difficulty. What should the nurse teach Ms.Gordon about managing symptoms of COPD? -Decrease fluid intake -Practice pulmonary hygiene -Use suppressants for the chronic cough -Open windows to allow fresh air into the home
Practice pulmonary hygiene
A client is visiting the outpatient clinic because of an increase in blood pressure despite taking diuretics as prescribed. What treatment changes would the health care provider prescribe? -Recommend nonpharmacologic methods of blood pressure reduction -Suggest a low-sodium diet -Change the diuretics to another antihypertensive -Prescribe another antihypertensive in addition to the diuretics
Prescribe another antihypertensive in addition to the diuretics
The nurse is obtaining the health history of a client who complains of dyspnea. Which would indicate a possible diagnosis of chronic obstructive pulmonary disease (COPD)? -Previous diagnosis of chronic bronchitis -No history of dyspnea -Yearly respiratory infections in the winter -Absent history of cigarette smoking
Previous diagnosis of chronic bronchitis
Mrs. Batista has come to her doctor to get help for a headache in the back of her head and neck that presents every morning when she wakes and subsides during the day. She says she is waking up more often in the middle of the night to go to the bathroom, and she reports that sometimes during the day, she has visual disturbances. In your physical examination of Mrs. Batista, you find that her blood pressure is elevated. Which of the following conditions is Mrs. Batista most likely to have? -Primary hypertension -Pheochromocytoma -Secondary hypertension -Hypertensive crisis
Primary hypertension
Max Katzer, a 57-year-old man with a history of type 2 diabetes mellitus and ischemic heart disease, is admitted to the hospital with systolic heart failure. During your shift, Mr. Katzer suddenly starts to report shortness of breath and he coughs up pink, frothy sputum. Upon physical examination, you notice that his breathing is labored and that his respiratory rate is 38 breaths/min. Upon auscultating his chest, you hear fine crackles and faint wheezes over all of his lung fields. Which finding explains Mr. Katzer's physical assessment findings? -Decreased pulmonary hydrostatic pressure -Pulmonary edema -Increased myocardial contractility -Hepatic engorgement
Pulmonary edema
The mother of a child diagnosed with bronchiolitis caused by respiratory syncytial virus (RSV) is upset to learn that the child will be admitted to a semi-private room. Which explanation by the nurse is the most appropriate regarding this room assignment? -The children will have companionship when the parents are not able to visit. -RSV is not contagious so the roommate will not contract the illness. -The nurse can provide care to both children at the same time. -RSV is contagious, however placing two children with the same illness is permissible.
RSV is contagious, however placing two children with the same illness is permissible.
Which is an intervention for imbalanced nutrition because of overweight or obesity in clients with primary or secondary hypertension? -Refer to a dietitian for meal plans -Monitor for peripheral edema -Administer medications per order -Monitor diagnostic test results
Refer to a dietitian for meal plans
A patient you are caring for has been diagnosed with a STEMI; what does STEMI stand for? -SubTerminal Erythrocytosis with Massive Irregularities -ST Elevation Myocardial Infarction -Sinus Tachycardia with Endocarditis and Mitral Insufficiency -Stable Tachycardia and Erratic Myocardial Insufficiency
ST Elevation Myocardial Infarction
A 14-month-old child is admitted to the intensive care unit for treatment of severe bronchiolitis caused by respiratory syncytial virus (RSV). Which medication does the nurse anticipate will be prescribed for this client? -Dopamine -Atropine -Ribavirin -Aminophylline
Ribavirin
Which diagnostic test used in the collaborative treatment of peripheral vascular disease (PVD) uses blood pressure cuffs and a Doppler device to compare blood pressures (BP) of the upper and lower extremities? -Stress test -Angiography -Duplex Doppler ultrasound -Segmental pressure measurements
Segmental pressure measurements
What risk factor for domestic violence applies to Mrs. Johnson's situation? -Unemployment -Socioeconomic status -Age -Relationship status
Socioeconomic status
As the nurse caring for Mr. Gooding, you obtain his vital signs: T 98.8°F, P 88 bpm, R 22/min, and BP 145/98 mm/Hg (right arm). As you perform your assessment, he says, I have been very stressed at my new job, and as a result my blood pressure has been running a little high lately. You nod in agreement and empathize with him on how tough job assignments can be.In which category does Mr. Goodings blood pressure fall? -Normal -Stage II hypertension -Prehypertension -Stage I hypertension
Stage I hypertension
The nurse is caring for a client with a history of atherosclerosis. The client has chest pain that occurs with physical exertion or stress and is relieved with sublingual nitroglycerin. The nurse recognizes that the client is most likely experiencing which disorder? -Myocardial infarction -Acute coronary syndrome -Prinzmetal angina -Stable angina
Stable angina
You expect what client reaction during a coronary artery spasm? -Sudden onset of acute chest pain -Gradual increase in systolic blood pressure -Acute reduction in level of consciousness -Gradual increase in peripheral edema
Sudden onset of acute chest pain
The nurse is caring for a client with a history of angina. Which assessment findings would support the diagnosis of a myocardial infarction (MI)? -Pain at rest -Sudden onset of burning chest pain -Pain radiating to the left arm -Substernal chest pain
Sudden onset of burning chest pain
A client reports weakness, fatigue, and decreased exercise tolerance. Based on the reportedsymptoms, the nurse anticipates that the healthcare provider will diagnose the client as having which classification of heart failure? -Left-sided -Systolic -Diastolic -Right-sided
Systolic
A client is seen in the emergency department (ED) for manifestations of stroke that resolved soon after the client entered the ED. The client was diagnosed with a transient ischemic attack (TIA). The client asks the nurse in the ED what TIA means. What is the most accurate response by the nurse? -"TIA can be a warning sign of an impending larger stroke." -"TIA causes brain cells to die and leaves a small cavity in the brain tissue." -"TIAs usually involve one large artery in the brain prior to stroke." -"TIAs are caused by blood clots that break off from larger clots in the body."
TIA can be a warning sign of an impending larger stroke."
The home care nurse is evaluating the care provided to an 18-month-old child recovering at home from bronchiolitis caused by respiratory syncytial virus (RSV). Which observation indicates that the parents have provided adequate care? -The child becomes drowsy while eating lunch -The child has a faint wheeze upon auscultation -The child's oxygen saturation is 98% on room air -The child has moderate nasal flaring with respirations
The child's oxygen saturation is 98% on room air
A nurse is providing care for a client with newly diagnosed stroke caused by thrombus. The nurse is explaining the steps for ischemic cascade to the client and the client's family. Which step should the nurse include as the first step of this process? -The blood supply is cut off to part of the brain. -The damaged cells release chemicals that affect other cells around the damaged part of the brain. -The cell membranes allow water to enter the cell, which causes damage to the cells. -Leukocytes (white blood cells) enter the area of damage, causing more damage to the brain.
The blood supply is cut off to part of the brain.
During a home visit, the nurse evaluates care provided to a client recovering from a DVT. Which observation indicates that additional teaching is required? -The client is sitting with the legs elevated. -The client frequently changes position. -The client is taking warfarin as prescribed. -The client has removed the antiembolism stockings.
The client has removed the antiembolism stockings.
Before receiving the morning report, the nurse makes rounds on assigned clients. At the bedside of one client, the nurse notes an ampule of vitamin K. What should the presence of this medication indicate to the nurse? -The client is receiving warfarin. -The client is receiving intravenous heparin. -The client is receiving low-molecular-weight heparin injections. -The client is receiving high-dose aspirin therapy.
The client is receiving warfarin.
The nurse is planning care for a client with chronic obstructive pulmonary disease (COPD). Which goal is appropriate for this client? -The client will develop only two respiratory infections per year. -The client will stop smoking. -The client will maintain oxygen saturations of greater than 98%. -The client will demonstrate appropriate breathing techniques.
The client will demonstrate appropriate breathing techniques.
The nurse is reviewing assigned clients to determine which are at risk for developing a DVT. Which client should the nurse identify as a candidate for DVT preventive therapy? -The client with elevated cholesterol levels -The client with a history of diabetes mellitus -The client with a recently fractured femur -The client with a history of hypertension
The client with a recently fractured femur
A nurse is caring for a client who will undergo an endarterectomy due to severe peripheral vascular disease (PVD). When reviewing this procedure with the client, which statement will the nurse include? -This is considered a nonsurgical procedure that treats your occluded vessel. -This procedure re-routes blood flow around your occluded vessel. -The plaque from your occluded vessel will be surgically removed. -The plaque from your occluded vessel will be removed by heat.
The plaque from your occluded vessel will be surgically removed.
The nurse is teaching the client with chronic obstructive pulmonary disease (COPD). What should the nurse include when teaching about pulmonary hygiene? -The "huff" coughing technique -The importance of using air filters -The importance of cough, vibration, percussion, and postural drainage -The use of the tripod position to facilitate respirations during distress
The importance of cough, vibration, percussion, and postural drainage
In anticipating the use of the tPA alteplase during or after the stroke, which condition must be present? -The stroke must be hemorrhagic in nature. -Atherosclerotic buildup in affected arteries must be greater than 90%. -The stroke must have occurred within 3 hours of administering the medication. -Aspirin therapy must have been received for 6 months for tPA to be effective.
The stroke must have occurred within 3 hours of administering the medication.
The mother of a 2-year-old child with bronchiolitis caused by respiratory syncytial virus (RSV) asks why the child has been coughing so much. Which response by the nurse is the most appropriate? -The bacterial infection forces white blood cells to move into the lungs which are removed by coughing. -The virus causes body fluids to move into the lungs, which the body coughs to try to remove. -The bacterial infection irritates the lining of the bronchial tubes and stimulates the cough reflex. -The virus causes cellular debris that creates large amounts of mucus that stimulate the cough reflex.
The virus causes cellular debris that creates large amounts of mucus that stimulate the cough reflex.
Mr. Gooding asks you, Now more than ever I really need to crack down on my health. With my wife having our first child in two months, I need to get my pressure under control. What can I do to decrease my blood pressure? What is your best response to Mr. Gooding? -You are obese and you need to lose weight quickly. -You need to stop eating fast food for lunch. -You need to exercise at least three times per week. -There are a number of factors, such as diet, exercise, stress, and smoking, that can increase your blood pressure.
There are a number of factors, such as diet, exercise, stress, and smoking, that can increase your blood pressure.
The nurse is reviewing the results of a client's electrocardiogram and notes changes in the QRS complex. What should this finding indicate to the nurse? -There is damage to the heart muscle. -There is a problem with the cardiac ventricles. -The impulse from the sinoatrial node is delayed. -There is a problem with the cardiac atria.
There is a problem with the cardiac ventricles.
Which supplement that may be prescribed to a client with heart failure will convert carbohydrates into glucose and metabolize fats and protein? -Coenzyme Q10 -Vitamin D3 -Magnesium -Thiamin
Thiamin
Why are corticosteroids prescribed to treat chronic obstructive pulmonary disease (COPD)? -To reduce the rate of airflow decline -As a recovery medication -To prophylactically treat infection -To reduce symptoms
To reduce symptoms
Benny Spencer, a 57-year-old man, arrives in the emergency department reporting persistent chest pain for the last 48 hours. The chest pain is rated as a 7 on a 1-10 scale, and it radiates up the client's neck. What lab values will be the most important for the nurse to monitor? -CBC and CPK -Troponin, CPK, and Ck-MB -BMP, CPK, and troponin -PTT, CBC, and Ck-MB
Troponin, CPK, and Ck-MB
Four-year-old Grayson Mills has just been diagnosed with a mild case of bronchiolitis. What action should the nurse take to help Grayson at this time? -Use an inhaled bronchodilator as prescribed -Administer palivizumab as prescribed -Administer ribavirin as prescribed -Use a humidifier to cool the air
Use a humidifier to cool the air
After a stroke, a client may experience impairment in verbal communication. Which intervention would address this area of rehabilitation? -Speak to the client's family instead of the client -Use computerized talking boards -Increase the volume of voice when speaking to the client -Stand 12 to 18 inches away from the client when speaking
Use computerized talking boards
A client who has recently had a stroke is having difficulty with verbal communication. Part of the client's speech is garbled, and other words are not appropriate. Which intervention would the nurse use in the care of this client? -Use flash cards -Use long and complex sentences when speaking to the client -Encourage quick responses from the client -Consult the client's family to discuss the client's needs
Use flash cards
You are developing a plan of care for a client with coronary artery disease. Which pharmacological treatment would help increase blood flow to the client's coronary arteries? -Discontinue the use of daily ibuprofen -Use an analgesic to control chest pain -Discontinue the use of statins -Use of salicylic acid daily
Use of salicylic acid daily
When placing a patient on a standard three lead ECG, where are the leads placed? -White to Right Shoulder, Red to Left Shoulder and Black to Left Upper Abdominal Area -Red to Right Shoulder, Black to Left Shoulder and White to Left Upper Abdominal Area -White to Right Shoulder, Black to Left Shoulder and Red to Left Upper Abdominal Area -Black to Right Shoulder, White to Left Shoulder and Red to Left Upper Abdominal Area
White to Right Shoulder, Black to Left Shoulder and Red to Left Upper Abdominal Area
Cyanosis
bluish discoloration of the skin
The nurse is providing care to a client recovering from a transient ischemic attack (TIA). Which medication order would the nurse question for this client? -Plavix -Aspirin -Ticlid -tPA
tPA
An older adult hospitalized for several days with dyspnea is diagnosed with chronic obstructive pulmonary disease (COPD). The client asks the nurse to explain the condition. Which information would the nurse include? -"COPD is not curable and will affect the client in later years." -"COPD is an inflammation of the bronchi." -"COPD is caused by bacteria, viruses, fungi, protozoa, and other microbes that destroy the lung tissue." -"COPD is shortness of air that is caused by aspiration of gastric contents and inhalation of toxic or irritating gases."
"COPD is not curable and will affect the client in later years."
A client is scheduled for a duplex venous ultrasonography to assist in the diagnosis of a DVT. What should the nurse instruct the client about this diagnostic test? -"Duplex venous ultrasonography removes thrombi to improve venous circulation and prevent pulmonary embolism or gangrene." -"Duplex venous ultrasonography uses an injected contrast medium to assess venous thrombosis." -"Duplex venous ultrasonography measures changes in blood flow through the veins." -"Duplex venous ultrasonography passes a balloon catheter through the skin, into the vessel, and through the vessel to the site of the lesion."
"Duplex venous ultrasonography measures changes in blood flow through the veins."
Mrs. Tate has a cough that is producing thick, tenacious mucus. She is a cigarette smoker who has smoked 1 pack a day for the past 30 years. What question could you ask Mrs. Tate to help determine whether she has chronic bronchitis? -"Have you had the flu at any time in the past 2 years?" -"Have you had difficulty breathing at any time in the past year?" -"Have you had a dry cough that lasted 3 or more months in the past year?" -"Have you had a productive cough that lasted 3 or more months in the past 2 years?"
"Have you had a productive cough that lasted 3 or more months in the past 2 years?"
You are providing postprocedure instructions to the client who requires an emergent angiogram. What client statement indicates the need for further instruction? -"I will be able to return to full duty at work within 24 hours." -"I will need to lie still for up to 8 hours after the procedure." -"I will need to use the call light when I need toileting assistance." -"I will need to let you know if there is moisture under me after the procedure."
"I will be able to return to full duty at work within 24 hours."
The nurse is providing instruction to a client about possible complications of hypertension. Which statement, if made by the client, indicates a need for further instruction? -"Hypertension can cause an increased pressure in the blood vessels in my brain and increases my risk for a stroke." -"High blood pressure makes my heart work harder to pump blood to my body." -"Going to the bathroom more often at night may mean my blood pressure is not under good control." -"I will feel the difference if my blood pressure goes up too much."
"I will feel the difference if my blood pressure goes up too much."
The nurse is teaching a 25-year-old female client who is taking oral contraceptives. Which instruction should the nurse include to minimize the risk for developing a DVT? -"Avoid high-sodium foods." -"Consume a low-fat diet." -"Decrease your alcohol consumption." -"Include periods of activity when traveling."
"Include periods of activity when traveling."
A home health nurse is caring for 62-year-old Allen Montgomery, a client with peripheral vascular disease (PVD). Allen has a venous stasis ulcer to the right medial lateral ankle and requires daily wound care. Allen tells the nurse, "I want to stay active but I am having a hard time getting motivated because every time I try to exercise, my legs hurt." What is the best response from the nurse? -"It is best to maintain activity with your condition. You should continue activity if you have pain to increase your endurance." -"It is best to rest with your condition. Once the peripheral vascular disease is treated, then you can start a moderate exercise program." -"It is best to rest with your condition. You will always have pain with activity and you should avoid activity as much as possible." -"It is best to maintain activity with your condition, but make sure to rest if you develop pain during activity."
"It is best to maintain activity with your condition, but make sure to rest if you develop pain during activity."
The nurse provides teaching to the parents of a child with bronchiolitis about care needed at home. Which statement by the parents indicates instructions have been effective? -"It is important to give our child extra fluids." -"We will provide extra stimulation for our child." -"We will administer the prescribed amoxicillin 1 hour before meals." -"We should stop the antibiotics once the bronchiolitis symptoms go away."
"It is important to give our child extra fluids."
Samuel Lewis, an 84-year-old client, is admitted for testing to rule out a DVT. While the nurse prepares an injection of low-molecular-weight heparin, Mr. Lewis asks why he needs injections in his stomach if the problem is in his leg. How should the nurse respond? -"Low-molecular weight heparin prevents blood clots from forming in your leg but must be given in your stomach." -"Didn't your doctor tell you that you need to take these shots in your stomach for the rest of your life?" -"This medication dissolves any clots in your legs but must be given in your stomach." -"People over the age of 80 should be receiving this medication in their stomach so that blood doesn't pool in the legs."
"Low-molecular weight heparin prevents blood clots from forming in your leg but must be given in your stomach."
The nurse is preparing discharge instructions for a client prescribed warfarin (Coumadin) for a DVT. What should the nurse include in this teaching? -"Take the warfarin at bedtime each day." -"Notify the healthcare provider of bleeding or bruising." -"Use a hard-bristled toothbrush." -"Omit warfarin on the days when laboratory tests are ordered."
"Notify the healthcare provider of bleeding or bruising."
Janice Jaworski, a 50-year-old client, is being discharged after treatment for a DVT. Ms. Jaworski is a freelance writer and spends prolonged periods of time working at a computer. What instruction should the nurse provide to Ms. Jaworski to reduce the risk of future DVT development? -"Take frequent breaks to prevent sitting for prolonged periods of time at the computer." -"It is best to stand and wear tight-fitting hose when working." -"Sitting is permitted as long as the legs are not crossed." -"Standing is preferred over sitting, so think about altering your work environment."
"Take frequent breaks to prevent sitting for prolonged periods of time at the computer."
The parents of a child diagnosed with bronchiolitis ask the nurse how the disorder is treated. Which response by the nurse is the most appropriate? -"The focus is on managing symptoms and providing supportive care." -"A medication called dexamethasone always produces improvement." -"An inhaler will be used and the symptoms will be gone in about 24 hours." -"Antibiotics will be given for a period of 10 days."
"The focus is on managing symptoms and providing supportive care."
A nurse on the medical-surgical unit is providing care for a client scheduled for carotid endarterectomy. The client asks the nurse how carotid endarterectomy will help blood supply to the brain. What is the best response by the nurse? -"The healthcare provider will establish a bypass around the plaque buildup in your carotid artery." -"The healthcare provider will remove plaque from your carotid artery, and this will improve perfusion to the brain." -"The healthcare provider will remove the clot in your carotid artery either manually or by suctioning." -"The healthcare provider will insert a balloon into your carotid artery to make it wider and place a stent."
"The healthcare provider will remove plaque from your carotid artery, and this will improve perfusion to the brain."
A nurse is caring for 65-year-old Nathan Robertson, who has recently been diagnosed with peripheral vascular disease. During the nursing assessment, Mr. Robertson tells the nurse, "My legs burn when I am relaxing on the couch. I can't seem to find a comfortable position when I want to wind down." What is the nurse's best response to Nathan's concern? -"The pain you're referring to is called intermittent claudication. Is it usually worse with activity?" -"The pain you're referring to is called intermittent claudication. Does it improve with movement?" -"The pain you're referring to is called rest pain. Does it improve when you hang your legs off the bed?" -"The pain you're referring to is called rest pain. Does it improve if you elevate your legs above your heart?"
"The pain you're referring to is called rest pain. Does it improve when you hang your legs off the bed?"
A nurse is caring for a client with a pulmonary embolism (PE) who is scheduled to have a lung scan (V/Q scan). When teaching the client about this procedure, which statement will the nurse include? -"This is a blood test that scans the blood for an embolism." -"This is the primary diagnostic test for pulmonary embolism (PE)." -"This is a nuclear medicine procedure that uses radioisotopes to visualize an embolism." -"This procedure involves injection of IV contrast to visualize the embolism."
"This is a nuclear medicine procedure that uses radioisotopes to visualize an embolism."
A nurse is caring for a client with peripheral vascular disease (PVD) who presents to the primary care clinic complaining of a burning pain in the legs, which occurs at night in bed. What is the best response from the nurse? -"This is known as rest pain. Elevating your legs may help your pain." -"This is known as rest pain. Dangling your legs off your bed may help your pain." -"This is known as intermittent claudication. Wearing compression socks to bed may help your pain." -"This known as intermittent claudication. Elevating your legs may help your pain."
"This is known as rest pain. Dangling your legs off your bed may help your pain."
A nurse is caring for a client with peripheral vascular disease (PVD) who complains of intermittent claudication, decreased exercise tolerance, and occasional pain in the lower extremities at rest. The client's healthcare provider has prescribed cilostazol (Pletal) for the collaborative treatment of the client's condition. Which statement will the nurse include in the client teaching about this medication? -"This medication is used to improve blood flow to your legs, decreasing incidence of cramping pain in your legs." -"This medication is used to increase your energy so that you can exercise more efficiently." -"This medication is used to decrease your risk of developing a blood clot." -"This medication is used to increase flexibility of red blood cells, improving your condition.
"This medication is used to improve blood flow to your legs, decreasing incidence of cramping pain in your legs."
The nurse is evaluating teaching provided to a client with newly diagnosed hypertension. Which client statement indicates that teaching has been effective? -"High blood pressure is the leading cause of disability in the United States." -"Uncontrolled high blood pressure can cause a heart attack or a stroke." -"High blood pressure is the leading cause of death in the United States." -"Half of the people with high blood pressure die within 5 years of diagnosis."
"Uncontrolled high blood pressure can cause a heart attack or a stroke."
Barry Marks, a 56-year-old man with a history of coronary artery disease, is admitted with reports of dyspnea and fatigue. Upon physical examination, you auscultate crackles halfway up Mr. Marks's lung fields. An echocardiogram reveals reduced cardiac output. Which response should you provide to Mr. Marks when he asks you to explain why a heart problem makes it is hard for him to breathe? -"The right side of your heart is too weak to pump blood effectively, so the blood is backing up and congesting your lungs." -"Your heart is too weak to pump blood effectively, so the blood is backing up and congesting your lungs." -"The right side of your heart is too weak to pump enough blood to your lungs." -"The right ventricle of your heart is not pumping properly."
"Your heart is too weak to pump blood effectively, so the blood is backing up and congesting your lungs."
Ms. Atchison is a 50-year-old woman who has been diagnosed with gallstones. She is preparing to have laboratory and diagnostic testing done. The healthcare provider explained the need for testing. She is scheduled for an ultrasound, complete blood count, and serum bilirubin. She asks why she is having an ultrasound instead of an x-ray. She is concerned that insurance will not cover it. What is your best response? -"Do you want us to cancel it" It really isn't necessary." -"An x-ray just shows the presence of gallstones, but an ultrasound also shows if the gallbladder is emptying." -"An x-ray is not indicated in your case, so it wouldn't be covered by insurance." -"The ultrasound will also show if you have pancreatitis."
-"An x-ray just shows the presence of gallstones, but an ultrasound also shows if the gallbladder is emptying."
Five-year-old Michael Smith has been diagnosed with asthma and is being discharged after a brief hospitalization. Which statement by the nurse is not appropriate to include in the discharge teaching? -"Michael should stay inside during sudden changes in temperature." -"Pursue allergy testing with an allergy specialist." -"Buy detergents and soaps that are free of perfumes and dyes." -"Caregivers who smoke should always step outside of the house to smoke."
-"Caregivers who smoke should always step outside of the house to smoke."
The nurse is assessing an adult client with a cough. A positive answer to which question about the cough would require further evaluation and questioning of this client -"Do you cough up clear sputum and how often?" -"Do you cough up blood and how often?" -"Do you have clear drainage from the nose?" -"Are you experiencing a dry cough?"
-"Do you cough up blood and how often?"
You are caring for Mr. Jones, who has been diagnosed with ARDS. You need to place him into a prone position, and he asks you why this is necessary. What is your best response to Mr. Jones when explaining the reason for prone positioning? -"You will be more comfortable in the prone position." -"Prone positioning helps to prevent thrombophlebitis." -"Prone positioning helps to improve oxygenation." -"Prone positioning helps to avoid fluid imbalances."
-"Prone positioning helps to improve oxygenation."
An older client with a ruptured appendix and peritonitis wants to know why the abdomen is swollen. Which explanation by the nurse is the most appropriate? -"This health problem causes chronic constipation." -"I really don't know but I'll ask your doctor to explain it to you." -"All of the fluids that you are ingesting are leaking into the abdominal area." -"The contents of the appendix are causing inflammation of the abdominal cavity."
-"The contents of the appendix are causing inflammation of the abdominal cavity."
You are teaching Mr. Chen, a 25-year-old man, to use a peak flow meter to monitor his asthma. Mr. Chen's healthcare provider has told him to take readings using the peak flow meter, throughout the day and over several weeks, to establish his normal flow readings. Mr. Chen tells you he has a busy schedule and asks you why it is necessary to take readings so often. What is your best response when explaining to Mr. Chen why he has to use the peak flow meter on the schedule his healthcare provider has prescribed? -"The readings will be used to evaluate which medication to use to treat your asthma." -"The readings will be used to evaluate the severity of future airway obstruction." -"The readings will be used to determine whether your asthma can be cured." -"The readings will be used to determine the cause of your asthma."
-"The readings will be used to evaluate the severity of future airway obstruction."
Mr. Johnson leaves to go bowling with a men's group from the church. This gives you an opportunity to explore whether or not Mrs. Johnson is on the receiving end of domestic violence. Which questions are appropriate to ask Mrs. Johnson? Select all that apply. -"Is your husband abusing you? -"What happens when you and your husband have an argument?" -"Do you feel safe at home?" -"Is there anything you want to tell me?" -"Tell me about your bruises."
-"What happens when you and your husband have an argument?" -"Do you feel safe at home?" -"Tell me about your bruises."
Which drug classifications are considered antihypertensives? (Select all that apply.) -Angiotensin-converting enzyme inhibitors -Adrenergic antagonists -Diuretics -Angiotensin II receptor blockers -Nitrates
-Angiotensin-converting enzyme inhibitors -Diuretics -Angiotensin II receptor blockers
The nurse is assessing the respiratory system of Tamara, a preschool-age client. Which difference does the nurse expect while assessing Tamara when compared to an adult client? -Larger nasopharynx -Long, floppy epiglottis -More functional muscles -Atrophy of the tonsils
-Long, floppy epiglottis
Michael Chin is a 34-year-old man with breathing difficulties after a fall. When listening for bronchial sounds, what is the sound if the findings are normal? -Sounds medium in loudness and pitch -Loud, high-pitched sounds -Harsh, high-pitched sounds -Soft and low-pitched sounds
-Loud, high-pitched sounds
A nurse is caring for a client who complains of diarrhea and epigastric pain. The client tells the nurse that he has recently been diagnosed with a gastrinoma. What additional condition does the nurse suspect the client has? -Zollinger-Ellison syndrome -Esophageal ulcer -Gastric ulcer -Sick sinus syndrome
-Zollinger-Ellison syndrome
A client is admitted to the hospital with a complaint of sudden dyspnea and cough. The client's health care provider has diagnosed the client with pulmonary embolism (PE). The client's nurse notes that the client's D-dimer result is elevated. What is the cause of this elevation? -D-dimer indicates inflammation in the vessel that contains a blood clot. -D-dimer is a portion of fibrin formed during lysis of a blood clot. -D-dimer is a portion of protein synthesized during the formation of a blood clot. -D-dimer indicates increased coagulation associated with a blood clot.
D-dimer is a portion of fibrin formed during lysis of a blood clot.
You find that Mrs. Johnson's pulse rises from 70 bpm when supine to 85 bpm when sitting. Her blood pressure changes from 130/85 mmHg when supine to 110/75 mmHg when sitting. Does your data support a finding of orthostatic hypotension? -No, the changes in the pulse and blood pressure are due to anxiety. -Yes, the changes in the pulse and blood pressure both support a finding of orthostatic hypotension. -No, the pulse should decrease when Mrs. Johnson moves from a supine position to sitting up. -No, the blood pressure should increase when Mrs. Johnson moves from a supine position to sitting up.
Yes, the changes in the pulse and blood pressure both support a finding of orthostatic hypotension.
