ATI Study Quiz

A nurse is providing teaching for a client who has a prescription for a low-sodium diet to manage hypertension. Which of the following statements indicates an understanding of the teaching? A. "I can snack on fresh fruit." B. "I can continue to eat lunchmeat sandwiches." C. "I can have cottage cheese with my meals." D. "Canned soup is a good lunch option."

A. "I can snack on fresh fruit." The nurse should identify that fresh fruits contain little to no sodium and are a good snack for a client who has hypertension.

A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change? A. Potassium 2.8 mEq/L B. Digoxin level 0.7 ng/mL C. Hemoglobin 9.8 g/dL D. Calcium 8.0 mg

A. Potassium 2.8 mEq/L A flattened T wave or development of U waves is indicative of a low potassium level.

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Pitting peripheral edema B. Crackles in the lung bases C. Jugular vein distention D. Hepatomegaly

B. Crackles in the lung bases. Left-sided heart failure precipates pulmonary congestion and edema, causing crackles in the lugs.

A nurse is providing discharge teaching to a client who has emphysema. Which of the following instructions should the nurse include? A. Be sure to take cough medicine to avoid coughing. B. Try to drink at least 2 to 3 liters of fluid per day. C. Try to reduce your smoking to 2 cigarettes per day. D. BE sure to eat 3 full meals each day.

B. Try to drink 2 to 3 liters of fluid per day. Although adequate hydration is essential for all clients, clients who have emphysema should drink 2 to 3 L per day to help liquefy secretions.

A nurse is caring for a client who reports calf pain. What is the first action the nurse should take? A. Notify the provider B. Elevate the affected extremity C. Check the affected extremity for warmth and redness D. Prepare to administer unfractionated heparin

C. Check the affected extremity for warmth and redness The first action the nurse hsould take using the nursing process is to assess the client's calf for swelling, redness, and warmth. These findings can indicate a DVT.

A nurse is teaching a client about dietary modifications to control blood pressure. Which of the following food choices should the nurse identify as an indication that the client understands the instructions? A. Onion soup and salad B. Vegetarian wrap with potato chips C. Grilled chicken salad with fresh tomatoes. D. Chicken bouillon and crackers.

C. Grilled chicken salad with fresh tomatoes

A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneaic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? A. Place a nonrebreather mask on the client and increase the oxygen flow to 3 L/min. B. Prepare the client for possible endotrachael intubation and mechanical ventilation. C. Increase the oxygen flow and request an arterial blood gas determination. D. Position the client supine and administer an antianxiety medication.

C. Increase the oxygen flow and request an arterial blood gas determination. The client requires oxygen therapy at a rate that will keep oxygen saturation between 88% and 92%. The nurse should increase the client's oxygen flow and evaluate its effectiveness with ABG results and oxygen saturation via pulse oximetry measurements.

A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect? A. Thick, white coating on the client's tongue. B. Decreased pulse rate C. Paresthesias in the hands and feet D. Joint pain in the extremities

C. Parasthesias in the hands and feet The nurse should identify that paresthesias (tingling sensations) in the hands and feet is an expected finding of pernicious anemia.

A nurse is assessing a client who is 85 years old. Which of the following findings shold the nurse identify as a manifestation of MI? A. Sudden hemoptysis B. Acute diarrhea C. Frontal headache D. Acute confusion

D. Acute confusion Acute confusion is a manifestation of MI in clients age 65 or older. Other manifestations can include nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness, palpitations, and fatigue.

A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? A. Chest pain is relieved soon after resting. B. Nitroglycerin relieves chest pain C. Physical exertion does not precipitate chest pain D. Chest pain lasts for longer than 15 min.

D. Chest pain lasts for longer than 15 mins. A client who has unstable angina will have chest pain lasting longer than 15 minutes. This is due to reduced blood flow in a coronary artery from artherosclerotic plaque and thrombus formation causing partial arterial obstruction or from an artery spasm.

A nurse is assessing a client who has right-sided heart failure. Which of the following should the nurse expect? A. Decreased capillary refill B. Dyspnea C. Orthopnea D. Dependant edema

D. Dependent edema Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent systemic venous backup leads to the development of dependent edema.

A nurse is assessing a client who is receiving a unit of whole blood. Which of the following findings should the nurse identify as a manifeatation of a hemolytic transfusion reaction? A. Bradycardia B. Parasthesia C. Hypertension D. Low back pain

D. Low back pain Low back pain is a manifestation of a hemolytic transfusion reaction. Other manifestations include a headache, chest pain, tachypnea, tachycardia and dark urine.

A nurse is showing a client who has right sided heart failure an illustration of the heart. Which of the following blood vessels carry deoxygenated blood to the right atrium? A. Right coronary artery B. Left carotid artery C. Aorta D. Superior vena cava

D. Superior vena cava

A nurse is providing teaching about lifestyle changes to a client who experienced a myocardial infarction and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching? A. "I should eat foods that are high in saturated fat." B. "Before taking my medication, I will count my radial pulse rate." C. "I will exercise once a week for an hour at the health club." D. "I will stop taking my medication when my blood pressure is within a normal range."

B. "Before taking my medication, I will count my radial pulse rate." A beta blocker will induce bradycardia. The client should take the pulse rate for 1 minute before self-administration.

A nurse is completing teaching with a client who has heart failure and is prescribed a 2g sodium diet. Which of the following statements by the client undicates an understanding of the teaching? A. "I should use salt sparingly while cooking." B. "I can have yogurt as a dessert." C. "I should use baking soda when I bake." D. "I should use canned vegetables instead of frozen."

B. "I can have yogurt as a dessert." The client understands the teaching when he selects yogurt as a dessert. Yogurt is low in fat and sodium and is a good source of calcium and protein.

A nurse is caring for a client who is experiencing acute opiod toxicity. Which of the following actions should the nurse identify as the priority? A. Insert a large-bore IV catheter B. Ensure an adequate airway C. Obtain an accurate medication history D. Prepare to administer an antagonist

B. Ensure an adequate airway Teh first action the nurse should take when using the ABC approach is to ensure the client's airway is adequate, as respiratory depression is a manifestation of opiod toxicity.

A nurse is caring for a client who has severely elevated blood pressure. Which of the following findings should the nurse identify as a manifestation of hypertension? A. Vertigo B. Epistaxis C. Exophtalmos D. Spondylolisthesis

B. Epistaxis A nosebleed is a manisfestation of elevated blood pressure. Hypertension is often asymptomatic, but when it is severely elevated it can also cause headaches, dizziness, facial flushing and fainting.

A nurse is completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? (Select all that apply) A. Hypothroidism B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking

B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking

A client is admitted to the ED following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? A. Friction rub B. Crackles C. Crepitus D. Tactile fremitus

C. Crepitus Crepitus, also called subcutaneous emphsema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus includes an air leak into the subcutaneous tissue, which is often a clinical manifestation of a pneumothorax.

A nurse is providing discharge teaching to a client who has a new permanant pacemaker. Which of the following statements by the client indicates an understanding of the teaching? A. "I should check my heart rate at the same time each day." B. "I don't have to take my hypertensive medications now that I have a pacemaker." C. "I should keep a pressure dressing over the generator until the incision is healed." D. "I cannot stand in front of our new microwave oven when it is on."

A. "I should check my heart rate at the same time each day." The nurse should instruct the client to check the heart rate at the same time each day and document the rate in a log for reporting to the provider.

A nurse is caring for a client who is undergoing treatment for hypertension. Which of the following statements indicates that the client is adhering to the treatment plan? A. "I would never have believed I could get used to enjoying my food without salt." B. "My blood pressure device at home usually shows about 156/98 or so." C. "I make sure I take my blood pressure medicine when I have headaches." D. "My blood pressure pills are very expensive. Could I take a cheaper medication?"

A. "I would never have believed I could get used to enjoying my food without salt." This statements implies that the client has stopped adding salt to food. Sodium restriction is a single aspect of the treatment plan, but it does indicate dietary adherence by the client.

A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus? A. A client who has a chest tube following a pneumothorax. B. A client who has an acute exacerbation of Crohn's disease. C. A client who is postoperative followin ga laparoscopic appendectomy. D. A client who is recovering from thyroid storm.

A. A client who has a chest tube following a pneumothorax. Crepitus, a crackling sound resulting from air trapped under the skin, can be palpated following a pneumothorax. The nurse should report this finding to the provider.

A nurse in the ED is assessing a client for closed pneumothorax and significant bruising of the left chest following a motor vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi

A. Absence of breath sounds A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.

A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (Select all that apply.) A. Assign the client to a private room with negative-pressure airflow. B. Add contact precautions to the client's plan of care. C. Wear an N95 respirator when entering the clients room. D. Ensure the client's environment provides 4 exchanges of fresh air per minute. E. Institute protective enviroment precautions as soon as the client arrives on the unit.

A. Assign the client to a private room with negative pressure airflow. C. Wear an N95 respirator when entering the clients room This clients history and present status suggest tuberculosis, a communicable infection that mandates a private room with negative pressure airflow. Airborne precautions will be required, including wearing an N95 respirator when entering the client's room.

A nurse is teaching about a low-cholesterol diet to a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching? A. Chicken breast and corn on the cob B. Shrimp and rice C. Cheese omelet and turkey bacon D. Liver and onions

A. Chicken breast and corn on the cob

A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document? A. Coarse crackles B. Wheezes C. Rhonchi D. Friction rub

A. Coarse crackles A client who had a recent MI is at risk for left sided heart failure. Crackles are breath sounds caused by movement of air through airways partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing.

A nurse is reviewing the laboratory findings of a client who has protein-calorie malnutrition. Which of the following findings should the nurse expect? A. Decreased albumin B Elevated hemoglobin C. Elevated lymphocytes D. Decreased cortisol

A. Decreased albumin A decrease in the albumin level can be an indication of a long-term protein depletion. Other potential conditions that result in decreased albumin levels include burns, wound drainage, and impaired hepatic function.

A nurse is reviewing the laboratory results of a client who has end-stage renal disease and reports fatigue. The client's hemoglobin level is 8 g/dL. The nurse should expect a prescription for which of the following medications? A. Erythropoietin B. Erythromycin C. Filgrastim D. Calcitriol

A. Erythropoietin Erythropoietin stimulates the production of RBC's and is used to treat anemia associated with chronic renal failure.

A nurse is assessing a client who has deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find? (Select all that apply.) A. Hardening along the blood vessel. B. Absence of peripheral pulse C. Tenderness in the calf D. Cool skin on the leg E. Increased leg circumfrence

A. Hardening along the blood vessel. C. Tenderness in the calf E. Increased leg circumference Deep vein thrombosis can cause hardening along the affected blood vessel and prominence of superficial veins, pain or tenderness in the calf, and an increase in the circumference of the leg due to swelling.

A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? A. Hyperkalemia B. Hyponatremia C. Hypercalcemia D. Hypomagnesemia

A. Hyperkalemia The nurse should monitor the client for hyperkalemia because chronic respiratory acidosis can result in high potassium levels due to potassium shifting out og the cells into the extracellular fluid.

A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? A. Hypokalemia B. Hypophosphatemia C. Hypercalcemia D. Hypermagnesemia

A. Hypokalemia Furosemide can cause the loss of potassium, sodium, calcium and magnesium. Manifestations of hypokalemia can include shallow respirations, muscle weakness, lethargy, and ectopic heartbeats.

A nurse is teaching a client with heart disease about a low cholersterol diet. Which of the following client statements indicates the teaching was effective? A. "I should remove the skin from poultry before eating it." B. "I will eat seafood once per week." C. "I should use margarine when preparing meals." D. "I can use whole milk in my oatmeal."

A. I should remove the skin from poultry before eating it. The nurse should identify the client understands the teaching when he states he will remove the skin from poultry before eating, as the skin contains the greatest amount of fat.

A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? A. Initiate bag-valve-mask ventilation B. Provide the client with a communication board. C. Obtain a blood sample for ABG analysis D. Document the ventilator settings

A. Initiate bag-valve-mask ventilation The nurse should apply the ABC priority setting framework.

A nurse is assessing a client who has a fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? A. JVD B. Moist crackles C. Postural hypotension D. Increased heart rate E. Fever

A. JVD B. Moist crackles D. Increased heart rate The increased venous pressure due to excessive circulating blood volume results in neck vein distension. Moist crackles are an indicator of pulmonary edema that can quickly lead to death. Fluid volume excess (hypervolemia) is an expansion of fluid volume in the extracellular fluid compartment, which results in an increased heart rate and bounding pulses.

A nurse is teaching a client who has coronary artery disease the difference between angina pectoris and myocardial infarction. Which of the following manisfestations should the nurse identify as indications of MI? (Select all that apply) A. Nausea and vomiting B. Diaphoresis and dizziness C. Chest and left arm pain that subsides with rest D. Anxiety and feelings of doom E. Bounding pulse and bradypnea

A. Nausea and vomiting B. Diaphoresis and dizziness D. Anxiety and feelings of doom Theses are all common manisfestations of MI.

A nurse is caring for an older adult client who had an acute MI. When assessing the client, the nurse should identify that older adults are prone to complications of MI from poor tissue perfusion because of which of the following age-related factors? A. Peripheral vascular resistance increases. B. The sensitivity of blood pressure-adjusting baroreceptors increases. C. Blood is hypercoagulable and clots more quickly. D. Cardiac medications are less effective.

A. Peripheral vascular resistance increases. Older adult clients are more prone to complications from poor tissue performance fillowing an acute MI because peripheral vascular resistance increases with aging. This results from calcification and loss of elasticity of the blood vessels.

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A. Stabbing chest pain B. Calf tenderness C. Elevated temperature D. Bradycardia

A. Stabbing chest pain A manifestation of a pulmonary embolism is sudden chest pain that is sharp and stabbing. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood), tachypnea, tachycardia, diaphoresis, and a feeling of impending doom.

A nurse is carying for a client immediately following extubation. Which of the following manifestations indicates that the nurse should call the rapid response team? A. Stridor B. Coughing C. Hoarseness D. Extensive oral secretions

A. Stridor The nurse should identify that stridor (a high-pitched crowing sound heart during inspiration) is caused by laryngeal edema and can indicate impending airway obstruction. The nurse should call the rapid response team for assistance before the airway becomes completely obstructed.

A nurse in a med-surg unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? A. Sudden onset of dyspnea B. Trachael deviation C. Bradycardia D. Difficulty swallowing

A. Sudden onset of dyspnea. Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs.

A nurse is reviewing the menu selections of a client who has heart failure and anticipates discharge to home the following day. Which of the dollowing lunch choices should the nurse identify as an indication that the client understands his dietary instructions? A. Turkey on whole-wheat bread B. Hamburger and french fries C. Frankfurter on a white roll D. Macaroni and cheese

A. Turkey on whole-wheat bread. The primary dietary alteration for a client who has heart failure is sodium restriction. A turkey sandwich with whole-wheat bread has a relatively low sodium content.

A nurse is providing discharge teaching about improving gas exchange for a client who has emphysema. Which of the following instructions should the nurse include in the teaching? A. Use pursed-lip breathing during periods of dyspnea. B. Limit fluid intake to 1,500mL per day C. Practice chest breathing each day D. Wear home oxygen to maintain an SaO2 of at least 94%.

A. Use pursed lip breathing during periods of dyspnea. The nurse should instruct the client about using pursed lip breathing during periods of dyspnea to slow expiration, increase airway pressure, and facilitate effective gas exchange.

A nurse is assessing a client who has late-stage heart failure and is experiencing fluid overload. Which of the following findings should the nurse expect? A. Weight gain of 1kg in 1 day B. Pitting edema +1 C. Client report of nocturnal cough D. B-type natriuretic peptide (BNP) level of 100pg/mL

A. Weight gain of 1kg in 1 day. A weight gain of 1kg in 1 day indicates that the client is retaining fluid and is at risk of fluid volume overload. This suggests the client's heart failure is worsening.

What are common manifestations of peripheral arterial disease? A. Ankle swelling B. Absent pedal pulses C. Hair loss D. Skin atrophy

All except for ankle swelling. Absent pedal pulses and hair loss of the affected extremity is seen in PAD.

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? A. Eliminating enviromental triggers that precipitate attacks. B. Addressing the client's perceptin of the disease process and what might have triggered past attacks. C. Overviewing the client's medicaiton regimen. D. Explaining manifestations of respiratory infections

B. Addressing the client's perception of the disease process and what might have triggered past attacks. The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Assessing the client will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first assess the client's current knowledge.

A nurse is assessing a client who has peripheral vasular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity? A. Absent pedal pulses B. Ankle swelling C. Hair loss D. Skin atrophy

B. Ankle swelling The nurse should identify that swelling of the ankle is a manifestation of venous insufficiency due to poor venous return. Other manisfestations can include brown pigmentations and cellulitis.

A nurse is caring for a client who has a platelet count of 50,000mm^3. After discontiniung the client's periperal IV ite, which of the following actions should the nurse take? A. Apply warm compresses B. Apply pressure to the catheter removal site for 5 min C. Place the affected arm in a dependent position D. Clean the insertion site with alcohol

B. Apply pressure to the catheter removal site for 5 in. A platelet count below 100,000mm^3 indicates theombocytopenia, which puts the client at an increased risk of bleeding. By applying pressure to the site for at least 5 minutes, the nurse promotes coagulation and prevents additional blood loss.

A nurse is caring for a client who has acute lymphocytic leukemia and reports a fever, chills, fatigue, and pallow over the past week. When checking the client's laboratory results, which of the following values should the nurse identify as contributing to the client's fatigue and pallow? A. Magnesium 2.0 mEq/L B. Hgb 6.5g/dL C. WBC count 9.6/mm3 D. Creatinine 0.8mg/dL

B. Hgb 6.5 g/dL The expected reference range of Hgb is 14 to 18 g/dL for men and 12 to 16 g/dL for women. Therefore a client with an Hgb level of 6.5 g/dL has anemia. Typical manifestations of a low Hgb level include fatigue, headaches, pallor, dizziness, and tachycardia.

A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? A. Increased cardiac output/ B. Increased pulmonary congestion C. Decreased left atrial pressure D. Decreased pulmonary artery pressure

B. Increased pulmonary congestion. Pulmonary congestion is a manifestation of mitral valve stenosis. Because of the defect in the mitral valve, the left atrial pressure rises and the left atrium dilates. The increased pressure results in a backflow of blood from the left atrium through the pulmonary vein and into the lungs resultating in pulmonary congestion.

A nurse is providing instructions about pursed-lip breathing for a client who has COPD with emphysema. This breathing technique accomplishes which of the following? A. Increases oxygen intake B. Promotes cardion dioxide elimination C. Uses the intercostal muscles D. Strengthens the diaphragm

B. Promotes carbon dioxide elimination A client with COPD with emphysema should use pursed lip breathing when experiencing dyspnea. This slows the pace of breathing, making each breath more effective. Pursed lip breathing releases trapped air in the lungs and prolongs exhalation in order to slow the breathing rate. This improved pattern moves carbon dioxide out of the lungs more efficiently.

The nurse is caring for an older adult client who has COPD with pneumonia. The nurse should watch the client for which of the following acid-base imbalances? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis

B. Respiratory acidosis Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.

A nurse is administering a unit of packed red blood cells to a client who is postoperative. The client reports itching and hives 30 min after the infusion begins. Which of the following actions should the nurse take first? A. Maintain IV access with 0.9% sodium chloride. B. Stop the infusion of blood C. Send the bloof container and tubing to the blood bank. D. Obtain a urine sample

B. Stop the infusion of blood. Using the urgent vs. non-urgent priority setting framework, the nurse should consider urgent needs the priority because they pose more of a threat to the client. The nurse should stop the infusion because the client is having manifestations of an allergic reaction

A nurse is providing discharge teaching to a client who had a pulmonary embolism. Which of the following statements indicates that the client understands the information? A. "I'll expect a little leg swelling since I won't be that active for awhile." B. "I'll see the doctor every week to change my vena cava filter." C. "I'll call the doctor is I see any blood in my uring or stool." D. "I'll have to take the blood thinner for a few more days."

C. "I'll call my doctor if I see any blood in my urine or stool." Bleeding precautions are essential for clients who had a pulmonary embolism because they take an anticoagulant. They should report any signs of bleeding immediately.

A nurse is teaching breathing techniques to a client who has emphysema. Which of the following statements indicates that the client understands the mechanics of pursed-lip breathing? A. "I'll inhale clowly through pursed lips to help me breathe better." B. "When I do my pursed lip breathing, I'll lie down first." C. "When I breathe out through pursed lips, my airways don't collapse between breaths." D. "I'll relax my stomach muscles when I am doing my pursed lip breathing exercises."

C. "When I breathe out through pursed lips, my airways don't collapse between breaths." Breathing through pursed lips slows exhalation and maintains inflation of the distal airways, which enhances respiration for clients who have emphysema. The client should use this technique during physical activity and episodes of dyspnea.

A nurse in clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect? A. Pitting edema B. Areas of reddish-brown pigmentation C. Dry, pale skin with minimal body hair D. Sunburned appearance with desquamation

C. Dry, pale skin with minimal body hair. A client who has peripheral arterial disease can display dry, scaly, pale or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittend claudication (leg pain with exercise) cold or numb feet at rest, loss of hair on lower legs, and weakened pulses.

A nurse is assessin ga client who has pericarditis. Which of the following manifestations should the nurse expect? A. Bradycardia with ST-segment depression. B. Relief of chest pain with deep inspiration. C. Dyspnea with hiccups D. Chest pain that increases when sitting upright.

C. Dyspnea with hiccups. A client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade.

A nurse is caring for an adult male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder? A. Cholesterol level 195 mg/dL B. Elevated HDL levels C. Elevated LDL levels D. Triglyceride level 135 mg

C. Elevated LDL levels. An elevated LDL level increases a client's risk of atherosclerosis. The client's desirable LDL level is <100 mg/dL.

A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse first take? A. Provide chest physiotherapy B. Perform oropharyngeal suction C. Encourage deep breathing and coughing D. Assist the client with ambulation

C. Encourage deep-breathing and coughing The first action the nurse should take when using the ABC approach is to encourage the client to breathe deeply and cough to clear secretions from the airway.

A nurse is preparing to assist a provider with an ABG withdrawal from a clients radial artery for ABG measurement. Which of the following actions should the nurse plan to take? A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen. B. Apply ice to the site after obtaining the specimen. C. Perform an Allen's test prior to obtaining the specimen. D. Release the pressure applied to the puncture site 1 min after the needle is withdrawn.

C. Perform an Allen's test prior to obtaining the specimen. The nurse should always ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery.

A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following findings indicates that the AAA is expanding? A. Increased BP and decreased pulse rate B. Jugular vein distention and peripheral edema. C. Report of sudden, severe back pain D. Report of retrosternal chest pain radiating to the left arm.

C. Report of sudden, severe back pain. An aortic aneurysm is a weak spot in the wall of the aorta that allows the aorta to expand and increase in diameter. Sudden and increasing abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerves.

A nurse is caring for a client who is extremely anxious and is hyperventilating. The clients ABG results are: pH 7.5, PaCO2 27mmHg, and HCO3 25mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

C. Respiratory alkalosis Because of rapid breathing, the client is echaling excessive amounts of carbon dioxide. This loss of carbon dioxide decreases the hydrogen ion level of the blood, which causes the pH to increase and results in respiratory alkalosis.

A nurse is preparing an inservice presentation about assessing clients who are having an acute MI. What is the most common assessment finding with acute MI? A. Dyspnea B. Pain in the shoulder and left arm C. Substernal chest pain D. Palpitations

C. Substernal chest pain Evidence-based practice indicates that the most common manifestations of acute MI is substernal chest pain that does not subside with rest or nitroglycerin. Therefore, nurses should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation.

A client who just learned that he has variant angina asks the nurse how this type of angina compares with stable angina. Which of the following replies should the nurse make? A. Exertion often brings on pain. B. Variant angina occurs randomly at various times. C. Variant angina can cause changes on your electrocardiogram. D. Reducing your cholerterol can help you experience less pain.

C. Variant angina can cause changes on your electrocardiogram. Variant angia causes ECG changes that reflect coronary artery spasms, which results in less oxygen supplying the myocardium.

A nurse is caring for a client who has peripheral vascular disease. Which of the following findings of PVD is a risk factor for ulceration of the extremities? A. Insufficient skin care B. Dehydration C. Immobility D. Impaired circulation

D. Impaired circulation Prolonged arterial insufficiency from PVD can contribute to the formation of ulcerations on the client's toes. Severe arterial disease is identified through an assessment of the quality of the client's posterior tibial pulses by comparing the pulses in both feet.

A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor? A. Hypokalemia B. Lead poisoning C. Hypercalcemia D. Iron toxicity

D. Iron toxicity A client who has received several blood transfusions is at risk of hemosiderosis, which is the excess storage of iron in the body. Excessive iron can come from overuse of supplements or from receiving frequent blood transfusions as in sickle cell anemia.

A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of COPD. Which of the following oxygen-delivery methods should the nurse plan to use for this client? A. Simple face mask B. Nonrebreather mask C. Bag-valve-mask deice D. Nasal cannula

D. Nasal cannula A nasal cannula delivers precise concentrations of oxygen, therefore, it is an appropriate device for a client who has COPD and requires a precise percentage of inspired oxygen.

A nurse is auscultating the lungs of a client who is having an acute asthma attack. Which of the following sounds should the nurse expect to hear? A. Soft blowing B. Loud bubbling C. Dry grating D. Noisy wheezing

D. Noisy wheezing Asthma causes the bronchioles of the lungs to constrict, creating a wheezing sound.

A nurse is caring for a client who has COPD and is experiencing shortness of breath. Which of the following actions should the nurse perform first? A. Monitor the client's arterial blood gas results. B. Instruct the client to perform controlled coughing. C. Teach the client how to use pursed-lip breathing. D. Place the client in an upright position.

D. Place the client in an upright position. Using the ABC approach, the nurse should place the client in an upright position to facilitate chest expansion and proper diaphragmatic contraction. Positionign the client uright will also assist with mobilizing secretions that might be impeding airflow.

A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. The nurse should identify these findings as manifestations of which of the following complications? A. Pulmonary edema B. Tension pneumothorax C. Flail chest D. Respiratory obstruction

D. Respiratory obstruction. Intercostal retractions and a high pitched inspiratory noise (i.e. stridor) are manifestations of an airway obstruction caused by laryngospasm and edema. The nurse should notify the rapid response team and plan to administer racemic epinephrine.

A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first? A. Elevate the clients feet and legs B. Administer epinephrine C. Infuse 0.9% sodium chloride D. Stop the medicaiton infusion

D. Stop the medication infusion The greatest risk to this client is an allergic reaction that can progress to anaphylaxis. The nurse should stop the infusion immediately to halt further exposure of the client to the allergen.

A nurse is reviewing the progress notes for a client who has heart failure. The provider noted some improvement in the client's cardiac output. The nurse should understand that cardiac output reflects which of the following physiologic parameters? A. The percentage of blood the ventricles pump during each beat B. The amount of blood the left ventricle pumps during each beat C. The amount of blood in the left ventricle at the end of diastole. D. The heart rate times the stroke volume.

D. The heart rate times the stroke volume. Cardiac output is the product of the client's heart rate and stroke volume (the amount of blood the left ventricle pumps with each contraction). In systolic heart failure, the heart cannot pump enough oxygenated blood into the circulation, causing cardiac output to decrease.