Cardio Exam 2
The client is admitted to the emergency department with chest trauma. When assess- ing the client, which signs/symptoms would the nurse expect to find that support the diagnosis of pneumothorax: Bronchovesicular lung sounds and bradypnea. (2) Unequal lung expansion and dyspnea. • Frothy bloody sputum and consolidation 4. Barrel chest and polycythemia
(2) Unequal lung expansion and dyspnea.
Which action should the nurse implement for the client with a hemothoray who has right-sided chest tube and there: is excessive bubbling in the water-seal compartment: I.Check the amount of wall suction being applied. 2. Assess the tubing for any blood clots. .3Milk the tubing proximal to distal. Encourage the client to cough forcefully
.Check the amount of wall suction being applied.
Which nursing interventions should the nurse implement for the chent diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? *Select all that apply* Keep protamine sulfate readily available. Avoid applying pressure to venipuncture sites 3) Assess for overt and covert signs of bleeding. 4.Avoid invasive procedures and injections. 5.Administer stool softeners as ordered.
1 3 4 5
The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client with a mechanical valve res acem lend The clients International Normalizec Ratio (INR) is 2.7. Which action should the nurse implement? 1 Administer the medication as ordered. Prepare to administer vitamin K (AquaMephyton). Hold the medication and notify the HCP. 4. Assess the client for abnormal bleeding.
1 Administer the medication as ordered
The nurse and an unlicensed nursing assistant (NA) are caring for an elderly client diagnosed with emphysema. Which nursing tasks could be delegated to the NA to improve gas exchange? Select all that apply. 1. Keep the head of the bed elevated 2 encourage deep breathing exercises 3.Record pulse oximeter reading. 4. Assess level of concionS 5. Auscultate breath sounds.
1. Keep the head of the bed elevated 2 encourage deep breathing exercises 3.Record pulse oximeter reading.
The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms would the nurse look for when assessing the client: 1. Pleuritic chest discomfort and anxiety. Asymmetrical chest expansion and pallor. • Leukopenia and CRT <3 seconds. 4. Substernal chest pain and diaphoresis.
1. Pleuritic chest discomfort and anxiety
The nurse is caring for the client diagnosed with bacterial pneumonia. Which priority intervention should the nurse implement? 1.Assess respiratory rate and depth 2. Provide for adequate rest period. 3. Administer oxygen as prescribed. 4.Teach slow abdominal breathing.
1.Assess respiratory rate and depth
Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fuctu- ation (tidaling) in the water compartment: 1.Assess the client's bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. Notify the health-care provider as soon as possible. 4. Document the findings in the clients chart
1.Assess the client's bilateral lung sounds.
The nurse is caring for a female client that is very anxious, has a respiratory rate of 40 and is complaining of her fingers tingling and her lips feeling numb. Which interven- tion should the nurse implement? 1.Have the client take slow, deep breaths. 2. Instruct her to put her head between her legs. . Determine why she is feeling so anxious. 4. Administer Xanax, an antianxiety agent.
1.Have the client take slow, deep breaths
The nurse is caring for a client diagnosed with a pneumothorax who had chest tubes inserted four (4) hours ago. There is no fluctuating (adaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse take first? Milk the chest tube. 2 Check the tubing for kinks. Instruct the client to cough. 4 Access the insertion site.
2 Check the tubing for kinks
A client presents to the emergency room following a motorcycle crash. The nurse assesses the client and notes uncoordinated and paradoxial chest rise and fall aswell as multiple bruises across the clients chest and torso, crepitus and tachypnea based on this assessment the nurse should 1) Assist in the placement of a cervical collar 2) Anticipate the need to intubate the client 3) Provide chest compressions. 4) Tape the chest wall
2) Anticipate the need to intubate the client
The nurse identified the client problem "decreased cardiac output" for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care? 1.Monitor the client's arterial blood gases. 2.Assess skin color-and temperature. 3. Check the client for signs of bleeding. 4. Keep the client in the Irendelenburg position
2) Assess skin color-and temperature.
The nurse in a long-term care facility is planning the care for a client with a percutaneous gastrostomy (PEG) feeding tube. Which interventions would the nurse included in the plan of care? Inspect the insertion line at the nare prior to instilling formula. 2) Elevate the head of the bed after feeding the client. Place the client in the Sims position following each feeding. Change the dressing on the feeding tube every three (3) days.
2) Elevate the head of the bed after feeding the client.
While feeding the client diagnosed with aspiration pneumonia, the client becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention would the nurse implement first? 1.Suction the client's nares 2Turn the client to the side. 3. Place the client in the Trendelenburg position. 4. Notify the health-care provider.
2. Turn the client to the side
The nurse is caring for a client with a right-sided chest tube secondary to a pneu- mothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. Place the client in low-Fowler's position. (2.)Assess chest tube drainage system frequently. 3.Maintain strict bed rest for the client 4 Secure a loop of drainage tubing to the sheet. 5 Observe the site for subcutaneous emphysema
2.)Assess chest tube drainage system frequently 4 Secure a loop of drainage tubing to the sheet. 5 Observe the site for subcutaneous emphysema
The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the physician is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? Gather the needed supplies for the procedure. 2.Obtain a signed informed consent form. Assist the chent into a side-lying position. 4. Discuss the procedure with the client.
2.Obtain a signed informed consent form
The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a cent diagnosed with a pulmonary embolus. Which data would cause the nurse to question administering the medication: The client's partial thromboplastin time (PTT) is 39 2.The client's international Normalized Ratio (INR) is 5. •3. The client's prothrombin time (PT) is 22. 4. The client's erythrocyte sedimentation rate (ESR) is 10.
2.The client's international Normalized Ratio (INR) is 5.
The client diagnosed with tuberculosis has been treated with antitubercular medica- tions for six (6 weeks. Which data would indicate the medication has been effective? A decrease in the white blood cells in the sputum. 2.The client's symptoms are improving. 3. No change in the chest x-ray. 4 The shin test is now negative
2.The client's symptoms are improving
The client admitted with pneumonia is taking Imuran, an immunosuppressive agent Which question should the nurse ask the client regarding this medication? "Do you know this medication has to be tapered off when discontinued? "Have you been exposed to viral hepatitis B or C recently?" 3 Why are you taking this medication, and how long have you taken it?" "Do you have a lot of allergies or sensitivities to different medications?"
3 Why are you taking this medication, and how long have you taken it?"
The nurse is discussing the results of a tuberculosis skin test. Which explanation should the nurse give the client? 1. A red area is a positive reading that means the chent has tuberculosis. The skin test is the only procedure needed to diagnose tuberculosis. 3. A positive reading means exposure to the tuberculosis bacilli. Do not get another skin test for one (I) year it the skin test is positive.
3. A positive reading means exposure to the tuberculosis bacilli
The client diagnosed with deep vein thrombosis (DVT) suddenly complains of severe chest pain and a feeling of impending doom. Which complication would the nurse suspect the client has experienced: 1. Myocardial infarction. 2. Pneumonia 3. Pulmonary embolus 4. Pneumothorax.
3. Pulmonary embolus
The community health nurse involved in programs to prevent rheumatic fever knows that the most important intervention to decrease the the incidence of the disease includes: 1. immunizing susceptible groups of people with streptococcal vaccine. 2. providing prophylactic antibiotics to people with a family history of rheumatic fever. 3. teaching people to seek medical diagnosis and treatment for streptococcal pharyngitis. 4. promoting hygienic measures to prevent the transmission of streptococcal infections.
3. teaching people to seek medical diagnosis and treatment for streptococcal pharyngitis.
The day shift charge nurse on a medical unit is making rounds after report. Which client should be seen first? 1. The 6S-year-old client diagnosed with tuberculosis who has a sputum specimen to be sent to the lab. 2. The 76-year-old client diagnosed with aspiration pneumonia who has a clogged feeding tube. 3.The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%. 4. The 39-year-old client diagnosed with bronchitis who has an arterial oxygenation level of 89%.
3.The 45-year-old client diagnosed with pneumonia who has a pulse oximetry read- ing of 92%
The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of "impaired gas exchange." Which would be an expected outcome for this problem? 1. Performs chest physiotherapy three (3) times a day. Able to complete activities of daily living. Ambulates in the hall and back several times during each shift. 4 Alert and oriented to person, place, time, and events.
4 Alert and oriented to person, place, time, and events.
The client has a right-sided chest tube. As the client is getting out of the bed it is acci- dentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. Instruct the client to take slow shallow breaths until the tube is reinserted Take no action and assess the client's respiratory status ever 15 minutes. 4 Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.
4 Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.
The public health department nurse is caring for the client diagnosed with active tuberculosis who has been placed on directly observed therapy (DOT). Which state- ment best describes this therapy? 1. The nurse accounts for all medications administered to the client. The nurse must complete federal, state, and local forms for this client. The nurse must report the client to the Centers for Disease Control. (4)The nurse must watch the client take the medication daily.
4)The nurse must watch the client take the medication daily.
The client is admitted with a diagnosis of rule out tuberculosis. Which type of isolation procedures should the nurse implement? 1.Standard Precautions. 2.Contact Precautions 3. Droplet Precautions. 4.Airborne Precautions.
4.Airborne Precautions.
The client has just been diagnosed with a pulmonary embolus. Which intervention should the nurse implement? 1. Administer oral anticoagulants. 2. Assess the clients bowel sounds. 3.Prepare the chient for a thoracentesis 4.Institute and maintain bed rest.
4.Institute and maintain bed rest
The client in the intensive care unit on a mechanical ventilator is bucking the ventila- tor, causing the alarms to sound. Which assessment data should the nurse obtain? List the order of priority. Assess the ventilator alarms. Assess the client's pulse oximetry reading. Assess the chients lung sounds. 4. Assess for symmetry of the clients chest expansion. 5.Assess the clients endotracheal tube tor secretions
5 2 3 4 1
The client is diagnosed with a pulmonary embolus and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour?
880
While the nurse is taking a health history from a patient with hypertrophic cardiomyopathy, information that the nurse recognizes as significant includes a ?
?
The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply. A. Place the client on oxygen by nasal cannula. B. Plan for periods of rest during activities of daily living. C. Place the client on a fluid restriction of 1000 mL. per day. D. Restrict the client's smoking to two (2) to three (3) cigarettes per day. E. Monitor the client's pulse oximetry readings every four (4) hours.
A,B,E
The nurse observes the unlicensed nursing assistant (NA) entering an airborne isolation room and leaving the door open. Which action would be the nurses best response? A. Close the door and discuss the NA's action when the NA comes out of the room. Make the NA come back outside the room and then renter closing the door Say nothing to the NA but report the incident to the nursing supervisor 4. Enter the clients room and discuss the matter with the NA immediately
A. Close the door and discuss the NA's action when the NA comes out of the room.
The nurse iS assessing a 79-year-old client diagnosed with pneumonia. Which signs and d symptoms would the nurse expect to find when assessing the client: 1Confusion and lethargy. 2. High fever and chills. 3. Frothy sputum and edema. 4. Bradypnea and jugular vein distention.
A. Confusion and lethargy
client diagnosed with a pulmonary embolus is being discharged. Which interven- ton should the nurse discuss with the client? A. Increase fluid intake to two (2) to three (3) liters a Day B. Eat a low-cholesterol, low-fat diet. C. Avoid being around large crowds 4. Receive pneumonia and Flu vaccines.
A. Increase fluid intake to two (2) to three (3) liters a Day
A hospitalized client is being treated for tuberculosis. When administering medications , which medication administration should the nurse conclude is used for treatment of TB A. Isoniazid (Nydrazid) B. Fluconnazole (Diflucan) C. Azithromycin (Zithromax) D. Acyclovir (Zovirax)
A. Isoniazid (Nydrazid)
A nurse receives the following medication orders while caring for multiple clients. Which medication should the nurse plan to administer first? A. Nitroglycerin B.Morphine C.Lorazepam D. One unit packed red blood cells
A. Nitroglycerin
A patient with dilated cardiomyopathy is admitted to the hospital with fatigue, orthopnea, and pulmonary crackles. The patient has a left ventricular ejection fraction 18%, and the physician prescribes continuous intravenous heparin. The nurse explains to the patient that heparin is used to: A. Prevent thrombus formation in the left ventricle B. Increase the circulation to the skin and skeletal muscles C. Prevent embolization to the lungs from clots in the legs D. Decrease the viscosity of the blood to decrease cardiac workload
A. Prevent thrombus formation in the left ventricle
The nurse recognizes that the goals of teaching regarding the transmission of TB have been met when the patient with TB A.covers the mouth and nose with a tissue when coughing or sneezing B.wears a mask when in contact with others. C.boils dishes and personal items between uses. D. Reports daily to the public health department
A.covers the mouth and nose with a tissue when coughing or sneezing
A patient with dilated cardiomyopathy is admitted to the hospital with fatigue, orthopnea, and pulmonary crackles. The patient has a left ventricular ejection fraction of 18%, and the physician prescribes continuous intravenous heparin. The nurse explains to the patient that that heparin is used to: A.prevent thrombus formation in the left ventricle b.increase the circulation to the skin and skeletal muscles
A.prevent thrombus formation in the left ventricle
The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an IN 2.8. What action should the nurse implement? 1. Assess the client for abnormal bleeding. 2.Prepare to administer vitamin K (AquaMephyton). 3.Administer the medication as ordered. 4 Notify the HCP to obtain an order to increase the dose.
Administer the medication as ordered
Which nursing interventions should the nurse implement for the client who has respiratory disorder? Select all that apply. Administer oxygen via a nasal cannula Assess the client's lung sounds Encourage the client to cough and deep breathe. 4. Monitor the clients pulse oximeter reading. Increase the clients tuid intake.
All
47. When caring for the client with a respiratory disorder, which intervention should the nurse implement first: 1. Administer a respiratory treatment. Assess the client's radial pulses daily. Monitor the client's vital signs daily. 4.Assess the client's capillary refill time.
Assess the client's capillary refill time
The 56-year-old client diagnosed with tuberculosis (TB) is being discharged. Which statement made by the client indicates an understanding of the discharge instructions? A. "I will take my medication for the full three (3) weeks prescribed." B. 1 must stay on the medication for months if I am to get well C. "I can be around my friends because I have started taking antibiotics." D. "I should get a TB skin test every three (3) months to determine if I am well."
B. 1 must stay on the medication for months if I am to get well
Complete lung expansion before the removal of chest tubes is evaluated by: A.return of normal tidal volume B. Comparison of chest x rays C. Clamp the tubing to prevent a rapid decline in pressure D.administer sedation because the client will be agitate
B. Comparison of chest x rays
A client diagnosed with cardiomyopathy is hyponatremic as a result of fluid volume overload. A fluid restriction of 800ml/24 hours is ordered by a physician. Which action by the nurse is most appropriate? A. Provide the ice chips and refill the glass every 4 hours B. Encourage the client to preform mouth care when feeling thirsty C. offer sugary lozenges for the client to hold in the mouth D. replenish the clients water every 2 hours and have the client take small sips
B. Encourage the client to preform mouth care when feeling thirsty
The client diagnosed with influenza A is being discharged from the emergency department with a prescription for antibiotics. Which statement by the client indicates an understanding of this prescription? A. These pills will make me feel better fast and I can return to work. 1.The antibiotics will help prevent me from developing a bacterial pneumonia. "If I had gotten this prescription sooner I could have prevented this illness. "I need to take these pills until I feel better: then I can stop taking the rest.
B. The antibiotics will help prevent me from developing a bacterial pneumonia.
Following a normal chest x ray for a client who had cardiac surgery, a nurse receives an order to remove the clients chest tubes . Which intervention should the nurse plan to administer first A. auscultate the clients lung sounds B. administer 4 mg morphine sulfate intravenously C. Turn off the suction to the chest drainage system D. prepare the dressing supplies at the clients bedside
B. administer 4 mg morphine sulfate intravenously because the peak action of morphine is 10-15 minutes this should be administered first
Which assessment data would support that the client has experienced a pulmonary embolus? a.Calf pain with dorsiflexion of the foot. B.Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade rever.
B.Sudden onset of chest pain and dyspnea.
A patient being treated for TB comes to the clinic after 2 months for a follow-up visit. Sputum smears for AFB are still positive. A sputum specimen is taken for culture and to determine whether the microorganism is sensitive to the drugs. The nurse questions the patient regarding the treatment regimen with the knowledge that A. treatment protocols involving twice weekly administration of the drugs are not effective methods for treatment B. directly observed therapy (DOT) will be necessary if the patient has been noncompliant C. if the drugs are causing side effects, a regimen including the administration of only isoniazid can be substituted. D. a combination product of isoniazid, rifampin, and pyrazinamide (Rifater) is indicated if the patient skips doses.
B.directly observed therapy (DOT) will be necessary if the patient has been noncompliant
The client is to receive a Mantoux PPD test for tuberculosis. The nurse recognizes that this injection is given: A.Subcutaneously 30 degrees B.intradermally I5 degrees Subcutaneously 45 degrees d. Intramuscularly 90 degrees
B.intradermally I5 degrees
patient who has been diagnosed with TB of the bone tells the nurse that he thought TB was a lung disease. The nurse explains to the patient that A.the microorganism that causes TB starts in the lungs but usually spreads from the lungs to other parts of the body B.lungs are the most common site of TI infection but the mictoorganism'can be 60185. spread to othet organs through the blood and lymph systems C.the tuberculosis organism makes a cheesy-like cyst that breaks open and spreads the infection throughout the body. D.the tubercular organism is a mild bacteria that spreads only in people who do not have good immune systems.
B.lungs are the most common site of TI infection but the microorganism can be spread to other organs through the blood and lymph systems
A patient who has been diagnosed with TB of the bone tells the nurse that he thought TB was a lung disease. The nurse explains to the patient that:
B.the lungs are the most common site of TB infection that the microorganism can be spread to other organs through the blood and lymph systems.
Which intervention should the nurse implement first when administering the first dose of in travenous antibiotic to the chient diagnosed with a respiratory infection? Monitor the cients current temperature Monitor the client's white blood cells. )Determine if a culture has been collected 4. Determine the compatibility of fluids.
C Determine if a culture has been collected
The client is suspected of having a pulmonary embolus. Which diagnostic test con- firms the diagnosis? A.Plasma D-dimer test. 2.Arterial blood gases. Chest x-ray. 4. Magnetic resonance imaging (MRI).
C Plasma D-dimer test
The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse take it there is no fluctuation (tidaling) in the water-seal compartment: Obtain an order for a stat chest x-ray. Increase the amount of wall suction. O) Check the tubing for kinks or clots. 4. Monitor the clients pulse oximeter reading.
C. Check the tubing for kinks or clots
Which of the following diagnostic tests is definitive for TB? A. Chest x-ray B. Mantoux test C. Sputum culture D. Tuberculin test
C. Sputum culture The sputum culture for Myobacterium tuberculosis is the only method of confirming the diagnosis. Lesions in the lung may not be big enough to be seen on x-ray. Skin tests may be falsely positive or falsely negative
The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis. Which statement indi- cates the need for radiological evaluation instead of skin testing? A. The client's first skin test indicates a purple flat area at the site of injection. B. The client's second skin test indicates a red area measuring four (4) mm. C. The clients previous skin test was read as positive 4. The client has never shown a reaction to the tuberculin medication.
C. The clients previous skin test was read as positive
The client diagnosed with a pulmonary embolus is in the intensive care unit. Which assessment data would warrant immediate intervention from the nurse? B. The clients telemetry exhibits occasional premature ventricular contractions C. The clients pulse oximeter reading is 90% D. The client's urinary output for the 12-hour shift is 800 mL.
C. The clients pulse oximeter reading is 90
A patient diagnosed with active TB is started on initial drug therapy. The nurse plans to teach the patient about the uses and effects of A.isoniazid, rifampin, and ethambutol. b.Isoniazid, pyrezinamide, and streptomycin, C.isoniazid, niampin, pyrizinamide, and ethambutol d.para-aminosalicylic acid, ethambutol, rifampin, and pyrazinamide.
C.isoniazid, niampin, pyrizinamide, and ethambutol
Which statement by the client indicates the discharge teaching for the client diagnosed with a pulmonary embolus is ettective? "I am going to use a regular-bristle toothbrush.' "I will take antibiotics prior to having my teeth cleaned." "I can take enteric-coated aspirin for my headache D. I will wear a medic alert band at all times.'
D. I will wear a medic alert band at all times
The nurse emphasizes the need for especially close monitoring in the patient who is taking antitubercular drugs and has a history of A.bowel disease. B.heart disease. C.penal disease. D.liver disease.
D. Liver disease
The charge nurse is making client assignments on a medical fioor. Which client should the charge nurse assign to the LPN? 1. The client with pneumonia who has a pulse oximeter reading of 91% The client with a hemothorax who has Hgb of 9 mg/dL and Het of 20%. The client with chest tubes who has jugular vein distention and BP of 96/60. 6 The client who is two (2) hours post-bronchoscopy procedure.
D.The client who is two (2) hours post-bronchoscopy procedure.
When a patient suffers a completc pneumothorax, there is a danger of a mediastinal shift. If such a shin occurs, it may lead to: A.infection of the sutpleural lining b.rupture of the pericardium or aorta C.increased volume of the unaffected side D.decreased filling of the right bear and cardiovasciular compromise
D.decreased filling of the right bear and cardiovasciular compromise
The nurse is caring for a client diagnosed with pneumonia who is having shortness of breath and difficulty breathing. Which intervention should the nurse implement first? Take the client's vital signs. Check the client's pulse oximeter reading. C. Elevate the client's head of the bed. Or give Oxygen Notify the respiratory therapist STAT.
Elevate the client's head of the bed. Or give Oxygen
The nurse is preparing to administer medications to the following clients. Which medication would the nurse question administering? 1. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9. Regular insulin to a client with a blood glucose level of 218 mg/dL Hanging the heparin bag to a client with a PT/PTT of 12.2/98. A calcium channel blocker to the client with a BP of 112/82.
Hanging the heparin bag to a client with a PT/PTT of 12.2/98.
Which intervention should the nurse implement for a male client who has had a left- sided chest tube for six (6) hours and retuses to take deep breaths because it hurts too I Medicate the client and have the client take deep breaths. Encourage the client to take shallow breaths to help with the pain. 3. Explain that deep breaths do not have to be taken at this time. 4. Tell the client that if he doesn't take deep breaths, he could die.
Medicate the client and have the client take deep breaths
The client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority: 1. Administer the oral antibiotic stat. 2. Order the meal tray to be delivered as soon as possible 3.Obtain a sputum specimen for culture and sensitivity 4.Have the unlicensed nursing assistant weigh the client.
Obtain a sputum specimen for culture and I sensitivity
The client is getting out of bed and becomes very anxious and has a feeling of impend- ing doom. The nurse thinks the client may be experiencing a pulmonary embolus. Which action should the nurse implement first? Administer oxygen ten (10) L via nasal cannula Place the client in a high Fowler's position. Obtain a STAT pulse oximeter reading. Auscultate the cents lung sounds.
Place the client in a high Fowler's position
The client is being evaluated for valvular heart disease. Which information would be most significant: The client has a history of coronary artery disease There is a family history of valvular heart disease. 3. The chient has a history of smoking for ten l0) vears. 4 The client has a history of rheumatic heart disease
The client has a history of rheumatic heart disease
The client is being evaluated for valvular heart disease. Which information would be most significant: The client has a history of coronary artery disease There is a family history of valvular heart disease. The client has a history of smoking for ten years. The client has a history of rheumatic heart disease
The client has a history of rheumatic heart disease
39. The client has iust received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching The client takes prophylactc an adiones The client uses a soft-bristle The client takes an enteric-coated aspirin dailv. The client alternates rest with activitv.
The client takes an enteric-coated aspirin dailv
The client has iust received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching The client takes prophylactc antibiotics The client uses a soft-bristle toothbrush The client takes an enteric-coated aspirin dailv. The client alternates rest with activitv.
The client takes an enteric-coated aspirin dailv.
The client is diagnosed with tuberculosis and prescribed rifampin and isoniazid (INH), both anti-tuberculosis medications. Which instruction is most important for the public health nurse to discuss with the client: 1.The client will have to take the medications for 9-12 months. Z. The client will have to stay in isolation as long as he or she is taking medications. 3. Explain that the client cannot eat any type of pork products while taking the medication The urine may turn turquoise in color, but this is an expected occurrence and harmless
The client will have to take the medications for 9-12 months
The unlicensed nursing assistant is assisting the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse: The client's chest tube is below the level of the chest. The nursing assistant has the chest tube attached to suction. The nursing assistant allowed the client out of the bed. The nursing assistant uses a bedside commode for the client.
The nursing assistant has the chest tube attached to suction
Which assessment data indicate that the chest tubes have been effective in treating the client with a hemothorax who has a right-sided chest tube? There is gentle bubbling in the suction compartment. @ There is no fluctuation (tidaling) in the water-seal compartment. 3. There is 250 mL of blood in the drainage compartment 4. The client is able to deep breathe without any pain.
There is no fluctuation (tidaling) in the water-seal compartment
When a spontaneous pneumothorax is suspected in a patient with a history of emphysema the nurse should call the physician and a. Give O2 @2L per minute via nasal cannula b.administer high concentration 02 90-100% with non-rebreather mask C.place the client on the unaffected side D.prepare for IV administration of electrolytes
a. Give O2 @2L per minute via nasal cannula
Heparin is prescribed for a patient who has dilated cardiomyopathy has been admitted to the hospital with fatigue and orthopnea. Which statement is appropriate for the nurse to use in patient teaching about anticoagulation therapy? a. heparin will prevent blood clots from forming in your heart chambers b. heparin is used to improve circulation to the muscles in your arms and legs c. heparin has been prescribed to stop blood clots from traveling to your lungs d. Heparin makes it easier for your heart to pump
a. heparin will prevent blood clots from forming in your heart chambers
A nurse is caring for a client following a coronary artery bypass graft. Which assessment finding in the immediate postoperative period should be most concerning to the nurse? a. no chest tube output for 1 hour when previously it was copious b. client temperature of 99.1F c. arterial blood gas results ph 7.32 pco 48 hco2 28 po 80 d. urine output of 160 ml in the last 4 hours
a. no chest tube output for 1 hour when previously it was copious a copiously draining chest tube that is no longer draining indicates an obstruction. There is an increased risk for cardiac tamponade or pleural effusion
A patient has a chest tube following a thoracotomy. Continuous bubbling in the suction chamber of the collection device would alert the nurse that a. the unit is functioning normally b. a tension pneumothorax is developing c. the lung has fully expanded d. an air leak may be present
a. the unit is functioning normally
A nurse evaluates that a client understands discharged teaching following aortic valve replacement surgery with a synthetic valve when the client states that he/she plans to SELECT ALL THAT APPLY a. use a soft toothbrush for dental hygiene b. floss teeth daily to prevent plaque formation c. wear loose-fitting clothing to avoid friction on the sternal incision d. use an electric razor for shaving e. report black starry stool f. consume foods high in vitamin K such as broccoli
a. use a soft toothbrush for dental hygiene c. wear loose-fitting clothing to avoid friction on the sternal incision d. use an electric razor for shaving e. report black starry stool
Which client would the nurse would suspect of having a mitral valve prolapse? a. 60 year old female with congestive heart failure b. a 23 year old male with marfan syndrome c. an 80 year old male with atrial fibrilation d. a 33 year old female with down syndrome
b. a 23 year old male with marfan syndrome
The nurse establishes the presence of tension pneumothorax when assessment findings reveal a. absence of lung sounds bilaterally upon auscultation b. deviation of the trachea forward the site opposite the pneumothorax c. a shift of the point of maximal impulse (PMI) to the left with bounding pulse d. inability to auscultate tracheal breath sounds forwards
b. deviation of the trachea forward the site opposite the pneumothorax
patient being treated for TB comes to the clinic after 2 months for a follow-up visit. Sputum smears for AFB are still positive. A sputum specimen is taking for culture and to determine whether the microorganism is sensitive to the drugs. The nurse questions the patient regarding the treatment regimen with the knowledge that:
b. directly observed therapy (DOT) will be necessary if the patient has been noncompliant.
Your patient was the driver in a motor vehicle accident and suffered chest trauma from the impact against the steering wheel. Symptoms include dyspnea, decreased breath sounds, dullness on percussion, shock, hypovelmia. Your care will be based on the fact that the patient is exhibiting signs of a. pneumothorax b. hemothorax c. tension pneumothorax
b. hemothorax
A patient who has developed acute pulmonary edema is hospitalized and diagnosed with dilated cardiomyopathy. Which information will the nurse plan to include when teaching the patient about management of this disorder a. careful compliance with diet and medications will control the patients symptoms b. notify the doctor about any symptoms of heart failure such as shortness of breath c. no more than one or two alcoholic drinks daily are permitted d. elevating the legs above the heart will help relieve angina
b. notify the doctor about any symptoms of heart failure such as shortness of breath
an 80 year old client living in an independent living facility with home health nursing support. The client is diagnosed with pneumonia and started oral antibiotics. Which nursing diagnosis would be most appropriate for this client? a. risk for imbalanced nutrition b. risk for fluid volume deficit c. fluid volume deficit d. fluid volume excess
b. risk for fluid volume deficit rationale: a diagnosis of pneumonia results in fever or increased respiratory rate that increases amount of fluid lost . Additionally older adults have a decreased sensation of thirst
The nurse is caring for a patient with left side chest tube attached to a wet suction tube system. Which observation by the nurse would require immediate intervention? a. Bubbling in the suction chamber b.Dependent loop hanging off the edge of the bed c. banded connections between tubing sections d. occlusive dressing over chest tube insertion site
b.Dependent loop hanging off the edge of the bed a dependent loop creates pressure back up and prevents fluid from draining: this require immediate intervention to prevent lung collapse bubbling in wet system indicates suction is working..
A patient experiences a flial chest as a result of an automobile accident. During the respiratory assessment the nurse would expect to find a. deep irregular respirations b. bloody sputum c. paradoxic chest movement d. laryngeal stridor
c. paradoxic chest movement
The nurse is taking a health history from a 24 year old patient with hypertrophic cardiomyopathy, which information obtained by the nurse is MOST relevant? a. the patient reports using cocaine at age 16 b. the patient has a history of recent upper respiratory infection c. the patients 29 year old brother has had a sudden cardiac arrest d. the patient has a family history if coronary artery disease
c. the patients 29 year old brother has had a sudden cardiac arrest
A male client confides to a clinic nurse that he is no longer dyspenic after receiving his new St Judes heart valve. He wants to have a vasectomy so that he can enjoy sex with his wife without the fear of his wife becoming pregnant. What is the nurses best response a. that is probably a good idea, the life expectancy after a heart valve replacement is 10 -15 years b. You seem to be releived that the heart valve replacement was successful and you can enjoy a normal life again c. if you have cardiac symptoms such as dyspnea during sexual intercourse you can take a nitroglycerin tablet before sex to prevent symptoms d. Be sure to inform the physician that you have an artificial heart valve so you are given antibiotics as a preventative measure before the procedure
d. Be sure to inform the physician that you have an artificial heart valve so you are given antibiotics as a preventative measure before the procedure
1. A 61-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg) tells the nurse that she has a glass of wine two or three times a week. The patient works for the post office and has a 5-mile mail-delivery route. This is her first contact with the health care system in 20 years. Which of these topics will the nurse plan to include in patient teaching about cancer? (Select all that apply.) a. Alcohol use b. Physical activity c. Body weight d. Colorectal screening e. Tobacco use f. Mammography g. Pap testing h. Sunscreen use
d. Colorectal screening f. Mammography g. Pap testing h. Sunscreen use
While obtaining a nursing history from a 23 year old man with rheumatic fever, the nurse recognizes that the most significant information related by the patient is that he: a. Has used illicit intravenous drugs within the last 3 months. b. Has been unemployed for 6 months and has been eating poorly. c. Suffered chest trauma with a fractured rib during a fight 2 weeks ago. d. Had an upper respiratory infection with a sore throat about 3 weeks ago
d. Had an upper respiratory infection with a sore throat about 3 weeks ago
A 60 year-old homeless man has a cough, late-afternoon fever, and night sweats. The patient's response to a purified protein derivate (PPD) skin test is 10 mm. The nurse recognizes that this response indicates that the patient
d. has class # 3 clinically active tuberculosis
a 60 year old homeless man has a cough,later afternoon fever and night sweats. The patients response to a purified protein derivate (PPD) skin test is 10mm. The nurse recognizes that this response indicates that the patient
d. has class #3 clinically active tuberculosis
To monitor for the complication of subcutaneous emphysema after the insertion of chest tubes, the nurse should : a. auscultate the breath sounds for crackled and ronchi b. compare the length of inspiration with the length of expiration c. assess for the presence of a barrel shaped chest d. palpate around the chest tube insertion sites for crepitus
d. palpate around the chest tube insertion sites for crepitus
A nurse is caring for a client suspected of having a pulmonary embolism. The client's arterial blood gas (ABG) results indicate respiratory alkalosis. Which findings support this diagnosis? pH = 7.54; Paco, = 25; Hco; = 24 2. pH = 7.35: Paco, = 35; Hco, = 22 -pH = 7.50; Paco, = 40; Hcoj = 28 4. pH = 7.32; Paco, = 48; Hco, = 24
pH = 7.54; Paco, = 25; Hco; = 24
