Care Management II: Exam 4

A nursing student caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air? a. 14% b. 21% c. 28% d. 31%

b. 21% Room air is 21% oxygen

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the client's support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the client's obligations.

b. Assist in finding one change the client can control. - all options are appropriate, but this client feels overwhelmed by the suggested lifestyle change. assist the client in choosing one the client feels optimistic about changing

The nurse instructs a client on how to correctly use an inhaler with a spacer. In which order should these steps occur? 1. press down firmly on the canister to release one dose of the medication 2. breathe in slowly and deeply 3. shake the whole unit vigorously three or four times 4. insert the mouthpiece of the inhaler into the non mouthpiece end of the spacer 5. place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece 6. remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds

4. insert the mouthpiece of the inhaler into the non mouthpiece end of the spacer 3. shake the whole unit vigorously three or four times 5. place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece 1. press down firmly on the canister to release one dose of the medication 2. breathe in slowly and deeply 6. remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds

The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur? 1. take as deep a breath as possible 2. stand up (unless you have a physical disability) 3. place the meter in your mouth, and close your lips around the mouthpiece 4. make sure the divide reads zero or is at base level 5. blow out as hard and as fast as possible for 1 to 2 seconds 6. write down the value obtained 7. repeat the prices two additional times, and record the highest number in your chart

4. make sure the divide reads zero or is at base level 2. stand up (unless you have a physical disability) 1. take as deep a breath as possible 3. place the meter in your mouth, and close your lips around the mouthpiece 5. blow out as hard and as fast as possible for 1 to 2 seconds 6. write down the value obtained 7. repeat the prices two additional times, and record the highest number in your chart

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service? a. African-american churches b. asian-americas groceries c. high school sports camps d. women health clinics

a. African-american churches - African Americans in the US have one of the highest rates of HTN in the world

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time

a. Applying suction while inserting the catheter - suction should only be applied while withdrawing the catheter

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. I can use a heating pad on my legs if its set on low b. I should not cross my legs when sitting or lying down c. I will go out and buy some warm, heavy socks to wear d. its going to be really hard but I will stop smoking

a. I can use a heating pad on my legs if its set on low - clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result

After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply) a. Ill read the nutritional labels on food items for salt content b. I will drink at least 3 liters of water each day c. using salt in moderation will reduce the workload of my heart d. I will eat oatmeal for breakfast instead of ham and eggs e. substituting fresh vegetables for canned ones will lower my salt intake

a. Ill read the nutritional labels on food items for salt content d. I will eat oatmeal for breakfast instead of ham and eggs e. substituting fresh vegetables for canned ones will lower my salt intake

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply) a. a 22-year-old client with asthma b. client who had a cholecystectomy last year c. client with well-controlled diabetes d. healthy 72-year-old e. client who is taking medication for hypertension

a. a 22-year-old client with asthma c. client with well-controlled diabetes d. healthy 72-year-old e. client who is taking medication for hypertension - clients over 65 years of age and any client (no matter what age) with a chronic health condition would be considered a priority for a pneumonia vaccination. Having a cholecystectomy a year ago does not quality as a chronic health condition

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oran and nasopharyngeal secretions? (Select all that apply) a. a 24-year-old with traumatic Brian injury b. a 36-year-old who fractured his left femur c. a 58-year-old at risk for aspiration following radiation therapy d. a 66-year-old who is a quadriplegic and has a sacral ulcer e. an 80-year-old who is aphasic after a cerebral vascular accident

a. a 24-year-old with traumatic Brian injury c. a 58-year-old at risk for aspiration following radiation therapy d. a 66-year-old who is a quadriplegic and has a sacral ulcer e. an 80-year-old who is aphasic after a cerebral vascular accident - risk for asphyxiation related to inspissated oral and nasopharyngeal secretions is caused by poor oral hygiene. clients at risk include those with altered mental status and level of consciousness (traumatic brain injury), dehydration, an inability to communicate (aphasic) and cough effectively (quadriplegic), and risk of aspiration (aspiration precautions)

A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure? a. a 36-year-old woman with aortic stenosis b. a 42-year-old man with pulmonary hypertension c. a 59-year-old woman who smokes cigarettes daily d. a 70-year-old man who had a cerebral vascular accident

a. a 36-year-old woman with aortic stenosis - most people with HF have failure that progresses from left to right, but it is possible to have only left for a short period

A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply) a. a 36-year-old woman with systemic lupus erythematous (SLE) b. a 42-year-old man recovering from coronary artery bypass graft surgery c. a 59-year-old woman recovering from a hysterectomy d. an 80-year-old man with a bacterial infection of the respiratory tract e. an 88-year-old woman with a stage III sacral ulcer

a. a 36-year-old woman with systemic lupus erythematous (SLE) b. a 42-year-old man recovering from coronary artery bypass graft surgery d. an 80-year-old man with a bacterial infection of the respiratory tract

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply) a. absorptive atelectasis b. combustion c. dried mucous membranes d. oxygen-induced hyperventilation e. toxicity

a. absorptive atelectasis b. combustion c. dried mucous membranes e. toxicity - these are the complications you would want to teach your patient about. oxygen-induced hyperventilation is a complication as well but not to teach a patient.

A hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply) a. amoxicillin (amoxil) b. ciprofloxacin (cipro) c. doxycycline (vibramycin) d. ethambutol (myambutol) e. sulfamethoxazole-trimethoprim (SMX-TMP) (Septra)

a. amoxicillin (amoxil) b. ciprofloxacin (cipro) c. doxycycline (vibramycin)

The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a. antibiotics started before admission b. blood cultures obtained within 20 minutes c. chest x-ray obtained within 30 minutes d. pulse oximetry obtained on all clients

a. antibiotics started before admission - goals for treatment include initiating antibiotics prior to inpatient admission or within 6 hours of presentation to the ED

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for DVT prevention? (Select all that apply) a. apply compression stockings b. assist with ambulation c. encourage coughing and deep breathing d. offer fluids frequently e. teach leg exercises

a. apply compression stockings b. assist with ambulation d. offer fluids frequently

A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)? a. apply water-soluble ointment to nares and lips b. periodically turn the oxygen down or off c. remove the tubing from the client's nose d. turn the client every 2 hours or as needed

a. apply water-soluble ointment to nares and lips - oxygen can be drying to lips and nares. other options UAP cannot do

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to an unlicensed assistive personnel (UAP)? (Select all that apply) a. applying water-soluble lip balm to the client's lips b. ensuring the humidification provided is adequate c. performing oral care with alcohol-based mouthwash d. reminding the client to cough and deep breathe often e. suctioning excess secretions through the tracheostomy

a. applying water-soluble lip balm to the client's lips d. reminding the client to cough and deep breathe often - UAP can perform hygiene measures like lip balm and reinforce teaching. oral care can be accomplished with normal saline, not products that dry the mouth

A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a. appropriate hand hygiene before giving care b. assessing the client's temperature every 4 hours c. clean technique when changing dressings d. monitoring the client's daily white blood cell count

a. appropriate hand hygiene before giving care - hand hygiene best way to prevent infections in hospitalized clients

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this client's safety prior to discharging home? (Select all that apply) a. are your bedroom and bathroom on the first floor? b. what social support do you have at home? c. will you be able to afford your oxygen therapy? d. what spiritual beliefs may impact your recovery? e. are you able to accurately weight yourself at home

a. are your bedroom and bathroom on the first floor? b. what social support do you have at home? d. what spiritual beliefs may impact your recovery?

A nurse is working with a client who takes atorvastatin (Lipitor). The client's recent laboratory results include a BUN of 33mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. ask if the client eats grapefruit b. assess the client for dehydration c. facilitate admission to the hospital d. obtain a random urinalysis

a. ask if the client eats grapefruit - drug-food interaction between statins and grapefruit

A nurse is caring for a client with a non healing arterial ulcer. The physician has informed the client about possibly needing to amputate the client's leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply) a. ask the client to describe his or her current emotions b. assess the client for support systems and family c. offer to stay with the client if he or she desires d. relate how smoking contributed to this situation e. tell the client that many people have amputations

a. ask the client to describe his or her current emotions b. assess the client for support systems and family c. offer to stay with the client if he or she desires

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this client's plan of care? (Select all that apply) a. ask the client to drink 2 liters of fluid daily b. add humidity to the prescribed oxygen c. suction the client every 2 to 3 hours d. use a vibrating positive expiratory pressure device e. encourage diaphragmatic breathing

a. ask the client to drink 2 liters of fluid daily b. add humidity to the prescribed oxygen d. use a vibrating positive expiratory pressure device

A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first? a. ask the client to gargle with mouthwash containing lidocaine b. administer prescribed intravenous pain medications c. explain that soreness is normal and will improve in a couple days d. assess the client's neck for redness and swelling

a. ask the client to gargle with mouthwash containing lidocaine - mouthwashes and throat sprays containing a local anesthetic agent such as lidocaine or diphenhydramine can provide relief form a sore throat after radiation therapy

A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. ask the spouse to explain the fear of visiting in further detail b. inform the spouse the precautions are meant to keep other clients safe c. show the spouse how to follow the isolation precautions to avoid illness d. tell the spouse that he or she has already been exposed, so its safe to visit

a. ask the spouse to explain the fear of visiting in further detail - the nurse needs to obtain further information about the spouse's specific fears so they can be addressed

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next? a. assess for symptoms of left-sided HF b. document this as a normal finding c. call the health care provider immediately d. transfer the client to the intensive care unit

a. assess for symptoms of left-sided HF - S3 gallop presence is an early diastolic filling sound indicative of increasing left ventricular pressure

A nurse is caring for a client on IV infusion if heparin. What actions does this nurse include in the client's plan of care? (Select all that apply) a. assess the client for bleeding b. monitor the daily aPTT results c. stop the IV for aPTT above baseline d. use an IV pump for the infusion e. weight the client daily on the same scale

a. assess the client for bleeding b. monitor the daily aPTT results d. use an IV pump for the infusion

An unlicensed assistive personnel (UAP) was feeing a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority? a. assess the client's lung sounds b. assign a different UAP to the client c. report the UAP to the manager d. request thicker liquids for meals

a. assess the client's lung sounds - oxygenation is priority to check for aspiration

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. the client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate? a. assess the client's lung sounds and oxygenation b. instruct the client on another anithypertensive c. obtain a set of vitals and document them d. remind the client that the cough is a side effect of prinivil

a. assess the client's lung sounds and oxygenation - this client could be having an exacerbation of HF or experiencing a side effect of lisinopril (and other ACE inhibitors)

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. assess the client's oxygen saturation b. notify the rapid response team c. oxygenate the client with a bag-valve-mask d. palpate the skin of the upper chest

a. assess the client's oxygen saturation - think ABC (airway, breathing, circulation)

A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? a. assess the client's respiratory status b. draw blood to assess the client's serum electrolytes c. administer intravenous furosemide (Lasix) d. ask the client about current medications

a. assess the client's respiratory status - assessing respiratory and oxygenation status is priority nursing intervention to prevent complications

A client has been diagnosed with a DVT and is to be discharged on warfarin (Coumadin). The client is adamant about refusing the drug because it's dangerous. What action by the nurse is best? a. assess the reason behind the client's fear b. remind the client about laboratory monitoring c. tell the client drugs are safer today than before d. warn the client about consequences of noncompliance

a. assess the reason behind the client's fear - may be related to an experience of someone the client knows. teaching is unsuccessful is nurse cannot address a specific rationale

A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply) a. assisting with chest tube insertion b. facilitating pleural fluid sampling c. performing frequent respiratory assessment d. providing antipyretics as needed e. suctioning deeply every 4 hours

a. assisting with chest tube insertion b. facilitating pleural fluid sampling c. performing frequent respiratory assessment d. providing antipyretics as needed - a client with an empyema is often treated with chest tube insertion, which facilitates obtaining samples of the pleural fluid for analysis and re-expands the lungs. the nurse should perform frequent respiratory system assessment

A nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply) a. atherosclerosis b. down syndrome c. frequent heartburn d. history of hypertension e. history of smoking

a. atherosclerosis d. history of hypertension e. history of smoking

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this client's teaching? (Select all that apply) a. avoid drinking fluids just before and during meals b. rest before meals if you have dyspnea c. have about six small meals a day d. eat high-fiber foods to promote gastric emptying e. increase carbohydrate intake for energy

a. avoid drinking fluids just before and during meals b. rest before meals if you have dyspnea c. have about six small meals a day

A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse induce in this client's teaching? a. avoid using salt substitutes b. take your medication with food c. avoid using aspirin-containing products d. check your pulse daily

a. avoid using salt substitutes - ACE inhibitors such as enalapril inhibit the secretion of potassium. hyperkalemia can be a life-threatening side effect, and clients need to limit potassium, which is in salt substitutes

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying I have been drinking tons of water. How am I dehydrated? What response by the nurse is next? a. breathing so quickly can be dehydrating b. everyone with pneumonia is dehydrated c. this is really just to administer your antibiotics d. why do you think you are so dehydrated?

a. breathing so quickly can be dehydrating - tachypnea and mouth breathing, both seen in pneumonia, increase insensible water loss and can lead to a degree of dehydration

A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? a. clean the skin and clip hairs if needed b. add gel to the electrodes prior to applying them c. place the electrodes on the posterior chest d. turn off oxygen prior to monitoring the client

a. clean the skin and clip hairs if needed - to ensure the best signal transmission, the skin should be clean and the hairs clipped

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply) a. cognition b. dexterity c. hydration d. range of motion e. vision

a. cognition b. dexterity d. range of motion e. vision - the older adult is at risk for having impairments in these things. hydration is not directly related to ability to perform self-care

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next? a. collect the nasal drainage on a piece of filter paper b. encourage the client to blow his or her nose c. perform a test focused on a neurologic examination d. palpate the nose, face, and neck

a. collect the nasal drainage on a piece of filter paper - the client could have a skull fracture that has resulted in leakage of CSF. is different from regular drainage bc it forms a halo when dripped on filter paper

A nurse is caring for a client with a non healing arterial lower leg ulcer. What action by the nurse is best? a. consult with the wound ostomy care nurse b. give pain medication prior to dressing changes c. maintain sterile technique for dressing changes d. prepare the client for eventual amputation

a. consult with the wound ostomy care nurse - a non healing would needs the expertise of the wound ostomy care nurse

While assessing a client who has a facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first? a. contact the provider and prepare for intubation b. administer prescribed albuterol nebulizer therapy c. place the client in high-Fowlers position d. ask the client to perform deep-breathing exercises

a. contact the provider and prepare for intubation - facial and neck edema can occur in clients with facial trauma. Airway patency is the highest priority and the client should be intubated immediately because of the stridor

A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. could you walk further than that a few months ago? b. do you walk mostly uphill, downhill, or on flat surfaces? c. have you ever considered swimming instead of walking? d. how much pain medication do you take each day?

a. could you walk further than that a few months ago? - as PAD progresses, it takes less oxygen demand to cause pain. needing to cut down on activity to be pain free indicates the disease is worsening

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply) a. create a communication system b. don't go out in public alone c. find hobbies to enjoy at home d. try loose-fitting shirts with collars e. wear fashionable scarves

a. create a communication system d. try loose-fitting shirts with collars e. wear fashionable scarves - telling client to stay home is not good advice. want to boost confidence. should have sound communication system to ease frustration

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply) a. decrease in cardiac output b. increase in cardiac output c. decrease in blood pressure d. increase in blood pressure e. decrease in urine output f. increase in urine output

a. decrease in cardiac output d. increase in blood pressure e. decrease in urine output - elevated HR in healthy clients initially cause blood pressure and cardiac output to increase, but a person who has CHF or long-term tachycardia, BP will eventually decrease. As cardiac output a dn BP decrease, urine output will fall

A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply) a. dietary restrictions b. driving restrictions c. follow-up laboratory monitoring d. possible drug-drug interactions e. reason to take medication

a. dietary restrictions c. follow-up laboratory monitoring d. possible drug-drug interactions e. reason to take medication

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. educating the client on adherence to the treatment program b. encouraging the client to eat a well-balanced diet c. informing the client about follow-up sputum cultures d. teaching the client ways to balance rest with activity

a. educating the client on adherence to the treatment program - treatment regimen for TB ranges from 6-12 months, making adherence problematic for many people

A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take? a. encourage oral rinsing after fluticasone administration b. obtain an oral specimen for culture and sensitivity c. start the client on a broad-spectrum antibiotic d. document the findings as a known side effect

a. encourage oral rinsing after fluticasone administration - fluticasone reduces local immunity and increases the risk for local infection, especially candida albicans. rinsing the mouth after will decrease the risk.

The nurse is caring for four hypertensive clients. Which drug/laboratory value combination should the nurse report immediately to the healthcare provider? a. furosemide (Lasix)/potassium 2.1 mEq/L b. hydrochlorothiazide (Hydrodiuril)/potassium 4.2 mEq/L c. spironolactone (Aldactone)/potassium 5.1mEq/L d. torsemide (Demadex)/sodium 142 mEq/L

a. furosemide (Lasix)/potassium 2.1 mEq/L - furosemide is a loop diuretic and can cause hypokalemia

A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply) a. hematocrit 32.8% b. serum sodium 130 mEq/L c. serum potassium 4.0 mEq/L d. serum creatinine 1.0 mg/dL e. proteinuria f. microalbuminuria

a. hematocrit 32.8% b. serum sodium 130 mEq/L e. proteinuria f. microalbuminuria

A nurse cares for a client with a 40-year smoking history who is experiencing distanced neck veins and dependent edema. Which physiologic process should the nurse correlate with this client's history and clinical manifestations? a. increased pulmonary pressure creating a higher workload on the right side of the heart b. exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c. increased number and size of mucus glands producing large amounts of thick mucus d. left ventricular hypertrophy creating a decrease in cardiac output

a. increased pulmonary pressure creating a higher workload on the right side of the heart - smoking increases pulmonary hypertension, resulting in for pulmonale, or right sided heart failure. increased pressure in the lungs makes it more difficult for blood to flow through the lungs

A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first? a. initiate standard precautions b. apply direct pressure c. sit the client upright d. loosely pack the nares with gauze

a. initiate standard precautions - the nurse should implement standard precautions and don gloves prior to completing the other actions

A nurse cares for a client who is prescribed an intravenous prostacyclin agent. Which actions should the nurse take to ensure the client's safety while on this medication? (Select all that apply) a. keep an intravenous like dedicated strictly to the infusion b. tach the client that this medication increases pulmonary pressures c. ensure that there is always a backup drug cassette available d. start a large-bore peripheral intravenous line e. use strict aseptic technique when using the drug delivery system

a. keep an intravenous like dedicated strictly to the infusion c. ensure that there is always a backup drug cassette available e. use strict aseptic technique when using the drug delivery system

A nurse prepares to discharge a client with cardiac dysrhythmias who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? a. medication reconciliation b. immunization history c. religious beliefs d. nutrition preferences

a. medication reconciliation - needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. mid-sternal chest pain b. increased urine output c. mold orthostatic hypotension d. P wave touching the T wave

a. mid-sternal chest pain - chest pain, possibly angina, indicates that tachycardia may be increasing the clients myocardial workload and oxygen demand

A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanies by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in the client's teaching? a. minimize or abstain from caffeine b. lie on your side until the attack subsides c. use your oxygen when you experience PACs d. take amiodarone (Cordarone) daily to prevent PACs

a. minimize or abstain from caffeine - for clients with PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress

A client is taking warfarin (Coumadin) and asks the nurse if taking St. Johns wort is acceptable What response by the nurse is best? a. no, it may interfere with the warfarin b. there isn't any information about that c. why would you want to take that? d. yes it is a good supplement for you

a. no, it may interfere with the warfarin - many foods and drugs interfere with warfarin and St. Johns wort is one of them

A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers at night is an acceptable intake. What answer by the nurse is best? a. no, women should only have one beer a day as a general rule b. no, you should not drink any alcohol with hypertension c. yes, since you are larger, you can have more alcohol d. yes, two beers per day is an acceptable amount of alcohol

a. no, women should only have one beer a day as a general rule - alcohol intake should be limited to one drink a day for women

A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply) a. observe for clear drainage b. assess for signs of bleeding c. watch the client for frequent swallowing d. ask the client to open his or her mouth e. administer a nasal steroid to decrease edema f. change the nasal packing

a. observe for clear drainage b. assess for signs of bleeding c. watch the client for frequent swallowing d. ask the client to open his or her mouth - observe for leakage for CSF. assess for signs of bleeding by opening mouth. frequent swallowing could indicate postnasal bleeding.

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply) a. pulmonary crackles b. confusion, restlessness c. pulmonary hypertension d. dependent edema e. cough that worsens at night

a. pulmonary crackles b. confusion, restlessness e. cough that worsens at night

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply) a. reposition the client every 2 hours b. teach the client to perform deep-breathing exercised c. accurately record intake and output d. use the same scale to weight the client each morning e. place the client on oxygen if the client becomes short of breath

a. reposition the client every 2 hoursbreathing exercised c. accurately record intake and output d. use the same scale to weight the client each morning

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply) a. shortness of breath b. abdominal bloating c. new-onset bradycardia d. increased ejection fraction e. hypertension

a. shortness of breath b. abdominal bloating c. new-onset bradycardia

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching? (Select all that apply) a. smoking cessation b. stress reduction and management c. avoiding vagal stimulation d. adverse effects of medications e. foods high in potassium

a. smoking cessation b. stress reduction and management d. adverse effects of medications

A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use? a. standard precautions b. bleeding precautions c. reverse isolation d. contact isolation

a. standard precautions - this client does not pose any specific threat of transmitting the causative organism

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply) a. stridor b. nasal stiffness c. edema of the cheek d. ecchymosis behind the ear e. eye pain f. swollen chin

a. stridor d. ecchymosis behind the ear - stridor is a sign of airway obstruction. ecchymosis (bruising) indicated a basilar skull fracture

A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply) a. teach the client about dietary restrictions b. ensure the client is prescribed an ACE inhibitor c. encourage the client to take a baby aspirin every day d. confirm that an echocardiogram has been completed e. consult a social worker for additional resources

a. teach the client about dietary restrictions b. ensure the client is prescribed an ACE inhibitor d. confirm that an echocardiogram has been completed

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (select all that apply) a. the client does not allow smoking in the house b. electrical cords are in good, working order c. flammable liquids are stored in the garage d. household lightbulbs are the fluorescent type e. the client does not have pets inside the home

a. the client does not allow smoking in the house b. electrical cords are in good, working order c. flammable liquids are stored in the garage - light bulbs and pets are not related to oxygen safety

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply) a. until your incision is healed, do not submerge your pacemaker. Only take showers b. report any pulse rates lower than your pacemaker settings c. if you feel weak, apply pressure over your generator d. have your pacemaker turned off before having an MRI e. do not lift your arm above the level of your shoulder for 8 weeks

a. until your incision is healed, do not submerge your pacemaker. Only take showers b. report any pulse rates lower than your pacemaker settings e. do not lift your arm above the level of your shoulder for 8 weeks

A nurse cares for a client with right-sided heart failure. The client asks, why do I need to weight myself everyday? how should the nurse respond? a. weight is the best indication that you are gaining or losing fluid b. daily weights will help us make sure that you are eating properly c. the hospital requires that all inpatients be weighed daily d. you need to lose weight to decrease the incidence of heart failure

a. weight is the best indication that you are gaining or losing fluid - daily weights needed to document fluid retention or loss

A nurse cares for an older adult client with HF. The client states, "I dont know what to do. I dont want to be a burden to my daughter, but I cant do it alone. Maybe I should die." How should the nurse respond? a. would you like to talk more about this? b. you are lucky to have such a devoted daughter c. it is normal to feel as though you are a burden d. would you like to meet with the chaplain?

a. would you like to talk more about this? - having the client talk about their feelings will help the nurse focus on the actual problem

A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in this client's teaching? a. you will need to cut the wires if you start vomiting b. eat six soft or liquid meals each day while recovering c. irrigate your mouth every 2 hours to prevent infection d. sleep in a semi-fowlers position after surgery e. gargle with mouthwash that contains Benadryl once a day

a. you will need to cut the wires if you start vomiting b. eat six soft or liquid meals each day while recovering c. irrigate your mouth every 2 hours to prevent infection d. sleep in a semi-fowlers position after surgery

After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. I should wear a snug-fitting shirt over the ICD b. I will avoid sources of strong electromagnetic fields c. I should participate in a strenuous exercise program d. now I can discontinue my antidysrhythmic medication

b. I will avoid sources of strong electromagnetic fields

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching? a. I'll be able to carry heavy loads after 6 months of rest b. I will have my teeth cleaned by my dentist in 2 weeks c. I must avoid eating foods high in vitamin K, like spinach d. I must use an electric razor instead of a straight razor to shave

b. I will have my teeth cleaned by my dentist in 2 weeks - clients with defective or repaired values are at high risk for endocarditis and should avoid dental procedures for 6 months

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on his client's medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

b. Warfarin (Coumadin) - Afib puts clients at risk for developing emboli. needs an anticoagulant

A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply) a. a 32-year-old who hd a radical neck dissection 6 hours ago b. a 43-year-old diagnosed with cancer after a lung biopsy 2 days ago c. a 55-year-old who needs discharge teaching after a laryngectomy d. a 67-year-old who is awaiting preoperative teaching for laryngeal cancer e. an 88-year-old with esophageal caner who is awaiting gastric tube placement

b. a 43-year-old diagnosed with cancer after a lung biopsy 2 days ago e. an 88-year-old with esophageal caner who is awaiting gastric tube placement - a nurse can delegate stable clients to the LPN

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. a 45-year-old who takes an aspirin daily b. a 50-year-old who is post coronary artery bypass graft surgery c. a 78-year-old who had a carotid endarterectomy d. an 80-year-old with chronic obstructive pulmonary disease

b. a 50-year-old who is post coronary artery bypass graft surgery - atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass surgery

A pulmonary nurse cares for clients ho have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? a. a 46-year-old with a 30pack-year history of smoking b. a 52-year-old in a tripod position using accessory muscles to breathe c. a 68-year-old who has dependent edema and clubbed fingers d. a 74-year-old with a chronic cough and thick, tenacious secretions

b. a 52-year-old in a tripod position using accessory muscles to breathe - this client is in acute distress. needs to be assesses first to establish breathing and interventions to minimize respiratory failure

A client has been takin isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately? a. albumin 5.1 g/dL b. alanine aminotransferase (ALT) 180 U/L c. RBC count 5.2/mm3 d. WBC count 12,500/mm3

b. alanine aminotransferase (ALT) 180 U/L - INH can cause liver damage, especially if the client drinks alcohol. The ALT (one of the liver enzymes) is extremely high and needs to be reported immediately.

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. ambulate the client b. apply a warm moist pack c. massage the clients leg d. provide an ice pack

b. apply a warm moist pack - warm moist packs help with the pain of DVT

What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply) a. administering mild analgesics for pain b. applying elastic compression stockings c. elevating the legs when sitting or lying d. reminding the client to do leg exercised e. teaching the client about surgical options

b. applying elastic compression stockings c. elevating the legs when sitting or lying d. reminding the client to do leg exercises - three Es of care for varicose veins (elastic compression hose, exercise, and elevation)

A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure? a. do you have trouble breathing or chest pain? b. are you able to walk upstairs without fatigue? c. do you awake with breathlessness during the night? d. do you have new-onset heaviness in your legs?

b. are you able to walk upstairs without fatigue? - clients with HF generally have negative findings, such as shortness of breath

A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first? a. review the client's pulmonary function test results b. ask about medications the client is currently taking c. assess how frequently the client uses a bronchodilator d. consult the provider and request arterial blood gases

b. ask about medications the client is currently taking - aspirin and NSAIDs can trigger asthma in some people

A client is 4 hours postoperative after femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority? a. administer pain medication as ordered b. assess distal pulses and skin color c. document the findings in the client's chart d. notify the surgeon immediately

b. assess distal pulses and skin color - once perfusion has been restored to an extremity, clients may feel throbbing pain due to increased blood flow. but it is important to differentiate this pain from ischemia

A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40mmHg. What actions by the nurse are most important? (Select all that apply) a. administer pain medication b. assess distal pulses every 10 minutes c. have the client sign a surgical consent d. notify the rapid response team e. take vital signs every 10 minutes

b. assess distal pulses every 10 minutes d. notify the rapid response team e. take vital signs every 10 minutes

A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate? a. ask the client what foods cause trouble swallowing b. assess the client for pain when swallowing c. determine if the client can swallow saliva d. palpate the client's jaw while swallowing

b. assess the client for pain when swallowing - odynophagia is painful swallowing

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the clients ECG. Which action should the nurse take next? a. administer intravenous diltiazem (Cardizem) b. assess vital signs and level of consciousness c. administer sublingual nitroglycerin d. assess capillary refill and temperature

b. assess vital signs and level of consciousness

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess? a. preventricular contractions b. atrial fibrillation c. symptomatic bradycardia d. sinus tachycardia

b. atrial fibrillation - atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis

A nurse teaches a client recovering form a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this client's discharge teaching? a. use a soft-bristled toothbrush and avoid flossing b. avoid large crowds and people who are sick c. change positions slowly to avoid hypotension d. check your heart rate before taking the medication

b. avoid large crowds and people who are sick - these agents cause immune suppression, leaving the client more vulnerable to infection

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? a. make certain that your bath water is warm b. avoid straining while you are having a bowel movement c. limit your intake of caffeinated drinks to one a day d. avoid strenuous exercise such as running

b. avoid straining while you are having a bowel movement - bearing down strenuously during a bowel movement is one type of Valsalva maneuver which stimulates the vagus nerve and results in slowing of the heart rate.

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. a 4-ounce steak, French fries, iceberg lettuce b. baked chicken breast, broccoli, tomatoes c. fried catfish, cornbread, peas d. spaghetti with meat sauce, garlic bread

b. baked chicken breast, broccoli, tomatoes - recommended diet low in saturated fats and red meat, high in veggies and whole grains (fiber), low in salt, low in trans fat

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "why will I need to take anticoagulants for the rest of my life?" How should the nurse respond? a. the prosthetic valve places you at greater risk for a heart attack b. blood clots form more easily in artificial replacement valves c. the vein taken from your leg reduces circulation in the leg d. the surgery left a lot of small clots in your heart and lungs

b. blood clots form more easily in artificial replacement valves - synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic response to the medication? a. bronchodilator stabilizes the membranes of mast cells and prevents the release of inflammatory mediators b. cholinergic antagonist causes bronchodilation by inhibiting the parasympathetic nervous system c. corticosteroid relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors d. cromone disrupts the production of pathways of inflammatory mediators

b. cholinergic antagonist causes bronchodilation by inhibiting the parasympathetic nervous system - allows sympathetic nervous system to dominate and release norepinephrine that activates beta2 receptors

A nurse is caring for four clients. Which one should the nurse see first? a. client who needs a beta blocker, and has a blood pressure of 92/58 mmHg b. client who had a first dose of captopril (Capoten) and needs to use the bathroom c. hypertensive client with a blood pressure of 188/92 mmHg d. client who needs pain medication prior to a dressing change of a surgical wound

b. client who had a first dose of captopril (Capoten) and needs to use the bathroom - ACE inhibitors can cause hypotension especially after the first dose. the patient could be a fall risk if they get up without assistance

The charge nurse on a medical unit is preparing to admit several clients who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. admit the clients on contact precautions b. cohort the clients in the same area of the unit c. do not allow pregnant caregivers to care for these clients d. place the clients on enhanced droplet precautions

b. cohort the clients in the same area of the unit - clients can be cohorted together in the same set of rooms on one part of the unit to use distancing to help prevent the spread of the disease

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first? a. assess for drainage from the site b. cover the insertion site with sterile gauze c. contact the provider and obtain a suture kit d. reinsert the tube using sterile technique

b. cover the insertion site with sterile gauze - immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? a. assess the client's oxygen saturation and, if normal, turn off the oxygen b. determine if the client can switch to a nasal cannula during the meal c. have the client life the mask off the face when taking bites of food d. turn the oxygen off while the client eats the meal and then restart it

b. determine if the client can switch to a nasal cannula during the meal - oxygen needs to be delivered constantly

A client had a percutaneous transluminal coronary angioplasty for peripheral material disease. What assessment finding by the nurse indicates a priority outcome for this client has been met? a. pain rated as 2/10 after medication b. distal pulse on affected extremity 2+/4+ c. remains on bedrest as directed d. verbalized understanding of procedure

b. distal pulse on affected extremity 2+/4+ - assessing circulation distal to the puncture sire is a critical nursing action. a pulse of 2+/4+ indicates good perfusion

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the client's activity tolerance? (Select all that apply) a. what color is your sputum? b. do you have any difficulty sleeping? c. how long does it take you to perform your morning routine? d. do you walk up stairs every day? e. have you lost any weight lately?

b. do you have any difficulty sleeping? c. how long does it take you to perform your morning routine? e. have you lost any weight lately?

A nurse assesses a client with mitral valve stenosis. What clinical manifestations should alert the nurse to the possibility that the client's stenosis has progressed? a. oxygen saturation of 92% b. dyspnea on exertion c. muted systolic murmur d. upper extremity weakness

b. dyspnea on exertion - this develops as the mitral valvular orifice narrows and pressure in the lungs increase

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? a. administer prescribed anxiolytic medication b. ensure informed consent is on the chart c. reinforce any teaching done previously d. start the preoperative antibiotic infusion

b. ensure informed consent is on the chart - informed consent is required for operative procedures

A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse? a. administer oxygen via non-rebreather mask b. ensure the client has a patent airway c. prepare to assist with suturing the artery d. start two large-bore IVs with normal saline

b. ensure the client has a patent airway - airway takes priority

A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that the work has become impossible. What action by the nurse is most appropriate? a. arrange for immediate hospitalization b. facilitate polymerase chain reaction testing c. have the client produce a sputum sample d. obtain two sets of blood cultures

b. facilitate polymerase chain reaction testing - polymerase chain reaction testing is used to diagnose pertussis, which this client is showing manifestations of

A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find? a. heart rate that speeds up and slows down b. friction rub at the left lower sternal border c. presence of a regular gallop rhythm d. coarse crackles in bilateral lung bases

b. friction rub at the left lower sternal border - clients with pericarditis may present with a pericardial friction rub at the left lower sternal border

A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this client's teaching? a. walk until you become short of breath, and then walk back home b. gather everything you need for a chore before you begin c. pull rather than push or carry items heavier than 5 pounds d. take a walk after dinner every day to build up your strength

b. gather everything you need for a chore before you begin - a client who has HF should be taught to conserve energy

A nurse assesses a client who has developed epistaxis. Which conditions in the client's history should the nurse identify as potential contributors to this problem? (select all that apply) a. diabetes mellitus b. hypertension c. leukemia d. cocaine use e. migraine f. elevated platelets

b. hypertension c. leukemia d. cocaine use - these are frequent causes of nosebleeds

A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best? a. collect a sputum sample for culture by deep suctioning b. inform the client that antibiotics will be needed for 60 days c. place the client on airborne precautions immediately d. tell the client that directly observed therapy is needed

b. inform the client that antibiotics will be needed for 60 days - this client has manifestations of early inhalation anthrax. for treatment, after IV antibiotics are finished, oral antibiotics are continued for at least 60 days.

After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client? a. provide food to decrease nausea and aid in absorption b. instruct the client to ask for assistance when rising from bed c. collaborate with unlicensed assistive personnel to bathe the client d. monitor potassium levels and check for symptoms of hypokalemia

b. instruct the client to ask for assistance when rising from bed - administration of the first dose of ACE inhibitors is often associated with hypotension (first dose effect). need to prevent postural hypotension

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are not being met? a. 100% of meals being eaten by the client b. intact skin behind the ears c. the client understating the need for oxygen d. unchanged weight for the past 3 days

b. intact skin behind the ears - oxygen tubing can cause pressure ulcers, so clients using oxygen have the nursing diagnosis of "risk for impaired skin integrity". intact skin means goals are being met.

A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply) a. blood urea nitrogen (BUN) 19 mg/dL b. international normalized ration (INR) 6.3 c. prothrombin time 35 seconds d. serum sodium 130 mEq/L e. white blood cell (WBC) 72,000/mm3

b. international normalized ration (INR) 6.3 c. prothrombin time 35 seconds - rifampin can cause liver damage, evidence by the clients with high INR and prothrombin time

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this client's teaching? a. add peppermint oil to the humidifier to relax the airway b. make sure you clean the humidifier to prevent infection c. keep the humidifier filled with water at all times d. use the humidifier when you sleep, even during daytime naps

b. make sure you clean the humidifier to prevent infection - priority teaching for a room humidifier is infection control. meticulously clean the humidifier to prevent the spread of mold or other sources of infection

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. elevate the head of the client's bed b. measure and compare cuff pressures c. place the client on NPO status d. request that the client have a swallow study

b. measure and compare cuff pressures - constant pressure from the cuff can cause tracheomalacia, leading to dilation of tracheal passage. can be manifested by food particles seen in secretion.

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse ie best? a. do you have trouble affording your medications? b. most people with hypertension do not have symptoms c. you are lucky; most people get severe morning headaches d. you need to take your medicine or you will get kidney failure

b. most people with hypertension do not have symptoms - most people with HTN are symptomatic, but small percentage do have symptoms like headache

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? a. I sleep with four pillows at night b. my shoes fit real tight lately c. I wake up coughing every night d. I have trouble catching my breath

b. my shoes fit real tight lately - signs of systemic congestion occur with right-sided HF. fluid is retained, pressure builds in the venous system, and peripheral edema develops

A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply) a. weight gain b. night sweats c. cardiac murmur d. abdominal bloating e. Oslers nodes

b. night sweats c. cardiac murmur e. Oslers nodes

A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority? a. assess the client's neurologic status b. notify the rapid response team c. prepare to administer vitamin K d. turn down the infusion rate

b. notify the rapid response team - sudden onset of neurologic signs may indicate the client is having a hemorrhagic stroke

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a. chest x-rays are always ordered when we suspect pneumonia b. older people often have vague symptoms, so an x-ray is essential c. the x-ray can be done and read before laboratory work is reported d. we are testing for any possible source of infection in the client

b. older people often have vague symptoms, so an x-ray is essential - it is essential to obtain an early chest x-ray in older adults suspected of having pneumonia because symptoms are often vague

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met? a. ambulates with assistance b. oxygen saturation of 98% c. pain of 2/10 after medication d. verbalizing risk factors

b. oxygen saturation of 98% - critical complications of DVT are pulmonary embolism. a normal oxygen saturation indicated that this has not occurred

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal? a. teach high school students heart-healthy living b. participate in blood pressure screenings at the mall c. provide pamphlets on heart disease at the grocery store d. set up an ask the nurse booth at the pet store

b. participate in blood pressure screenings at the mall - an important goal of HP2020 is to increase the proportion of adults who have had their blood pressure measures within the preceding 2 years and can state whether its normal or high

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. sinus tachycardia b. speech alterations c. fatigue d. dyspnea with activity

b. speech alterations - clients with atrial fibrillation are at risk for embolic stroke.

Which teaching point is most important for the client with bacterial pharyngitis? a. gargle with warm salt water b. take all antibiotics as directed c. use a humidifier in the bedroom d. wash hands frequently

b. take all antibiotics as directed - any client on antibiotics must be instructed to complete the entire course of antibiotics

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicated that goals for the nursing diagnosis Impaired Self-Esteem are being met? a. the client demonstrates good understanding of stoma care b. the client has joined a book club that meets at the library c. family members take turns assisting with stoma care d. skin around the stoma is intact without signs of infection

b. the client has joined a book club that meets at the library - client is going outside of the home; best sign that goal for this diagnosis is being met

After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client's understanding. Which action demonstrates that the client correctly understands the teaching? a. the client lays on their side with their knees bent b. the client places their hands on their abdomen c. the client lays in a prone position with their legs straight d. the client places their hands above their head

b. the client places their hands on their abdomen - placing hands on abdomen creates resistance

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond? a. I will consult the speech therapist to ensure you are swallowing properly b. this is normal after surgery. What types of food do you like to eat? c. I will ask the dietitian to change the consistency of the food in your diet d. replacement of protein, calories, and water is very important after surgery

b. this is normal after surgery. What types of food do you like to eat? - many clients experience changes in taste after surgery. the nurse should identify foods that the client wants to eat to ensure the client maintains necessary nutrition.

A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply) a. production of pink sputum b. tracheal deviation c. sudden onset of shortness of breath d. pain at insertion site e. drainage of 75 mL/hr

b. tracheal deviation c. sudden onset of shortness of breath

A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply) a. production of pink sputum b. tracheal deviation c. pain at insertion site d. sudden onset of shortness of breath e. drainage greater than 70 mL/hr f. disconnection at Y sites

b. tracheal deviation d. sudden onset of shortness of breath e. drainage greater than 70 mL/hr f. disconnection at Y sites

A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration? a. tilt the head back as far as possible when swallowing b. tuck the chin down when swallowing c. breathe slowly and deeply while swallowing d. keep the head very still and straight while swallowing

b. tuck the chin down when swallowing - client with open vocal cord paralysis may aspirate. tucking chin during swallowing prevents aspiration

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. administer intravenous adenosine b. turn off oxygen therapy c. ensure a tongue blade is available d. position the client on the left side

b. turn off oxygen therapy - for safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire

After teaching a client who is prescribed voice rest therapy for vocal cord polyps, a nurse assesses the client's understanding. Which statement indicated the client needs further teaching? a. I will stay away from smokers to minimize inhalation of secondhand smoke b. when I speak, I will whisper rather than use a normal tone of voice c. for the next several weeks, I will not lift more than 10 pounds d. I will drink at least three quarts of water each day to stay hydrated

b. when I speak, I will whisper rather than use a normal tone of voice - treatment for vocal cord polyps include no speaking, no lifting, and no smoking. the client has to be educated to not even whisper when resting the voice.

A nurse working in a geriatric clinic sees clients with cold symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms? a. Chlorpheniramine (Chlor-Trimeton) b. Diphenhydramine (Benadryl) c. Fexofenadine (Allegra) d. Hydroxyzine (Vistaril)

c. Fexofenadine (Allegra) - A second-generation antihistamine is appropriate

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. I have been drinking more water than usual b. I am awakened by the need to urinate at night c. I must stop halfway up the stairs to catch my breath d. I have experienced blurred vision on several occasions

c. I must stop halfway up the stairs to catch my breath - clients with left-sided HF report weakness or fatigue while performing normal ADLs, difficulty breathing, or catching their breath

The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching? a. I plan to wear my oxygen when I exercise and feel short of breath b. I will use my portable oxygen when grilling burgers in the backyard c. I plan to use cotton balls to cushion the oxygen tubing on my ears d. I will only smoke while I am wearing my oxygen via nasal cannula

c. I plan to use cotton balls to cushion the oxygen tubing on my ears - cotton balls can decrease pressure ulcers from the oxygen tubing

Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply) a. a good abrasive pumice stone will keep my feet soft b. Ill always wear shoes if I can buy cheap flip-flops c. I will keep my feet dry, especially between the toes d. lotion is important to keep my feet smooth and soft e. washing my feet in room-temperature water is best

c. I will keep my feet dry, especially between the toes d. lotion is important to keep my feet smooth and soft e. washing my feet in room-temperature water is best

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates the client comprehends the teaching? a. I will carry this medication with me at all times in case I need it b. I will take this medication when I start to experience an asthma attack c. I will take this medication every morning to help prevent an acute attack d. I will be weaned off this medication when I no longer need it

c. I will take this medication every morning to help prevent an acute attack - long-acting beta2 agonist medications will help prevent an acute asthma attack because they are long acting

A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective? a. I need to take extra vitamin C while on INH b. I should take this medication with milk or juice c. I will take this medication on an empty stomach d. my contact lenses will be permanently stained

c. I will take this medication on an empty stomach - INH needs to be taken on an empty stomach, either 1 hour before or 2 hours after meals

After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. I will be certain to shake the inhaler well before I use it b. It may take a while before I notice a change in my asthma c. I will use the drug when I have an asthma attack d. I will be careful not to let the drug escape out of my nose and mouth

c. I will use the drug when I have an asthma attack - Salmeterol is designed to prevent an asthma attack; it does not relieve or reverse symptoms

The nurse is caring for a client with lung cancer who states, "I don't want any pain medication because I am afraid I'll become addicted". How should the nurse respond? a. I will ask your provider to change your medication to a drug that is less potent b. Would you like me to use music therapy to distance you from your pain? c. It is unlikely you will become addicted when taking medicine for pain d. would you like me to give you acetaminophen (Tylenol) instead?

c. It is unlikely you will become addicted when taking medicine for pain - client should be encouraged to take their pain medications. addiction is not usually an issue with clients in pain

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond? a. there are a variety of support groups for people who have COPD b. I will ask your provider to prescribe you an anti-anxiety agent c. Share any thoughts and feelings that cause you to limit social activities d. Friends can be a good support system for clients with chronic disorders

c. Share any thoughts and feelings that cause you to limit social activities - encourage client to verbalize thoughts and feelings so that appropriate interventions can be selected

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? a. a 26-year-old woman who is 8 months pregnant b. a 42-year-old man with gastroesophageal reflux disease c. a 55-year-old woman who is 50 pounds overweight d. a 73-year-old man with type 2 diabetes

c. a 55-year-old woman who is 50 pounds overweight - the client at highest risk would be the one who is extremely overweight

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply) a. administer prescribed salmeterol (Serevent) inhaler b. assess the client for a tracheal deviation c. administer oxygen to keep saturations greater than 94% d. perform peak expiratory flow readings e. administer prescribed albuterol (Proventil) inhaler

c. administer oxygen to keep saturations greater than 94% e. administer prescribed albuterol (Proventil) inhaler - wheezing means narrowed airway. need rescue inhaler and oxygen

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery? a. assess airway patency, breathing, and circulation b. administer prescribed intravenous pain medication c. assist the client to choose a communication method d. ambulate the client in the hallway to assess gait

c. assist the client to choose a communication method - client will not be able to speak after surgery. the nurse should assist the client to choose a communication method that he or she would like to use after surgery.

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" How should the nurse respond? a. substance abuse puts clients at risk for many health issues b. the hospital requires that I ask you about cocaine use c. clients who use cocaine are at risk for fatal dysrhythmias d. we can provide services for cessation of substance abuse

c. clients who use cocaine are at risk for fatal dysrhythmias

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first? a. Do you have a strong support system? b. what do you understand about your disease? c. do you experience shortness of breath with basic activities? d. what medications are you prescribed to take each day?

c. do you experience shortness of breath with basic activities? - Clients with severe COPD may not be able to perform daily activities including bathing and eating because of excessive shortness of breath

A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this client's teaching? a. take an antibiotic every day b. contact your provider to obtain genetic screening c. eat a well-balanced, nutritious diet d. plan to exercise for 30 minutes every day

c. eat a well-balanced, nutritious diet - clients with CF are often malnourished due to vitamin deficiency and pancreatic malfunction

The nurse assesses the client using the device pictured below to deliver 50% O2. The nurse finds the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3L/min. What action by the nurse is best? a. assess the client's oxygen saturation b. document these findings in the chart c. immediately increase the flow rate d. turn the flow rate for to 2L/min

c. immediately increase the flow rate - for Venturi mask to deliver high flow of oxygen, flow rate must be set usually between 4 and 10L/min

A student nurse asks what essential hypertension is. What response by the nurse is best? a. it means it is caused by another disease b. it means it is essential that it be treated c. it is hypertension with no specific cause d. it refers to sever and life-threatening hypertension

c. it is hypertension with no specific cause - most common type of HTN, no specific cause such as an underlying disease process

A nurse cares for a client who is infected with Burkholderia cepacia. Which action should the nurse take first when admitting this client to a pulmonary care unit? a. instruct the client to wash his or her hands after contact with other people b. implement droplet precautions and don a surgical mask c. keep the client isolated from other clients with cystic fibrosis d. obtain blood, sputum and urine culture specimens

c. keep the client isolated from other clients with cystic fibrosis - Burkholderia cepacia infection is spread through casual contact between cystic fibrosis clients. these clients need to be separated from one another

A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. pulmonary auscultation b. pulse strength and amplitude c. level of consciousness d. mobility and gait stability

c. level of consciousness - 40BPM or less with widened QRS complexes could have hemodynamic consequences. the client is at risk for inadequate cerebral perfusion. assess for LOC, light-headedness, confusion, syncope, and seizure activity

A nurse is assessing an obese client in the clinic for follow-up after an episode of DVT. The client has lost 20 pounds since the last visit. What action by the guest is best? a. ask if the weight loss was intended b. encourage a high-protein, high-fiber diet c. measure for new compression stockings d. review a 3-day food recall diary

c. measure for new compression stockings - compression stockings must fit correctly in order to work

A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this client? a. spaghetti with meat sauce, ice cream b. chicken soup, grilled cheese sandwich c. omelet, soft whole wheat bread d. pasta salad, custard, orange juice

c. omelet, soft whole wheat bread - side effects of radiation therapy may include inflammation of the esophagus. bland, soft, high-calorie foods are best along with liquid supplements

A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a. encourage between-meal snacks b. monitor temperature every 4 hours c. provide oral care every 4 hours d. report any new onset of cough

c. provide oral care every 4 hours - oral colonization by gram-negative bacteria is a risk factor for healthcare-associated pneumonia.

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client's concerns? a. administer oxygen therapy at 2 liters per nasal cannula b. provide the client with a sleeping pill to stimulate rest c. schedule periods of exercise and rest during the day d. ask unlicensed assistive personnel to help bathe the client

c. schedule periods of exercise and rest during the day - clients with afib are at risk for decreased cardiac output and fatigue when completing activities of daily living. the nurse should schedule periods of exercise and rest during the day to reduce fatigue

A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. decreased intraocular pressure b. increased heart rate c. short period of asystole d. hypertensive crisis

c. short period of asystole - clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain

A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, "will my children have cystic fibrosis?" How should the nurse respond a. since many of your family members are carriers, your children will also be carriers of the gene b. cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder. c. since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested d. cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of the disorder

c. since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested - cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutates for the disorder to be expressed

A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, "how will this medication help me?" How should the nurse respond? a. this medication will treat your sleep apnea b. this sedative will help you to sleep at night c. this medication will promote daytime wakefulness d. this analgesic will increase comfort while you sleep

c. this medication will promote daytime wakefulness - Modafinil is helpful for clients who have narcolepsy related to sleep apnea

A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a. ice packs may help with the facial pain b. limit fluids to dry out your sinuses c. try warm, moist heat packs on your face d. we will schedule you for a computed tomography scan this week

c. try warm, moist heat packs on your face - the client has rhino sinusitis. comfort measures include breathing in warm steam, hot packs, nasal saline irrigations, sleeping with head elevated, increased fluids, and avoiding cigarette smoke

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? a. holding the device securely when changing ties b. suctioning the client first if secretions are present c. tying a square know at the back of the neck d. using half-strength peroxide for cleansing

c. tying a square knot at the back of the neck - to prevent pressure ulcers and for client safety, ties must be knotted on the side of the client's neck, not in back

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "why is this important?" How should the nurse respond? a. rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures b. your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness c. your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes d. while your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke when you stand up

c. your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes - because the new heart is denervated, the baroreceptor and other mechanisms that compensate for bp drops caused by position changes do not function

A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, what does this mean? How should the nurse respond? a. your children will be at high risk for the development of chronic obstructive pulmonary disease b. I will contact your genetic counselor to discuss your condition c. your risk for chronic obstructive pulmonary disease is higher, especially if you smoke d. this is a recessive gene and should have no impact on your health

c. your risk for chronic obstructive pulmonary disease is higher, especially if you smoke - the gene for AAT is a recessive gene. Clients with only one allele produce enough AAT to prevent COPD, unless the client smokes.

The nurse is caring for a client who is prescribed a long-acting beta2 agonist. The client states, "the medication is too expensive to use every day. I only use my inhaler when I have an attack". How should the nurse respond? a. you are using the inhaler incorrectly. This medication should be taken daily b. if you decrease environmental stimuli, it will be okay for you to use the inhaler only for asthma attacks c. tell me more about your fears related to feelings of breathlessness d. It is important to use this type of inhaler every day. lets identify potential community services to help you

d. It is important to use this type of inhaler every day. lets identify potential community services to help you

A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best? a. Educate the client on oseltamivir (Tamiflu). b. Facilitate admission to the hospital. c. Instruct the client to have a flu vaccine. d. Teach the client to sneeze in the upper sleeve.

d. Teach the client to sneeze in the upper sleeve. - helps prevent the spread of upper respiratory infections

A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first? a. a 66-year-old client with a barrel chest and clubbed fingernails b. a 48-year-old client with an oxygen saturation level of 92% at rest c. a 35-year-old client who has a longer expiratory phase than inspiratory phase d. a 27-year-old client with a heart rate of 120 beats/min

d. a 27-year-old client with a heart rate of 120 beats/min - tachycardia can indicate hypoxemia as the body tried to circulate the oxygen that is available

A nurse assesses a client after administering isosorbide mononitrate (Immure). The client reports a headache. Which action should the nurse take? a. initiate oxygen therapy b. hold the next dose of imdur c. instruct the client to drink water d. administer PRN acetaminophen

d. administer PRN acetaminophen - Vasodilating effects frequently cause clients to have headaches. some clients obtain relief with mild analgesics, such as acetaminophen

A nurse cares for a client who had a chest tube places 6 hours ago and refused to take deep breaths because of the pain. Which action should the nurse take? a. ambulate the client in the hallway to promote deep breathing b. auscultate the client's anterior and posterior lung fields c. encourage the client to take shallow breaths to help with the pain d. administer pain medication and encourage the client to take deep breaths

d. administer pain medication and encourage the client to take deep breaths - the chest tube may be uncomfortable for the client. the nurse should provide pain medication to minimize discomfort and encourage deep breathing

A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first? a. facial pain b. vital signs c. bone displacement d. airway patency

d. airway patency - patient airway is priority (ABC)

A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first? a. contact the provider for a prescription for sleep medication b. tell the client not to drink beverages with caffeine before bed c. educate the client to sleep upright in a reclining chair d. ask the client if he or she has ever ben evaluated for sleep apnea

d. ask the client if he or she has ever ben evaluated for sleep apnea - clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. causes of the problem should be assessed before the client is offered suggestions for treatment.

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client's teaching? a. avoid taking aspirin or aspirin-containing products b. increase your intake of foods that are high in potassium c. hold this medication if your pulse rate is below 80 BPM d. do not take this medication within 1 hour of taking an antacid

d. do not take this medication within 1 hour of taking an antacid - antacids interfere with GI absorption of digoxin

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. make sure the defibrillator is set to the synchronous mode b. administer 1mg of intravenous epinephrine c. test the equipment by delivering a smaller shock at 100 joules d. ensure that everyone is clear of contact with the client and the bed

d. ensure that everyone is clear of contact with the client and the bed - to avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliant before delivery of the shock

A nurse evaluates the following arterial blood gas and vital sign results for a client with COPD. pH = 7.32 PaCO2 = 62 mmHg PaO2 = 46mmHg HCO3 = 28 mEq/L Heart rate = 110 beats/min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mmHg O2 sat = 76% Which action should the nurse take first? a. administer a short-acting beta2 agonist inhaler b. document the findings as normal for a client with COPD c. teach the client diaphragmatic breathing techniques d. initiate oxygenation therapy to increase saturation to 92%

d. initiate oxygenation therapy to increase saturation to 92% - client is hypoxic. oxygen shouldn't be given to a pt that is hypoxic, even with copd

A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment? a. stripe the tubing to minimize clot formation and ensure patency b. secure tubing junctions with clamps to prevent accidental disconnections c. connect the chest tube to wall suction at the level prescribed by the provider d. keep padded clamps at the bedside for use if the drainage system is interrupted

d. keep padded clamps at the bedside for use if the drainage system is interrupted - padded clamps should be kept at the bedside for use if the drainage system becomes dislodged or it interrupted

A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first? a. assess the client's pain level b. keep the client's head elevated c. teach the client about the causes of nasal bleeding d. make sure the string is taped to the client's cheek

d. make sure the string is taped to the client's cheek - make sure the string is attached to the client's cheek to hold the packing in place so that it doesn't occlude the client's airway

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. I nearly always wear comfy sweatpants and house shoes b. im glad I get energy assistance so my house isn't so cold c. my daughter makes sure I have plenty of lotion for my feet d. my hands shake when I try to do things requiring coordination

d. my hands shake when I try to do things requiring coordination - clients with PVD need to pay special attention to their feet. clients whose hands shake may cause injury when trimming toenails

A client has the diagnosis of valley fever accompanied by myalgia and arthralgia. What treatment should the nurse educate the client on? a. intravenous amphotericin B b. long-term anti-inflammatories c. no specific treatment d. oral fluconazole (Diflucan)

d. oral fluconazole (Diflucan) - Valley fever, or coccidioidomycosis, is a fungal infection. many people do not need treatment and the disease resolves on its own. however, the presence of joint and muscle pain indicates a moderate infection that needs treatment with anti fungal medications.

A nursing student is caring for a client with an abdominal aneurysm. what action by the student requires the registered nurse to intervene? a. assesses the client for back pain b. auscultates over abdominal bruit c. measures the abdominal girth d. palpates the abdomen in four quadrants

d. palpates the abdomen in four quadrants - abdominal aneurysms should never be palpated as this increases the risk of rupture

A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. assessing blood pressure in both upper extremities b. auscultating the carotid arteries for any bruits c. classifying capillary refill for 4 seconds as normal d. palpating both carotid arteries at the same time

d. palpating both carotid arteries at the same time - the student should not compress both carotid arteries at the same time to avoid brain ischemia

A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) a. administering preoperative medication b. ensuring the consent is signed c. marking pulses with a pen d. raising the siderails on the bed e. recording baseline vital signs

d. raising the siderails on the bed e. recording baseline vital signs

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement? a. apply an ice pack to the client's chest b. provide a neck rub, especially on the left side c. allow the client to lie in bed with the lights down d. sit the client up with a pillow to lean forward on

d. sit the client up with a pillow to lean forward on - pain from acute pericarditis may worsen when the client lays supine

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. call the operating room to inform them of a pending emergency case b. no action is needed at this time; this is a normal finding in some clients c. remove the tracheostomy tube; ventilate the client with a bag-valve-mask d. stay with the client and have someone else call the provider immediately

d. stay with the client and have someone else call the provider immediately - client may have a tracheainnominate artery fistula, which can be life-threatening emergency if the artery is breached and the client begins to hemorrhage.

The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. cholesterol 126 mg/dL b. high-density lipoprotein cholesterol (HDL-C) 48 mg/dL c. low-density lipoprotein cholesterol (LDL-C) 122 mg/dL d. triglycerides 198mg/dL

d. triglycerides 198mg/dL - triglycerides in men should be below 160 mg/dL

A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. the client has hyperkalemia causing irregular QRS complexes b. ventricular tachycardia is overriding the normal atrial rhythm c. the client's chest leads are not making sufficient contact with the skin d. ventricular and atrial depolarizations are initiated from different sites

d. ventricular and atrial depolarizations are initiated from different sites - normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. community social worker for Meals on Wheels b. occupational therapy for job retraining c. physical therapy for homebound therapy services d. visiting nurses for directly observed therapy

d. visiting nurses for directly observed therapy - directly observed therapy is often utilized for managing clients with TB in the community. Meal on Wheels, job retraining, and home therapy may or may not be appropriate

A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this client's discharge teaching? a. avoid drinking more than 3 quarts of liquids each day b. eat six small meals daily instead of three larger meals c. when you feel short of breath, take an additional diuretic d. weigh yourself daily while wearing the same amount of clothing

d. weigh yourself daily while wearing the same amount of clothing - clients with HF are instructed to weight themselves daily to detect worsening heart failure early, and avoiding complications

A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important? a. are any family members also ill? b. have you traveled recently? c. how long have you been ill? d. what is your occupation?

d. what is your occupation? - inhalation anthracites is rare and is an occasional hazard among people who work with animal wool, bone meal, hides, and skin, such as taxidermists and veterinarians. inhalation anthrax in someone without an occupational risk is considered a bioterrorism event and must be reported to the authorities immediately

A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax? a. when the insertion site becomes red and warm to the touch b. when the tube drainage decreases and becomes sanguineous c. when the client experiences pain at the insertion site d. when the tube becomes disconnected from the drainage system

d. when the tube becomes disconnected from the drainage system - if it becomes disconnected, air can be sucked into the pleural space and cause pneumothorax

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I dont want to become a vegetable". How should the nurse respond? a. would you like to speak with a priest of chaplain? b. I will arrange for a psychiatrist to speak with you c. do you want to come off the transplant list d. would you like information about advance directives?

d. would you like information about advance directives? - the client is verbalizing a real concern or feat about negative outcomes of the surgery. the best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though he or she is crazy