Exam 1
The clinic nurse is caring for a client who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The client asks, "What exactly is this test for?" What would be the nurse's best response?
"A PFT measures how much air moves in and out of your lungs when you breathe."
A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask?
"Are you allergic to seafood or iodine?"
The nurse cares for a client with diabetes who is scheduled for a cardiac catheterization. Prior to the procedure, it is most important for the nurse to ask which question?
"Are you allergic to shellfish?"
A nurse is teaching a client how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the client?
"Breathe in deeply through the spirometer, hold your breath briefly, and then exhale."
While being prepared for echocardiography, the client asks nurse why this test is necessary. What would be the nurse's best response?
"Echocardiography is a way of determining the functioning of the left ventricle of your heart."
A patient had a cardiac catheterization and is now in the recovery area. What nursing interventions should be included in the plan of care? (Select all that apply.)
-Assessing the peripheral pulses in the affected extremity -Checking the insertion site for hematoma formation -Evaluating temperature and color in the affected extremity
A client is following up after a visit to the emergency department where testing indicated that the client had suffered a transient ischemic attack. What lifestyle changes would the nurse include in teaching to prevent further reoccurrence? Select all that apply.
-Blood pressure control -Weight loss -Smoking cessation
Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations validate the nurse's concern? Select all that apply.
-Compromised gas exchange -Decreased airflow -Wheezes
The student nurse is preparing a teaching plan for a client being discharged status post MI. What should the nurse include in the teaching plan? Select all that apply.
-Need for careful monitoring for cardiac symptoms -Need for carefully regulated exercise -Need for dietary modifications
A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply.
-To provide adequate transport of oxygen in the blood -To decrease the work of breathing -To reduce stress on the myocardium
Nursing students are reviewing information about Parkinson's disease in preparation for class the next day. The students demonstrate understanding of the material when they identify which of the following as a cardinal sign of this disorder? Select all that apply.
-Tremor -Rigidity -Bradykinesia -Postural instability
The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply.
-Unequal pupils -Pinpoint pupils -Absence of pupillary response
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?
4:00 p.m.
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?
A client with a nasogastric tube
The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern?
Airway clearance
A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication?
Bleeding
To alleviate pain associated with trigeminal neuralgia, a client is taking carbamazepine. What health education should the nurse provide to the client before initiating this treatment?
Blood levels of the drug must be monitored.
What finding by the nurse may indicate that the client has chronic hypoxia?
Clubbing of the fingers
The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?
Cyanosis
The nurse is performing an assessment of a clients peripheral pulses and indicates that the pulse quality is +1 on a scale of 0-4. What does this documented finding indicate?
Difficult to palpate and is obliterated with pressure.
You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?
Encourage increased fluid intake.
The nurse assesses a client returning from the post anesthesia unit with a new onset of sinus tachycardia with a heart rate of 138 beats per minute and a blood pressure of 128/80mmHg after elevating the head of the bed. What intervention does the nurse consider?
Evaluating laboratory values
A client is brought by ambulance to the ED after experiencing what the family thinks is a stroke. The nurse caring for this client is aware that which is an absolute contraindication for thrombolytic therapy?
Evidence of hemorrhagic stroke
When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause?
Frustration around changes in function and communication
A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?
Group A, beta-hemolytic streptococci
A client is brought into the ED by family members who tell the nurse the client grabbed their chest and reported substernal chest pain. What form of monitoring should the nurse anticipate being implemented?
Hardwire continuous electrocardiogram (ECG) monitoring
What information should the nurse include in client discharge teaching for a client as a way to prevent epistaxis?
Humidify the indoor environment.
During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?
Hypercapnia
A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?
Lioresal (Baclofen)
The nurse is caring for a client with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the client's neurologic assessment?
Loss of voluntary control of movement
A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. Which of the following is the most important for the nurse to assess?
Lung sounds
A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for
Nuchal rigidity
A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?
Oxygen toxicity
Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention?
Positioning the client to avoid intercranial pressure (ICP)
The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits?
Rapid, jerky, involuntary movements
A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize which of the following actions?
Removing all metal-containing objects
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. What breath sound should the nurse document?
Rhonchi
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?
The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.
A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse's response to the family?
The client should mobilize as soon as physically able.
The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes?
They can be heard during inspiration and expiration.
A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient?
This is significant for poor neurologic outcomes.
The nurse is caring for a client experiencing a severe nosebleed. A nasal sponge has been inserted and needs to remain in place up to 6 days before it is removed. The nurse should discuss the risk of what complication with the client?
Toxic shock syndrome
When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip?
Trochanter roll
A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention?
Urine retention or incontinence
The nurse is caring for a client with Bell's palsy. Which of the following teaching points is a priority in the management of symptoms for this client?
Use ophthalmic lubricant and protect the eye.
The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first?
Ventricular fibrillation
The nurse is performing an assessment for an older adult client and auscultates an S3 heart sound. What condition does the nurse determine may correlate with this finding?
heart failure
A nursing instructor is reviewing the parts of an EKG strip with a group of students. One student asks about the names of all the EKG cardiac complex parts. Which of the following items are considered a part of the cardiac complex on an EKG strip? Choose all that apply.
p wave p-r interval t wave
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
sit upright, leaning slightly forward.
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
use short, simple sentences.