Exam 2 p2
Following an acute myocardial infarction, a previously healthy 63-yr-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about
angiotensin-converting enzyme (ACE) inhibitors
A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-lb weight gain in the past 3 days. The nurse's priority action will be to
assess the patient for clinical manifestations of acute heart failure.
The nurse is caring for a client with newly diagnosed hypertension. What statement by the client indicates adequate understanding of his or her diet restrictions? A. "I can have regular coffee only in the morning." B. "I will give my canned soups to the food pantry." C. "I will mostly use salt substitutes for flavoring." D. "I'm going to miss my evening glass of wine."
"I will give my canned soups to the food pantry."
A student nurse asks what "essential hypertension" is. What response by the registered nurse is best
"It is hypertension with no specific cause."
A patient has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?
"Most people with hypertension do not have symptoms."
A nurse teaches a patient who has chronic obstructive pulmonary disease. Which statements related to nutrition would the nurse include in this patient's teaching? (Select all that apply.)
"Rest before meals if you have dyspnea." "Avoid drinking fluids just before and during meals." "Have about six small meals a day."
When do clients who have gastric ulcers MOST often complain of pain?
1 to 2 hours after eating
A nurse assesses patients on a cardiac unit. Which patient would the nurse identify as being at greatest risk for the development of left-sided heart failure?
A 36-year-old woman with aortic stenosis
A nurse assesses patients on the medical-surgical unit. Which patient is at greatest risk for development of obstructive sleep apnea?
A 55-year-old woman who is 50 lbs (23 kg) overweight
A nurse prepares a patient for a colonoscopy scheduled for tomorrow. The patient states, "My provider told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it." How would the nurse respond?
A negative fecal occult blood test does not rule out the possibility of colon cancer."
A nurse admits a patient from the emergency department. Patient data are listed below: HistoryPhysical AssessmentLaboratory Values70 years of ageHistory of diabetesOn insulin twice a dayReports new-onset dyspnea and productive coughCrackles and rhonchi heard throughout the lungsDullness to percussion LLLAfebrileOriented to person onlyWBC: 5,200/mm3 (5.2 ´109/L)PaO2 on room air 85 mm Hg What action by the nurse is the priority?
Administer oxygen at 4 L per nasal cannula.
What information about nutrition does the nurse teach a client with chronic obstructive pulmonary disease (COPD)? (Select all that apply.)
Avoid drinking fluids just before and during meals. Rest before meals if you have dyspnea. Have about six small meals a day.
A nurse is teaching a patient with heart failure who has been prescribed enalapril (Vasotec). Which statement would the nurse include in this patient's teaching?
Avoid using salt substitutes. Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and patients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the patient's pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not contraindicated
A patient has just been diagnosed with hypertension and has been started on captopril . Which information is mostimportant to include when teaching the patient about this drug?
Change position slowly to help prevent dizziness and falls.
The nurse is evaluating a 3-day diet history with a patient who has an elevated lipid panel. What meal selection indicates that the patient is managing this condition well with diet?
Baked chicken breast, broccoli, tomatoes
A hospital nurse is participating in a drill during which many patients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.)
Ciprofloxacin (Cipro) Amoxicillin (Amoxil) Doxycycline (Vibramycin
The nurse is caring for four clients with asthma. Which client does the nurse assess first? A. Client whose heart rate is 120 beats/min B. Client with a barrel chest and clubbed fingernails C. Client with an SaO2 level of 92% at rest D. Client whose expiratory phase is longer than the inspiratory phase
Client whose heart rate is 120 beats/min
While assessing a patient who has facial trauma, the nurse auscultates stridor. The patient is anxious and restless. What action would the nurse take first?
Contact the provider and prepare for intubation.
An example of a proton pump inhibitor is:
omeprazole
A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding as
paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alteration of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.
A nurse teaches a patient who has a history of heart failure. Which statement would the nurse include in this patient's discharge teaching?
"Weigh yourself daily while wearing the same amount of clothing."
A nurse cares for a patient newly diagnosed with colon cancer who has become withdrawn from family members. Which action would the nurse take?
Encourage the patient to verbalize feelings about the diagnosis
A client is admitted with the diagnosis Rule out appendicitis. Which nursing action is MOST important?
avoiding administering analgesics
A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement to the nurse indicates that additional teaching about GERD is needed?
"I eat small meals during the day and have a bedtime snack."
When teaching the client with gastritis, the nurse should include which of these instructions?
"Avoid eating at bedtime."
A nurse teaches a patient who is prescribed digoxin (Lanoxin) therapy. Which statement would the nurse include in this patient's teaching?
"Do not take this medication within 1 hour of taking an antacid."
A nurse assesses a patient with chronic obstructive pulmonary disease. Which questions would the nurse ask to determine the patient's activity tolerance? (Select all that apply.)
"Do you have any difficulty sleeping?" "How long does it take to perform your morning routine?" "Have you lost any weight lately?"
The nurse has just finished teaching a hypertensive patient about the newly prescribed drug, ramipril (Altace). Which patient statement indicates that more teaching is needed?
"I can expect some swelling around my lips and face." Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health care provider should be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy.
The nurse is teaching a client with pneumonia ways to clear secretions. Which intervention is the most effective? A. Having the client cough and deep breathe hourly B. Administering an antiemetic medication C. Administering an antitussive medication D. Increasing fluids to 2 L/day if tolerated
Increasing fluids to 2 L/day if tolerated
A client is admitted with diverticulitis of 1 day's duration. Which of these nursing interventions should be included in the client's plan of care?
Maintain NPO
Which of these factors contributes to a client developing gastritis?
exposure to irritating substances, i.e., ibuprofen
A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure
"I must stop halfway up the stairs to catch my breath." Patients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or "catching their breath." This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.
A nurse is caring for a patient who has sleep apnea and is prescribed modafinil (Provigil). The patient asks, "How will this medication help me?" How would the nurse respond?
"This medication will promote daytime wakefulness."
A nurse assesses a patient with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. What actions would the nurse take? (Select all that apply.)
Administer prescribed albuterol (Proventil) inhaler. Administer oxygen to keep saturations greater than 94%
A nurse assesses a patient who reports waking up feeling very tired, even after 8 hours of good sleep. What action would the nurse take first?
Ask the patient if he or she has ever been evaluated for sleep apnea.
A nurse plans care for a patient who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions would the nurse include in this patient's plan of care? (Select all that apply.)
Ask the patient to drink 2 L of fluids daily. Add humidity to the prescribed oxygen. Use a vibrating positive expiratory pressure device.
Which action should the nurse take when giving the initial dose of oral labetalol to a patient with hypertension?
Ask the patient to request assistance before getting out of bed
A patient is 4 hours postoperative after a femoral-popliteal bypass. The patient reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority?
Assess distal pulses and skin color.
While assessing a patient on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next?
Assess for symptoms of left-sided heart failure
A nurse admits a patient who is experiencing an exacerbation of heart failure. What action would the nurse take first?
Assess the patient's respiratory status.
The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure? A. Older woman who smokes cigarettes daily B. Older man who has had a myocardial infarction C. Middle-aged man with pulmonary hypertension D. Middle-aged woman with aortic stenosis
Middle-aged woman with aortic stenosis
A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change? A. Increase in stroke volume B. Increase in oxygen saturation C. Decrease in tissue perfusion D. Decrease in arterial vasoconstriction
Decrease in tissue perfusion
A home health nurse evaluates a patient who has chronic obstructive pulmonary disease. Which assessments would the nurse include in this patient's evaluation? (Select all that apply.)
Examination of mucous membranes and nail beds Determine the patient's need and use of oxygen Measurement of rate, depth, and rhythm of respirations
A patient has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this patient? (Select all that apply.)
Facilitating pleural fluid sampling Performing frequent respiratory assessment Assisting with chest tube insertion Providing antipyretics as needed
A 37-yr-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function?
Glomerular filtration rate (GFR)
Which statement indicates that the client understands teaching about the use of long-acting beta2 agonist medications?
I will take this medication daily to prevent an acute attack.
A patient in the emergency department is taking rifampin (Rifadin) for tuberculosis. The patient reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.)
International normalized ratio (INR): 6.3 Prothrombin time: 35 seconds
The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient?
No regular physical exercise The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber, but increasing fiber alone will not prevent hypertension from developing. The patient's alcohol intake is within guidelines and will not increase the hypertension risk.
A nurse is caring for a patient with a deep vein thrombosis (DVT). What nursing assessment indicates that a priority outcome has been met?
Oxygen saturation of 98%
A nursing student is caring for a patient with an abdominal aneurysm. What action by the student requires the registered nurse to intervene?
Palpates the abdomen in four quadrants
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?
Palpating both carotid arteries at the same time
The nurse is assessing a client who reports claudication after walking a distance of one block. The nurse notes a painful ulcer on the fourth toe of the client's right foot. What condition do these findings correlate with?
Peripheral arterial disease
A client who has diverticulitis should be instructed to follow which of these prescribed diets when the acute episode is resolved?
high fiber
While assessing a 68-yr-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates
increased right atrial pressure.
Clients with diverticulitis will frequently complain of abdominal pain located in which area of the abdomen?
left lower side
In GERD, gastric secretions flow upward into the esophagus, damaging the tissues. This is caused by the inability of which of the below to fully close?
lower esophageal sphincter (LES)
When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of
rapid, deep respirations.
The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that
she will call the clinic if her weight goes up 3 pounds in 1 week
A nurse is teaching a patient how to perform pursed-lip breathing. Which instructions would the nurse include in this teaching? (Select all that apply.)
"Use your abdominal muscles to squeeze air out of your lungs." "Exhale at least twice the amount of time it took to breathe in." "Breath out slowly without puffing your cheeks."
A nurse assesses a patient after administering isosorbide mononitrate (Imdur). The patient reports a headache. What action would the nurse take?
Administer PRN acetaminophen The vasodilating effects of isosorbide mononitrate frequently cause patients to have headaches during the initial period of therapy. Patients would be told about this side effect and encouraged to take the medication with food. Some patients obtain relief with mild analgesics, such as acetaminophen. The patient's headache is not related to hypoxia or dehydration; therefore, these interventions would not help. The patient needs to take the medication as prescribed to prevent angina; the medication would not be held.
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 patients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.)
Patient who is taking medication for hypertension Healthy 72-year-old patient Patient with well-controlled diabetes 22-year-old patient with asthma
A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). What assessment finding requires action by the nurse? A. Potassium of 2.9 mEq/L B. Cough C. Pulse of 62 beats/min D. Headache
Potassium of 2.9 mEq/
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective?
Reduced dyspnea with the head of bed at 30 degrees
The nurse is assisting the hospitalized client with his food selections for breakfast. The client is on a low-cholesterol diet. What recommendations are most appropriate for this client? A. Skim milk, oatmeal, banana, orange juice, coffee B. Whole wheat French toast, a side of bacon, coffee C. Cheese omelet, skim milk, whole wheat toast, coffee D. Blueberry muffin, orange juice, decaffeinated coffee
Skim milk, oatmeal, banana, orange juice, coffee
A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which group of drugs will the nurse plan to include when teaching about PAD management?
Statins
The emergency department nurse is participating in a bioterrorism drill in which several patients are suspected to have inhalation anthrax. Which patients should the nurse see as the priorities? (Select all that apply.)
Stridor Oxygen saturation of 91% Diaphoresis
A nurse assesses a patient who has a chest tube. For which manifestations would the nurse immediately intervene? (Select all that apply.)
Tracheal deviation Sudden onset of shortness of breath
A nurse assesses a patient who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.)
Tracheal deviation Sudden onset of shortness of breath Disconnection at Y site Drainage greater than 70 mL/hr
The nurse is reviewing the lipid panel of a male patient who has atherosclerosis. Which finding is most concerning?
Triglycerides: 198 mg/dL
When discussing risk factor modification for a patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus teaching on which patient risk factor?
Uncontrolled hypertension All of the factors contribute to the patient's risk, but only hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm.
A nurse cares for a patient who is prescribed an intravenous prostacyclin agent. What actions would the nurse take to ensure the patient's safety while on this medication? (Select all that apply.
Use strict aseptic technique when using the drug delivery system. Keep an intravenous line dedicated strictly to the infusion. Ensure that there is always a backup drug cassette available.
A patient is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate?
Visiting nurses for directly observed therapy
A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patient's
breath sounds.
The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Appropriate instructions for the patient include
notify the health care provider if nausea develops Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60 beats/min, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption.
When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, "I will
use a heating pad on my feet at night to increase the circulation."
