Exam 4-102

The nurse is instructing a client on the impact of cigarette smoking and the development of hypertension. Which of the following would not be appropriate for the nurse to include in these instructions? a. tobacco damages the lining of the artery walls b. tobacco temporarily constricts blood vessels, increasing pulse and blood pressure c. tobacco thins the blood and makes the person at risk for bleeding d. carbon monixide in tobacco replaces the O2 in the blood, forcing the heart to work harder to supply oxygen

3 Tobacco and smoking have been shown to increase heart rate and blood pressure because of vasoconstriction and the accumulation of plaque on the artery walls. Because of the replacement of oxygen with carbon monoxide from tobacco smoke, the heart has to work harder to supply oxygen to the organs. There is no evidence that smoking thins the blood and causes bleeding.

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 As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates the clients disease is worsening. The other questions are useful, but not as important.

The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA). Family members ask the nurse why their father had a seizure. Which response is best for the nurse to make? a. "The seizure was most likely caused by brain cells being deprived of oxygen due to a blood clot in the brain." b. "The stroke generated a toxin that excites the brain cells." c. "The stroke causes an alteration in the cells adjacent to the blood clot." d. "The stroke causes an increase in the depolarization of the brain cells due to the clot formation."

A Thrombi from a CVA can occlude vessels, cutting off oxygen supply to cells of the brain and causing a seizure.

Which herbs and supplements lower cholesterol? (Select all that apply.) a. Garlic b. Bananas c. Oatmeal d. St. John's wort e. Soy products

A, C, E Garlic, whole-grain foods, and soy products are thought to decrease cholesterol. Bananas and St. John's wort are not known to lower cholesterol.

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-American groceries c. High school sports camps d. Womens health clinics

ANS: A African Americans in the United States have one of the highest rates of hypertension in the world. The nurse has the potential to reach this priority population by providing services at African-American churches. Although hypertension education and screening are important for all groups, African Americans are the priority population for this intervention.

A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a 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.

ANS: A Alcohol intake should be limited to two drinks a day for men and one drink a day for women. A drink is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited alcohol intake is acceptable with hypertension. The womans size does not matter.

18. A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the clients favorite channel. d. Speak loudly to the client in case of hearing problems.

ANS: A Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more.

A nurse cares for a client with right-sided heart failure. The client asks, Why do I need to weigh myself every day? 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 youre 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.

ANS: A Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds. The other responses do not address the importance of monitoring fluid retention or loss.

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

ANS: A Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.

A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered a test on my heart, how should the nurse respond? a. Most of these types of blood clots come from the heart. b. Some of the blood clots may have gone to your heart too. c. We need to see if your heart is strong enough for therapy. d. Your heart may have been damaged in the stroke too.

ANS: A An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate.

A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this clients teaching? a. Avoid using salt substitutes. b. Take your medication with food. c. Avoid using aspirin-containing products. d. Check your pulse daily.

ANS: A Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients 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 clients pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not contraindicated.

A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? a. Assess the clients respiratory status. b. Draw blood to assess the clients serum electrolytes. c. Administer intravenous furosemide (Lasix). d. Ask the client about current medications.

ANS: A Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take priority over assessing respiratory status.

After a stroke, a client has ataxia. What intervention is most appropriate to include on the clients plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post-void residuals.

ANS: A Ataxia is a gait disturbance. For the clients safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.

A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? a. Increased pressure from the abscess can cause seizures. b. Preventing febrile seizures with an abscess is important. c. Seizures always occur in clients with brain abscesses. d. This drug is used to sedate the client with an abscess.

ANS: A Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.

A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? a. Continue to educate the client on possible healthy changes. b. Emphasize complications that can occur with noncompliance. c. Tell the client that denial is normal and will soon go away. d. You need to make sure the client understands this illness.

ANS: A Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client.

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.

ANS: A Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.

A nurse cares for an older adult client with heart failure. 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?

ANS: A Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly. The other options minimize the clients concerns and do not allow the nurse to obtain more information to provide client-centered care.

The nurse is caring for an anxious 20-year-old college student who just suffered his first seizure in his dorm room. The patient asks the nurse if he is now an epileptic. What is the nurse's best response? a. "No. All other causes of seizure activity must be ruled out before the diagnosis of epilepsy is made." b. "Yes, but you may never have another seizure since it has just now manifested itself." c. "No, but you should see a physician to get a prescription for a preventative antispasmodic." d. "Yes. All seizures are considered to be epilepsy."

ANS: A Epilepsy diagnosis is made after all other causes of seizure activity have proven negative. All seizures are not considered to be epilepsy.

Which nursing intervention best encourages self-feeding in a patient with right-sided paralysis after a CVA? a. Place finger foods on the left side of the plate. b. Support the right hand in holding an adaptive cup. c. Seat the patient in the dining room with other residents. d. Place large helpings of food in the center of the plate.

ANS: A Finger foods on the nonparalyzed side encourage self-feeding. Privacy is more supportive to early efforts than being in a common dining room. Smaller helpings on the same side of the nonparalyzed limb are conducive to self-feeding.

A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke? a. A 27-year-old heavy cocaine user b. A 30-year-old who drinks a beer a day c. A 40-year-old who uses seasonal antihistamines d. A 65-year-old who is active and on no medications

ANS: A Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor.

An 86-year-old patient asks why her ankles have a brownish discoloration and the skin looks thick. Which response best addresses the patient's concern? a. "The valves in the vessels in your legs aren't working as well as they used to, which causes the discoloration and thickening of your skin." b. "You probably aren't getting enough iron in your diet. We should talk to your doctor about adding an iron supplement." c. "How many years have you smoked? Nicotine will cause these changes in your skin." d. "These are just normal changes seen in most older people."

ANS: A Hemosiderin leaks out of the trapped red blood cells in the dilated vessels of the feet and ankles, and stains the skin of people with venous insufficiency. In addition, fibrous tissue replaces subcutaneous tissue around the ankles and causes the skin to become thick and hardened. Iron and nicotine do not play a role in these skin changes with venous insufficiency, and these are not normal changes associated with aging.

The nurse is assisting a patient with agnosia after a CVA. Which intervention is most appropriate? a. Showing the patient a spoon while calling it by name and describing its purpose. b. Moving the patient's hand with a toothbrush in repetitive motion to brush teeth. c. Describing the placement of food on the plate. d. Providing an adaptive fork to enhance self-feeding.

ANS: A Identifying objects and their intended use is helpful to people with agnosia who can no longer recognize items. The other options are helpful to people with apraxia, hemianopsia, and altered coordination, respectively.

the nurse is caring for four hypertensive clients. Which druglaboratory value combination should the nurse report immediately to the health care provider? a. Furosemide (Lasix)/potassium: 2.1 mEq/L b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L d. Torsemide (Demadex)/sodium: 142 mEq/Lt

ANS: A Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and should be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal.

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 isnt any information about that. c. Why would you want to take that? d. Yes, it is a good supplement for you.

ANS: A Many foods and drugs interfere with warfarin, St. Johns wort being one of them. The nurse should advise the client against taking it. The other answers are not accurate

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask? a. Do you live in a crowded residence? b. When was your last tetanus vaccination? c. Have you had any viral infections recently? d. Have you traveled out of the country in the last month?

ANS: A Meningococcal meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. A tetanus vaccination would not place the client at increased risk for meningitis or protect the client from meningitis. A viral infection would not lead to bacterial meningitis but could lead to viral meningitis. Simply knowing if the client traveled out of the country does not provide enough information. The nurse should ask about travel to specific countries in which the disease is common, for example, sub-Saharan Africa.

The nurse is caring for a patient with brain tumor-related hydrocephalus who is scheduled to undergo placement of a ventriculoperitoneal (V-P) shunt. Which information is most important for the nurse to include when explaining the purpose of the procedure? a. A V-P shunt redirects the cerebrospinal fluid (CSF) from the ventricles to the peritoneum. b. A V-P shunt stimulates ventricles to reabsorb excess CSF. c. A V-P shunt channels excess CSF to the left atrium. d. A V-P shunt provides a port from which excess CSF can be aspirated.

ANS: A Obstruction of CSF flow may require placing a shunt to reduce CSF pressure and prevent increased intracranial pressure (ICP). A shunt is a tube placed in a ventricle and attached to a small manual pump that moves excess CSF fluid from the ventricles to the peritoneal cavity or into the atrium of the heart, so that it may be absorbed.

An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.

ANS: A Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed.

The nurse is providing teaching to a patient newly diagnosed with simple partial seizure disorder. Which statement by the nurse is most accurate? a. "Your seizures will typically only affect one side of your body." b. "Simple partial seizures may result in an alteration of consciousness." c. "The simple partial seizure may cause motor impairment to begin in all of your extremities." d. "Simple partial seizures are not treatable."

ANS: A Simple partial seizures only involve one side of the brain and one side of the body. Complex partial seizures may or may not result in an alteration in level of consciousness. Generalized seizures affect both sides of the body. Simple partial seizures may respond to treatment.

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

ANS: A The client with infective endocarditis does not pose any specific threat of transmitting the causative organism. Standard Precautions should be used. Bleeding precautions or reverse or contact isolation is not necessary.

The nurse is caring for a patient with bacterial meningitis. What interventions should the nurse include in the plan of care? a. Maintain a quiet environment with minimal stimulation. b. Provide all care using sterile technique. c. Limit intake of oral fluids. d. Provide magazines and other activities to reduce daytime naps.

ANS: A The environment is kept quiet with minimal stimulation to reduce the possibility of seizure. The care is done with general precautions. Fluid intake is encouraged, as are daytime naps to preserve energy.

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client is adamant about refusing the drug because its dangerous. What action by the nurse is best? a. Assess the reason behind the clients 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.

ANS: A The first step is to assess the reason behind the clients fear, which may be related to the experience of someone the client knows who took warfarin. If the nurse cannot address the specific rationale, teaching will likely be unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe. General statements like drugs are safer today do not address the root cause of the problem. Warning the client about possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial relationship.

A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The clients mental status is deteriorating. What action by the nurse is most appropriate? a. Attempt to find the family to sign a consent. b. Inform the provider that the procedure cannot occur. c. Nothing; no consent is needed in an emergency. d. Sign the consent form for the client.

ANS: A The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent. The nurse should not just sign the consent form.

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 heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.

ANS: A The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.

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

ANS: B A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not the priority.

A nurse is working with a client who takes atorvastatin (Lipitor). The clients recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/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.

ANS: A There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse should assess if the client eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may or may not be ordered.

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 clients lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil.

ANS: A This client could be having an exacerbation of heart failure or be experiencing a side effect of lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse should assess the clients lung sounds and other signs of oxygenation first. The client may or may not need to switch antihypertensive medications. Vital signs and documentation are important, but the nurse should assess the respiratory system first. If the cough turns out to be a side effect, reminding the client is appropriate, but then more action needs to be taken.

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

ANS: A, B, C Clinical manifestations of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction.

1. A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter.

ANS: A, B, C If the client has kidney disease (as indicated by BUN and creatinine results), fluids and Mucomyst may be given 12 to 24 hours before the procedure for renal protection. The client should be assessed for allergies to iodine, including shellfish; the contrast medium used during the catheterization contains iodine. A Foley catheter and central venous catheter are not required for the procedure and would only increase the clients risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.

The nurse is caring for a patient admitted with a transient ischemic attack (TIA). A carotid ultrasound reveals a 40% obstruction. The nurse anticipates that the treatment will likely consist of which factor(s)? (Select all that apply.) a. Diet modification b. Lifestyle alteration c. Aspirin for antiplatelet aggregation d. Daily doses of nitrates e. Endarterectomy

ANS: A, B, C Since the patient has a carotid obstruction below 60%, the patient will likely be treated conservatively with measures that include diet and lifestyle modification in conjunction with aspirin therapy. Nitrates and endarterectomy are not initial treatment options for carotid obstruction below 60%.

nurse is caring for a client with a nonhealing arterial ulcer. The physician has informed the client about possibly needing to amputate the clients 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.

ANS: A, B, C When a client is upset, the nurse should offer self by remaining with the client if desired. Other helpful measures include determining what and whom the client has for support systems and asking the client to describe what he or she is feeling. Telling the client how smoking has led to this situation will only upset the client further and will damage the therapeutic relationship. Telling the client that many people have amputations belittles the clients feelings.

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 erythematosus (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

ANS: A, B, D Acute pericarditis is most commonly associated acute exacerbations of systemic connective tissue disease, including SLE; with Dresslers syndrome, or inflammation of the cardiac sac after cardiac surgery or a myocardial infarction; and with infective organisms, including bacterial, viral, and fungal infections. Abdominal and reproductive surgeries and pressure ulcers do not increase clients risk for acute pericarditis.

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the clients plan of care? (Select all that apply.) a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. c. Stop the IV for aPTT above baseline. d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale.

ANS: A, B, D Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2 times normal in order to demonstrate that the heparin is therapeutic. Weighing the client is not related.

Which blood pressure findings constitute a diagnosis of hypertension? a. 120/80 ́ 2, 2 weeks apart b. 140/90 ́ 2, 2 weeks apart c. 120/80 on 3 consecutive days d. 140/90 every day for a week

ANS: B A diagnosis of hypertension is made if the systolic pressure is equal to or greater than 140 mm Hg and the diastolic pressure is equal to or greater than 90 mm Hg at least twice on two different occasions 2 weeks apart.

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 angiotensin-converting enzyme (ACE) inhibitor. c. Encourage the client to take a baby aspirin each day. d. Confirm that an echocardiogram has been completed. e. Consult a social worker for additional resources.

ANS: A, B, D The Heart Failure Core Measure Set includes discharge instructions on diet, activity, medications, weight monitoring and plan for worsening symptoms, evaluation of left ventricular systolic function (usually with an echocardiogram), and prescribing an ACE inhibitor or angiotensin receptor blocker. Aspirin is not part of the Heart Failure Core Measure Set and is usually prescribed for clients who experience a myocardial infarction. Although the nurse may consult the social worker or case manager for additional resources, this is not part of the Core Measures.

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 deep vein thrombosis (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.

ANS: A, B, D The UAP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT. The UAP can also encourage the client to do pulmonary exercises, but these do not decrease the risk of DVT. Teaching is a nursing function

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this clients 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 weigh yourself at home?

ANS: A, B, D To ensure safety upon discharge, the nurse should assess for structural barriers to functional ability, such as stairs. The nurse should also assess the clients available social support, which may include family, friends, and home health services. The clients ability to adhere to medication and treatments, including daily weights, should also be reviewed. The other questions do not address the clients safety upon discharge.

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

ANS: A, B, E Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided heart failure occurs with problems from the pulmonary vasculature onward including pulmonary hypertension. Signs will be noted before the right atrium or ventricle including dependent edema.

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

ANS: A, B, E, F a hematocrit of 32.8% is low (should be 42.6%), indicating a dilutional ratio of red blood cells to fluid. A serum sodium of 130 mEq/L is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. These are early warning signs of decreased compliance of the heart. The potassium level is on the high side of normal and the serum creatinine level is normal.

A nurse evaluates the results of diagnostic tests on a clients cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.) a. Clear b. Cloudy c. Increased protein level d. Normal glucose level e. Bacterial organisms present f. Increased white blood cells

ANS: A, C, D In viral meningitis, CSF fluid is clear, protein levels are slightly increased, and glucose levels are normal. Viral meningitis does not cause cloudiness or increased turbidity of CSF. In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to be cloudy.

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 exercises. c. Accurately record intake and output. d. Use the same scale to weigh the client each morning. e. Place the client on oxygen if the client becomes short of breath.

ANS: A, C, D The UAP should reposition the client every 2 hours to improve oxygenation and prevent atelectasis. The UAP can also accurately record intake and output, and use the same scale to weigh the client each morning before breakfast. UAPs are not qualified to teach clients or assess the need for and provide oxygen therapy.

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking

ANS: A, C, D, E Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.

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

ANS: A, C, D, E The Joint Commissions Core Measures state that clients being discharged on warfarin need instruction on follow-up monitoring, dietary restrictions, drug-drug interactions, and reason for compliance. Driving is typically not restricted.

The 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

ANS: A, D, E Atherosclerosis, hypertension, hyperlipidemia, and smoking are the most common related factors. Down syndrome and heartburn have no relation to aneurysm formation.

A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.) a. Discharging the client on a statin medication b. Providing the client with comprehensive therapies c. Meeting goals for nutrition within 1 week d. Providing and charting stroke education e. Preventing venous thromboembolism

ANS: A, D, E Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thromboembolism. The client must be assessed for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures.

After teaching a client with congestive heart failure (CHF), the nurse assesses the clients 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.

ANS: A, D, E Nutritional therapy for a client with CHF is focused on decreasing sodium and water retention to decrease the workload of the heart. The client should be taught to read nutritional labels on all food items, omit table salt and foods high in sodium (e.g., ham and canned foods), and limit water intake to a normal 2 L/day.

A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Have suction equipment at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.

ANS: A, D, F Oxygen and suctioning equipment with an airway must be readily available. The bed rails should be up at all times while the client is in the bed to prevent injury from a fall if the client has a seizure. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the client during a seizure and should not be used. Dietary restrictions and strict bedrest are not interventions associated with epilepsy. The client should be encouraged to eat a well-balanced diet and ambulate while in the hospital.

7. A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses.

ANS: B Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.

A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take? a. Start fluids via a large-bore catheter. b. Turn the clients head to the side. c. Administer IV push diazepam. d. Prepare to intubate the client.

ANS: B The nurse should turn the clients head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and should be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.

A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this clients 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.

ANS: B A client who has heart failure should be taught to conserve energy. Gathering all supplies needed for a chore at one time decreases the amount of energy needed. The client should not walk until becoming short of breath because he or she may not make it back home. Pushing a cart takes less energy than pulling or lifting. Although walking after dinner may help the client, the nurse should teach the client to complete activities when he or she has the most energy. This is usually in the morning.

A patient diagnosed with a primary brain tumor asks the nurse if this is a common disease. Which response is most appropriate for the nurse to make? a. "Brain tumors are very rare." b. "About 40,000 people a year are diagnosed with a primary brain tumor." c. "It doesn't really matter. We are just concerned with helping you." d. "Almost all primary brain tumors are malignant."

ANS: B About 200,000 new brain tumors are discovered each year in the United States with approximately 40,000 of those being primary tumors and the rest are metastatic tumors from a different site of origin. Many primary brain tumors are benign. Telling the patient his question doesn't really matter is dismissive and nontherapeutic.

fter 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.

ANS: B Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension. ACE inhibitors do not need to be taken with food. Collaboration with unlicensed assistive personnel to provide hygiene is not a priority. The client should be encouraged to complete activities of daily living as independently as possible. The nurse should monitor for hyperkalemia, not hypokalemia, especially if the client has renal insufficiency secondary to heart failure.

The student nurse is planning a community group presentation on hypertension. Which group of individuals should the student identify as having the highest incidence of hypertension? a. Muslims b. African Americans c. Whites d. Latinos

ANS: B African Americans have a higher incidence of hypertension than any other minority group or whites.

A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The clients spouse asks why the client needs this medication. What response by the nurse is best? a. The t-PA didnt dissolve the entire coronary clot. b. The heparin keeps that artery from getting blocked again. c. Heparin keeps the blood as thin as possible for a longer time. d. The heparin prevents a stroke from occurring as the t-PA wears off.

ANS: B After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a blood thinner, although laypeople may refer to it as such.

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 clients 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 clients obligations.

ANS: B All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse should assist the client in choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can move forward with another change. Determining support systems, daily stressors, and delegation opportunities does not directly impact the clients feelings of control.

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.

ANS: B An important goal of HP2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. Participating in blood pressure screening in a public spot will best help meet that goal. The other options are all appropriate but do not specifically help meet a goal.

The nurse is caring for a patient with agina pectoris who asks what happens to make his body experience pain. The nurse explains that pain results from which underlying causative factor? a. Congestion that backs up into the lungs b. Inadequate blood flow and poor oxygen supply c. Edema from fluid overload d. Inflammation in the vessels

ANS: B Angina pectoris (chest pain) occurs when blood supply to the heart is decreased or totally obstructed. Pain results from ischemia (inadequate blood and oxygen supply).

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 mm Hg 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 mm Hg d. Client who needs pain medication prior to a dressing change of a surgical wound

ANS: B Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse should see this client first to prevent falling if the client decides to get up without assistance. The two blood pressure readings are abnormal but not critical. The nurse should check on the client with higher blood pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards state to hold it if the systolic blood pressure is below 90 mm Hg. The client who needs pain medication prior to the dressing change is not a priority over client safety and assisting the other client to the bathroom.

Which medication is the most common and effective antiplatelet aggregation agent? a. Warfarin b. Aspirin c. Alteplase (Activase) d. Reteplase (Retavase)

ANS: B Aspirin is the most common and effective antiplatelet agent.

A client had a percutaneous transluminal coronary angioplasty for peripheral arterial 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. Verbalizes understanding of procedure

ANS: B Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+ indicates good perfusion. Pain control, remaining on bedrest as directed after the procedure, and understanding are all important, but do not take priority over perfusion.

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

ANS: B Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis. Preventricular contractions and bradycardia are not associated with valvular problems. These are usually identified in clients with electrolyte imbalances, myocardial infarction, and sinus node problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease in cardiac output.

The dysarthric patient seated in the dining room of the long-term care facility yells, "Poon! Poon! Poon!" with increasing frustration. What is the nurse's best response? a. "Slow down so that I can understand what you are saying." b. "Are you asking for a spoon?" c. "Not being able to speak is frustrating." d. "If you tell me what you want, I will get it."

ANS: B Attempting to interpret the dysarthric communication through questions that can be answered simply will reduce frustration.

The nurse is caring for a patient with a history of left-sided congestive heart failure (CHF). Which finding leads the nurse to suspect that the patient could be experiencing an acute exacerbation of this condition? a. The abdomen is tight and shiny. b. Wheezes are present during lung auscultation. c. The pupils react sluggishly to light. d. The heart rate is irregularly irregular.

ANS: B Left-sided heart failure causes increased pressure on the lungs and may manifest in wheezing. A tight and shiny abdomen is consistent with ascites, a manifestation of right-sided CHF. Sluggish pupillary reaction is consistent with a neurologic problem, and an irregularly irregular heart rate is consistent with a cardiac arrhythmia like atrial fibrillation.

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 clients neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.

ANS: B Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurological examination, but should first call the Rapid Response Team based on the clients manifestations. The nurse notifies the Rapid Response Team first. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful if the client is still receiving any of the drug.

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the clients understanding. Which client statement indicates a need for additional teaching? a. Ill 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.

ANS: B Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing a mitral valve replacement surgery, the client needs to be placed on anticoagulant therapy to prevent vegetation forming on the new valve. Clients on anticoagulant therapy should be instructed on bleeding precautions, including using an electric razor. If the client is prescribed warfarin, the client should avoid foods high in vitamin K. Clients recovering from open heart valve replacements should not carry anything heavy for 6 months while the chest incision and muscle heal.

A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the clients 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?

ANS: B Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the clients activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the clients heart failure.

The nurse is providing medication teaching to a patient with epilepsy who is taking phenytoin (Dilantin). Which statement best indicates that the nurse's teaching has been successful? a. "I should decrease my alcohol intake to a single drink per day." b. "I should visit the dentist every 3 to 6 months while taking this medication." c. "I should take my antacid an hour after my Dilantin." d. "This medication may turn my urine orange."

ANS: B Dilantin can cause gingival hyperplasia. The patient should brush teeth and floss regularly, and schedule dentist visits every 3 to 6 months. Alcohol interferes with the metabolism of anticonvulsants, increases lethargy, and may trigger seizures. The patient should not consume alcohol at all while taking Dilantin. The patient should not take antacids within 2 hours of taking Dilantin. Dilantin may turn the urine pink.

A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the clients stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

ANS: B Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other manifestations do not relate to the progression of mitral valve stenosis.

The nurse is caring for a patient who underwent endovenous laser treatment. Which statement indicates that the nurse's teaching about postprocedure management has been successful? a. "I should wear compression stockings for 5 days." b. "I should walk at least an hour every day for 2 weeks." c. "I should massaging the legs to stimulate circulation." d. i should notify my doctor if my foot is warm to the touch

ANS: B Endovenous occlusion using laser is done by placing a catheter within the vein under duplex ultrasound guidance. A laser heats the vessel, causing it to collapse and close off. Patients ambulate immediately after the procedure for 30 to 60 minutes and 1 to 2 hours per day for 1 to 2 weeks. The patient should wear compression stockings for 1 to 2 weeks. The patient should not massage the legs or notify the doctor of warm feet (a normal finding).

The nurse is educating a patient on a low-fat, low-cholesterol diet after a myocardial infarction (MI). Which food choice should the nurse recommend? a. "Avoid eating frozen foods." b. "Replace a serving of red meat with a serving of fish." c. "Use nondairy creamer in your decaffeinated coffee." d. "Drink a serving of grapefruit juice each day."

ANS: B Fish have a high content of omega-3 fatty acids, which are helpful in reducing cholesterol. Not all frozen foods are unhealthy. Frozen vegetables with no sodium added are a good choice for a low-fat, low- cholesterol diet. Nondairy creamer is high in trans fat and saturated fat. Grapefruit juice often interferes with metabolism of a variety of medications.

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.

ANS: B If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse should notify the provider immediately. The nurse should not independently increase the suction, re-position the chest tube, or take the tubing apart.

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)

ANS: B Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These medications are typically administered for hypertension and heart failure.

The nurse is caring for a patient with a deep venous thrombosis (DVT). Which medication would likely be used for initial inpatient treatment? a. Dabigatran (Pradaxa) b. Heparin c. Warfarin (Coumadin) d. Edoxaban (Lixiana)

ANS: B Inpatient medical treatment for DVT usually consists of intravenous (IV) heparin. Low-molecular-weight heparin (LMWH) such as enoxaparin (Lovenox) by injection may be used for inpatient management and is used more frequently for outpatient treatment. Fondaparinux (Arixtra), a Factor Xa inhibitor, may be used instead of enoxaparin. After initial IV or injection anticoagulation treatment oral anticoagulation is started with warfarin sodium (Coumadin), rivaroxaban (Xarelto), edoxaban (Lixiana), dabigatran (Pradaxa), or apixaban (Eliquis). Anticoagulation is continued for 3 to 6 months for the first episode of DVT and a year for recurrent episodes (Patel, 2014).

The nurse is caring for a patient who has a new prescription for a loop diuretic. Which nutritional intervention is most important for the nurse to add to the care plan? a. Increase intake of leafy green vegetables. b. Increase intake of bananas and potatoes. c. Avoid foods like canned soups and hot dogs. d. Limit caffeine intake.

ANS: B Loop diuretics are potent, potassium-wasting diuretics. After talking with the health care provider, the patient should recommend that the patient increase intake of potassium-rich foods like bananas and potatoes to offset potassium depletion from the diuretic. Leafy green vegetables are rich in vitamin K and may increase clotting times. Sodium-rich foods like canned soups and hot dogs should be avoided to prevent excess water retention, but this intervention does not address the risk for potassium depletion with loop diuretics. Caffeine is a stimulant that causes vasoconstriction and may increase blood pressure. While avoiding caffeine may improve blood pressure, this intervention does not address the risk of potassium depletion with a loop diuretic.

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 is 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.

ANS: B Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance.

How does a myocardial infarction (MI) alter the pumping efficiency of the heart? a. An MI reduces the impulse from the sinoatrial node. b. An MI causes myocardial necrosis. c. An MI shunts all myocardial blood flow to a specific cardiac region. d. An MI causes myocardial swelling and inflammation.

ANS: B Myocardial necrosis (damaged or dead heart muscle tissue) cannot contract effectively, which decreases pumping efficiency (cardiac output).

A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. Fish oil is contraindicated with most drugs for CAD. b. The best source is fish, but pills have benefits too. c. There is no evidence to support fish oil use with CAD. d. You can reverse CAD totally with diet and supplements.

ANS: B Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The best source is fish three times a week or some fish oil supplements. The other options are not accurate.

A client is 4 hours postoperative after a 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 clients chart. d. Notify the surgeon immediately.

ANS: B Once perfusion has been restored or improved to an extremity, clients can often feel a throbbing pain due to the increased blood flow. However, it is important to differentiate this pain from ischemia. The nurse should assess for other signs of perfusion, such as distal pulses and skin color/temperature. Administering pain medication is done once the nurse determines the clients perfusion status is normal. Documentation needs to be thorough. Notifying the surgeon is not necessary.

A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity? a. Atonic seizure b. Tonic-clonic seizure c. Myoclonic seizure d. Absence seizure

ANS: B Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment.

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 really tight lately. c. I wake up coughing every night. d. I have trouble catching my breath.

ANS: B Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.

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.

ANS: B Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate.

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

ANS: B The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related.

The home health nurse is caring for a patient with a blood pressure reading of 200/160. The patient denies any discomfort. The nurse should immediately contact the health care provider to report that the patient is experiencing which problem? a. Primary hypertension b. Hypertensive crisis c. Essential hypertension d. Secondary hypertension

ANS: B The diastolic pressure rising to readings between 140 and 170 and the patient being asymptomatic indicates hypertensive crisis.

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

ANS: B The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.

The nurse is caring for a patient diagnosed with an abdominal aortic aneurysm who complains of sudden, intense abdominal pain and light-headedness. What action should the nurse take next? a. Monitor the patient's blood pressure every 15 minutes. b. Contact the physician immediately. c. Notify the patient's family of the change in condition. d. Continue to assess the patient's pain.

ANS: B The patient is most likely experiencing a ruptured aneurysm, which is a medical emergency requiring surgical repair. The nurse should contact the physician immediately. The vital signs may need to be measured more often than every 15 minutes. Notifying the family is not the priority intervention. Ongoing assessment of pain should continue, but after the physician is notified of the emergent status change.

A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 4.2 mEq/L

ANS: B The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable.

A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this clients 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.

ANS: B These agents cause immune suppression, leaving the client more vulnerable to infection. The medication does not place the client at risk for bleeding, orthostatic hypotension, or a change in heart rate.

a client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the clients neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol)

ANS: B This clients manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the clients O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.

ANS: B This clients physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.

The nurse is teaching a pregnant patient who works as a cashier in a grocery store about varicose vein prevention. Which instruction is most important for the nurse to include in the teaching plan? a. Add vitamin C to diet. b. March in place while standing at the counter. c. Avoid tight support hose. d. Wear supportive shoes.

ANS: B Varicose veins are enlarged and tortuous veins that are distorted in shape by accumulations of pooled blood. Treatment of varicose veins includes exercising the legs and feet periodically throughout the day, like marching in place while standing at the counter, elevating the legs whenever possible, and wearing support hose. Supportive shoes and vitamin C do not prevent venous congestion.

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.

ANS: B Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the clients legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.

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

ANS: B, C, E Clinical manifestations of infective endocarditis include fever with chills, night sweats, malaise and fatigue, anorexia and weight loss, cardiac murmur, and Oslers nodes on palms of the hands and soles of the feet. Abdominal bloating is a manifestation of heart transplantation rejection.

client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the clients blood pressure at 82/40 mm Hg. 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.

ANS: B, D, E This client may have a ruptured/rupturing aneurysm. The nurse should notify the Rapid Response team and perform frequent client assessments. Giving pain medication will lower the clients blood pressure even further. The nurse cannot have the client sign a consent until the physician has explained the procedure.

A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Intermittent rigidity b. Lip smacking c. Sudden loss of muscle tone d. Brief jerking of the extremities e. Picking at clothing f. Patting of the hand on the leg

ANS: B, E, F Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, picking at clothing, and patting. Rigidity of muscles is associated with the tonic phase of a seizure, and jerking of the extremities is associated with the clonic phase of a seizure. Loss of muscle tone occurs with atonic seizures.

A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commissions Core Measures set, by what time should the client have a percutaneous coronary intervention performed? a 1530 (3:30 PM) b. 1600 (4:00 PM) c. 1630 (4:30 PM) d. 1700 (5:00 PM)

ANS: C The Joint Commissions Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of diagnosis of myocardial infarction. Therefore, the client should have a percutaneous coronary intervention performed no later than 1630 (4:30 PM).

Which symptom is a key sign of a brain tumor? a. Morning nausea b. Difficulty reading c. A headache that awakens patient d. Increasing blood pressure

ANS: C A headache that awakens the patient is an early sign of a brain tumor. Morning nausea, difficulty reading, and increasing blood pressure are nonspecific findings that can be attributed to multifactorial causes.

The nurse is educating an older adult patient who is taking antihypertensives with diuretics. Which information regarding safety precautions is most important for the nurse to include? a. Consider purchasing a home blood pressure monitor. b. Limit sodium intake in the diet. c. Sit on the side of the bed before standing. d. Keep an updated list of all medications.

ANS: C Age-related changes (reduced baroreceptor sensitivity) and risk for fluid shifts related to diuretics predispose the older adult patient to orthostatic hypotension. In order to prevent falls, the patient should change positions slowly and cautiously, like taking time to sit on the edge of the bed before standing. While purchasing a home blood pressure monitor, limiting sodium in the diet, and keeping an updated list of medications may assist with management of hypertension, fall prevention and safety are most important for the older adult patient.

A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.

ANS: C Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the providers prescription and the clients current medications.

The nurse is caring for a patient with peripheral arterial disease who complains of 3/10 pain in the lower extremities. The nurse observes a 0.5 cm ́ 1 cm ulcer on the left lower leg, and the lower legs are shiny and hairless bilaterally. The nurse identifies which priority problem statement/nursing diagnosis? a. Injury related to loss of peripheral circulation. b. Acute pain related to ischemia to lower extremities. c. Altered skin integrity related to ulcers on lower extremities. d. Insufficient knowledge related to new diagnosis of hypertension.

ANS: C Altered skin integrity is the priority problem statement/diagnosis in this situation. Acute pain is a nursing diagnosis, but the pain is 3/10 so it is not the priority since there is an open wound. Injury and insufficient knowledge could be problems, but there is not enough information to support these diagnoses.

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse 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.

ANS: C Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client should be re-measured and new stockings ordered if needed. The other options are appropriate, but not the most important.

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.

ANS: C Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period. The other options are false statements and do not correctly address the clients question.

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.

ANS: C Clients 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.

The nurse is caring for a patient with a compression dressing. Which action indicates appropriate wound care? a. The nurse changes the compression dressing daily. b. The nurse uses an alcohol-based cleanser before applying the compression dressing. c. The nurse places a compression dressing over the wound dressing. d. The nurse dons a face mask before applying a compression dressing.

ANS: C Compression therapy options include compression stockings, elastic tubular support bandages, intermittent compression devices, a paste bandage such as Unna boot, or placement of two to four layers of compression dressings to the affected area. Venous return is accomplished as the patient moves his leg and achieves pressure on the calf muscles. Compression dressings can be placed over wound dressings. The dressings help to reduce ulcer pain, keep the wound moist, and assist debridement. The dressing is changed from every 2 to 3 days to every few weeks depending on the type of dressing applied. An alcohol-based cleanser would be drying and harsh. Compression dressings do not necessitate use of a face mask.

A student nurse asks what essential hypertension is. What response by the registered 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 severe and life-threatening hypertension.

ANS: C Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension.

The nurse is assessing a patient on intravenous (IV) phenytoin (Dilantin). Which assessment finding is most concerning to the nurse? a. Blood pressure (BP) 138/92 b. Frequent hiccups c. Irregular apical pulse d. Nausea and vomiting

ANS: C IV phenytoin can cause cardiac arrhythmias and hypotension, especially if given faster than 50 mg/min.

The nurse is caring for a patient with a history of peripheral arterial disease. The patient complains of significant claudication, and findings of an ankle-brachial index are abnormal. The nurse anticipates that this patient will most likely require which type of procedure? a. Left heart catheterization b. Stress echocardiogram c. Percutaneous transluminal angioplasty (PTA) d. Nuclear medicine stress test

ANS: C PTA may be done to open an artery to reduce claudication symptoms and improve extremity perfusion.

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours

ANS: C Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.

The nurse is caring for a post-myocardial infarction (MI) patient who has been started on daily simvastatin (Zocor) and a low-fat diet. Which statement best indicates that the nurse's teaching has been successful? a. "I will need to have blood work every month while taking Zocor." b. "I should take my Zocor with grapefruit juice to help absorption. c. "I should call my doctor if I experience unexplained muscle pain." d. "I should take Zocor an hour before my biggest meal of the day."

ANS: C Statins can injure muscle tissue and are toxic to the liver in some patients. Patients should report any unexplained muscle tenderness or pain persisting for more than a few days. Laboratory tests for liver enzymes are recommended at the start of therapy and only when clinically indicated. Grapefruit juice interferes with drug metabolism and should be avoided to prevent increased risk of toxicity. Zocor can be taken without regard to meals.

The nurse is writing the care plan for a cerebrovascular accident (CVA) patient who has partial left-sided paralysis and is experiencing ataxia. Which intervention is most beneficial for this patient? a. Encourage the patient to ambulate as much as possible when she feels the energy to do so. b. Ensure the patient receives pureed foods and thickened liquids. c. Place the patient's call light on the right side of the patient and remind her to call for assistance before getting up. d. Encourage the patient to use a communication board.

ANS: C The patient with ataxia has experienced a loss of balance or poor coordination; therefore, placing the call light on this patient's right side and reminding her to call for help will best address her high risk for falling. Pureed foods and thickened liquids are necessary for the patient with dysphagia, and a communication board would assist a patient with dysarthria or aphasia.

The nurse is caring for a patient with severe congestive heart failure (CHF) who denies pain and is fearful of taking prescribed morphine. Which explanation best works to alleviate the patient's anxiety about risk of addiction? a. "Many people with CHF use morphine for pain control." b. "We can treat your pain with aspirin or ibuprofen." c. "Morphine has properties that help relieve air hunger in CHF patients." d. "You can refuse to take it."

ANS: C The primary purpose of morphine is its relief of air hunger and anxiety. Nonsteroidal anti-inflammatory drugs do not have the same vasodilation properties as morphine. Telling the patient that many CHF patients take morphine provides a generalized statement that does not therapeutically address the patient's anxiety or confusion about the medication. Telling the patient that he may refuse is a dismissive, nontherapeutic response.

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.

ANS: C, D, E Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry; wearing good, comfortable shoes; using lotion; washing the feet in room-temperature water; and cutting the nails straight across are all important measures. Abrasive material such as pumice stones should not be used. Cheap flip-flops may not fit well and wont offer much protection against injury.

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

ANS: D Abdominal aneurysms should never be palpated as this increases the risk of rupture. The registered nurse should intervene when the student attempts to do this. The other actions are appropriate.

The nurse is caring for a patient with congestive heart failure (CHF). Which intervention should the nurse include in the plan of care? a. Encourage intake of canned soups. b. Place the patient in a side-lying position to prevent venous pooling. c. Encourage large meals for increased nutritional impact. d. Alternate rest with activity.

ANS: D Alternating rest with activity preserves the patient's energy. Canned soups are high in sodium, and CHF patients are often placed on restricted-sodium diets. Patients are more comfortable in semi-Fowler position to ease breathing and should eat small meals that are easy to chew and use less energy.

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 isnt 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.

ANS: D Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse should refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.

A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this clients 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.

ANS: D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of heart failure. The client should be taught to eat a heart-healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.

After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. To prevent complications, I will drink at least 2 liters of water daily. b. This medication will stop me from getting an aura before a seizure. c. I will not drive a motor vehicle while taking this medication. d. Even when my seizures stop, I will continue to take this drug.

ANS: D Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.

The nurse reinforces the information given by the physician that endarterectomy as an intervention for stroke prevention is reserved for people who have carotid obstruction of greater than what percentage? a. 30% b. 40% c. 50% d. 60%

ANS: D Endarterectomy is reserved for people with carotid obstruction of more than 60%.

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this clients 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 beats/min. d. Do not take this medication within 1 hour of taking an antacid.

ANS: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin absorption, nor do these statements decrease complications of digoxin therapy.

The nurse is caring for a stroke patient who is experiencing homonymous hemianopsia. The patient asks if he is going to have any limitations when discharged from the hospital. The nurse anticipates the patient will be restricted from what activity? a. Ambulating independently b. Cooking on a stove c. Reading a book d. Driving a vehicle

ANS: D Homonymous hemianopsia is blindness in part of the visual field of both eyes. Driving a vehicle may be very dangerous for this patient. With proper occupational therapy, the patient should be able to ambulate independently, cook, and read.

Following a craniotomy for the removal of a brain tumor, the patient exhibits nuchal rigidity, rash on the chest, headache, and a positive Brudzinski sign. What do these assessment findings indicate to the nurse? a. Intracranial bleeding b. Encephalitis c. Increasing intracranial pressure d. Meningitis

ANS: D Nuchal rigidity, skin rash, headache, and a positive Brudzinski sign are indicative of meningitis.

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 clients 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.

ANS: D Pain from acute pericarditis may worsen when the client lays supine. The nurse should position the client in a comfortable position, which usually is upright and leaning slightly forward. Pain is decreased by using gravity to take pressure off the heart muscle. An ice pack and neck rub will not relieve this pain.

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 or 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?

ANS: D The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. 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. The client needs to feel that he or she has some control over the future. The nurse personally provides care to address the clients concerns instead of pushing the clients issues off on a chaplain or psychiatrist. The nurse should not jump to conclusions and suggest taking the client off the transplant list, which is the best treatment option.

After teaching a client newly diagnosed with epilepsy, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. I will wear my medical alert bracelet at all times. b. While taking my epilepsy medications, I will not drink any alcoholic beverages. c. I will tell my doctor about my prescription and over-the-counter medications. d. If I am nauseated, I will not take my epilepsy medication.

ANS: D The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseous. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the doctor aware of all medications to prevent complications of polypharmacy.

The nurse is caring for a 75-year-old patient with a history of diabetes and peripheral vascular disease (PVD). The nurse observes an inflamed and excoriated area on the patient's right shin. Which intervention should the nurse perform first? a. Document the findings. b. Review the patient's diet. c. Notify the primary care provider. d. Cover with clear occlusive dressing.

ANS: D The nurse should first cover the area with a clear, occlusive dressing to protect the area from scratching and infection. The nurse should then document the findings, notify the primary care provider, and review nutritional intake to confirm adequacy for wound healing.

The nurse is caring for a patient with a deep venous thrombosis (DVT). Which finding requires the nurse's immediate attention? a. Hematuria b. Decreased sensation in the affected leg c. Urine output of 35 mL in 1 hour d. Hemoptysis

ANS: D The primary concern for a patient with a DVT is the potential for embolisms. Hemoptysis (coughing up rust colored sputum) is the cardinal sign of a pulmonary embolus and is a medical emergency. Hematuria (bloody urine) is a finding that requires additional assessment but is not the priority. Hematuria may occur from trauma from Foley catheter insertion, use of blood thinners to treat the DVT, or a variety of other causative factors. Decreased sensation in the affected leg is an expected abnormal finding. Urine output of 35 mL/hr is normal.

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 of 4 seconds as normal d. Palpating both carotid arteries at the same time

ANS: D The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated.

A nurse assesses a client after administering isosorbide mononitrate (Imdur). 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.

ANS: D The vasodilating effects of isosorbide mononitrate frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. The clients headache is not related to hypoxia or dehydration; therefore, these interventions would not help. The client needs to take the medication as prescribed to prevent angina; the medication should not be held.

The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.

ANS: D To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority.

he 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: 198 mg/dL

ANS: D Triglycerides in men should be below 160 mg/dL. The other values are appropriate for adult males.

The nurse is caring for a female patient with a family history of heart disease who is undergoing a workup for cardiovascular disease. Which finding is most concerning to the nurse? a. Fainting b. Dry mouth c. Dizziness d. Fatigue

ANS: D Women frequently experience fatigue with heart disease. Many women do not even experience chest pain. Fainting, dry mouth, and dizziness are not typical signs of heart disease in women.

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment should the nurse wear? (Select all that apply.) a. Particulate respirator b. Isolation gown c. Shoe covers d. Surgical mask e. Gloves

ANS: D, E Meningeal meningitis is spread via saliva and droplets, and Droplet Precautions are necessary. Caregivers should wear a surgical mask when within 6 feet of the client and should continue to use Standard Precautions, including gloves. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.

while instructing a client on stroke prevention, the nurse mentions medications that are useful in stroke prevention. the following medications are effective in preventing a stroke except a. anticoagulants b. antiplatelets c. anticholinergics d. neuroprotective agents

Although anticholinergic drugs have a variety of uses, stroke prevention is not one of them. All the other medications are used in a variety of ways to help with stroke prevention.

1.The nurse suspects a clients heart is failing when which of the following heart sounds is assessed? a. s1 b. s2 c. s3 d. s4

An auscultated S3 is a sign that increased blood volume remains in the ventricle with each beat and that the heart is beginning to fail. S1 and S2 sounds are the first and second sounds heard when auscultating the heart. An S4 sound may indicate increased resistance to ventricular filling.

The patient has been prescribed a low-sodium diet. Which food choice indicates that the patient requires additional teaching? a. Fresh spinach b. Pickles c. Whole-grain pasta d. Grapefruit

B High-sodium foods include pickled vegetables, canned soups, and processed meats. Fresh spinach, whole- grain pasta, and grapefruit are appropriate low-sodium choices.

The nurse is caring for a 38-year-old African American patient with diabetes. The patient manages her diabetes with dietary control, takes oral contraceptives, and is a nonsmoker. Which characteristic(s) in this patient's history increase the patient's risk for coronary artery disease (CAD)? (Select all that apply.) a. Age b. Race c. Diabetes d. Nonsmoker status e. Use of oral contraceptives

B, C, E African Americans have an ethnic tendency to CAD. Taking birth control pills and diabetes are both risk factors for CAD. Older patients are at increased risk for CAD, and a nonsmoking status decreases the likelihood of developing CAD.

A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.

B, E The UAP can take and document vital signs, including oxygen saturation, and keep the clients head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.

The nurse is teaching a patient who takes warfarin (Coumadin) about a coagulation monitoring device. Which blood clotting time should the device monitors? a. PT b. PTT c. INR d. ACT

C A coagulation monitoring device measures the INR level for clotting time for a person on therapeutic doses of warfarin.

Which of the following should the nurse instruct a client in order to reduce the risk factors for developing arteriosclerosis? a. limit diet to contain less than 40 % fat b. restrict exercise c. stop smoking d. avoid prescription medications

C To reduce the risk for arteriosclerosis, the nurse should instruct the client to stop smoking. The diet should be limited to less than 30% of fat. Exercise should be encouraged. Prescription medications are often prescribed for clients with symptoms of arteriosclerosis.

The nurse is caring for a patient with suspected right-sided heart failure. Which manifestation best supports this potential diagnosis? a. Wheezing b. Orthopnea c. Edema d. Pallor

C- Right-sided heart failure leads to edema from systemic backup. Wheezing, orthopnea, and pallor are indicative of left-sided failure.

2.The family of a client diagnosed with a stroke asks the nurse if this health problem is very common. The nurse should respond that in the United States a person has a stroke every: a. 40 seconds b. one minute c. 2 minutes d. 5 minutes

In the United States, a person has a stroke every 40 seconds, and 700,000 new or recurrent strokes each year. Strokes are the third leading cause of death in the United States behind heart disease and cancer and are the leading cause of long-term disability.

A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.) a. Sodium level b. Liver enzymes c. Clotting factors d. Cardiac enzymes e. Creatinine level

NS: A, C Inflammation associated with meningitis can stimulate the hypothalamus and result in excessive production of antidiuretic hormone. The nurse should monitor sodium levels for early identification of syndrome of inappropriate antidiuretic hormone. A systemic inflammatory response (SIR) can also occur with meningitis. A SIR can result in a coagulopathy that leads to disseminated intravascular coagulation. The nurse should monitor clotting factors to identify this complication. The other laboratory values are not specific to complications of meningitis.

A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the clients pupillary responses. b. Request a neurologic consultation. c. Stop the infusion and call the provider. d. Take and document a full set of vital signs.

NS: C A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.

The nurse is explaining the difference between exertional angina and unstable angina. Which statement about unstable angina is accurate? a. Unstable angina occurs with moderate exercise. b. Unstable angina occurs when the blood pressure increases sharply. c. Unstable angina occurs when the body reacts to high stress levels. d. Unstable angina occurs unpredictably, even in sleep.

Unstable angina attacks are unpredictable and do not follow a pattern, as do stable angina attacks. Unstable angina can progress into a myocardial infarction (MI) and a medical emergency.

The nurse in a skilled nursing facility is caring for an 80-year-old patient who develops a productive cough with pink, frothy sputum. Which independent interventions should the nurse implement immediately? (Select all that apply.) a. Limit the patient's activity. b. Administer morphine. c. Administer lasix. d. Place the patient in high Fowler position. e. Weigh the patient daily.

a d

A client is instructed to reduce his intake of daily sodium intake so that the total amount is what his body needs. The nurse should instruct the client to reduce sodium intake to: a. 500 mg a day b. 1000 mg a day c. 2500 mg a day d. 4500 mg a day

a A human body needs about 500 mg of sodium each day. The average intake of sodium for individuals in the United States is between 4000 to 6000 mg a day.

Which of the following would the nurse most likely assess in a client diagnosed with right-sided heart failure? a. distended neck veins b. oliguria c. cough with frothy blood tinged sputum d. syncope

a An assessment finding in a client diagnosed with right-sided heart failure is distended neck veins. Oliguria, cough with frothy blood-tinged sputum, and syncope are all clinical manifestations of left-sided heart failure.

A client diagnosed with hypertension should be instructed by the nurse to avoid which of the following foods? a. cold cuts b. bananas c. milk d. oatmeal

a Cold cuts are processed meats that are usually high in sodium and may cause water retention and an increase in blood pressure. The rest of the foods really have no effect on blood pressure.

A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. Do you have any concerns about sexuality? b. Im glad to hear you are sleeping well now. c. Sleep near your spouse in case of emergency. d. Why would you move into the guest room?

a Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse should investigate the reason for the move. The other two responses are likely to cause the client to be defensive.

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure? a. i get short of breath when i climb stairs b. i see halos floating around my head c. i have trouble remembering things d. i have lost weight over the past month

a Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.

A client is learning about cholesterol. The nurse explains that the good cholesterol transports plasma cholesterol away from plaques and to the liver for metabolism. This type of cholesterol is called: a. high density lipoprotein b. low density lipoprotein c. very high density lipoprotein d. very low density lipoprotein

a High-density lipoprotein transports plasma cholesterol away from atherosclerotic plaques and to the liver for metabolism and excretion. Low-density lipoproteins, or bad cholesterol, are the main component of the atherosclerotic plaque. Very-low-density lipoproteins are considered more atherogenic and are more common in men and people with diabetes.

1. A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect? a. heart rate of 120 npm b. cool clammy skin c. o2 saturation of 90 percent d. respiratory rate of 8 bpm

a When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturations and perfusion. The client may not be able to compensate for long, and decreased oxygenation and cool, clammy skin will occur later.

.A client diagnosed with a brain tumor is going to receive chemotherapy. The nurse realizes that which of the following medications would most likely be prescribed for this clients treatment? a. carmustine b. digoxin c. aminophylline d. acetaminophen

a One of the biggest obstacles for chemotherapeutic agents when treating brain tumors is selecting a medication that will cross the blood-brain barrier. Carmustine can cross the blood-brain barrier. The other medications are not used as chemotherapy for brain tumors.

11.A client is being instructed on treatments available for a newly diagnosed brain tumor. The nurse realizes that this clients treatment could include all of the following EXCEPT: a. photo dna therapy b. radiation c. chemotherapy d. surgery

a Photo DNA therapy is not a therapy. The other answers are common treatment modalities for patients with brain tumors in addition to photodynamic and adjunctive medication therapy.

A client is being evaluated for a stroke. The nurse knows that one of the easiest and most common diagnostic tests used to differentiate between strokes is: a. computed tomography CT b. MRI c. EEG d. PET

a The CT scan is widely available in most hospitals and is an important tool to differentiate between ischemic strokes and hemorrhagic stroke. It is the most common tool used to diagnose a stroke. An MRI is contraindicated in clients with metal implants or pacemakers, and it can exacerbate claustrophobia. An EEG will determine the presence of brain waves, and it is not a diagnostic test for a stroke. A PET scan determines brain tissue functioning but, it will not be able to differentiate between the types of strokes.

1.Which of the following should the nurse instruct a client who is newly diagnosed with hypertension? a. it is a lifelong process b. it can be managed easily c. it is a short term problem d. it only happens in the poor and treatment is expensive

a Treatment of hypertension is a lifelong process. It requires lifestyle modification and occurs in all racial and economical groups. Hypertension can either be easy or difficult to manage.

One of the most important things a nurse can teach a client about seizure control is to: a. take the medication every day as prescribed by the doctor b. eat a balanced diet c. get lots of exercise d. take naps during the day

a Medication is effective only if it is taken as prescribed, and suddenly stopping the medication can trigger an increase in seizure activity. Diet and exercise are important to a healthy lifestyle but do little to control seizure activity.

A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.) a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury d. A 66-year-old female client with multiple sclerosis e. A 72-year-old man with chronic obstructive pulmonary disease

a b c

The patient with a right-sided paralysis from a stroke becomes frustrated when attempting to self-feed. He throws the spoon at the nurse and begins to cry. What nursing action(s) is/are most appropriate at this time? (Select all that apply.) a. Retrieve the spoon and sit quietly for a few seconds. b. Touch the patient and inquire if he would rather have a high-protein milkshake for his meal. c. Remind the patient that such behavior is not acceptable. d. Add an intervention to the NCP for increased support with self-feeding. e. Complete an incident report.

a b c d

Which problems are potential complications of uncontrolled hypertension? (Select all that apply.) a. Stroke b. Kidney failure c. Heart attack d. Congestive heart failure e. Deep vein thrombosis (DVT)

a b c d

2.The nurse is assessing a client diagnosed with a peripheral arterial occlusion. Which of the following will the nurse assess in this client? (Select all that apply.) a. pulselessness b. pain c. pallor d. paresthesia e. paralysis f. petechiae

a b c d e

Which condition(s) may cause seizures? (Select all that apply.) a. Stroke b. Cerebral tumor c. Hyperpyrexia d. Epilepsy e. Metabolic toxicity

a b c d e

Which factor(s) may be useful in preventing peripheral vascular disease (PVD)? (Select all that apply.) a. Stress relief b. Diabetes control c. Weight control d. Routine exercise e. Smoking cessation

a b c d e

A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.) a. Advanced age b. Diabetes c. Ethnic background d. Medication use e. Smoking

a b c e

The nurse is caring for an 80-year-old long-resident in a term care facility. Which intervention(s) should the nurse plan to enhance blood flow? (Select all that apply.) a. Apply light blankets over legs while sitting. b. Elevate legs frequently. c. Encourage walking. d. Avoid tight compression stockings. e. Maintain a warm environment.

a b c e

The nurse is caring for an adult patient with a history of seizures. In the event of a seizure, the nurse should document which information? (Select all that apply.) a. Duration of seizure b. Location of initiation of seizure c. Description of movements d. Family's reaction during the seizure e. Presence of incontinence

a b c e The nurse should document seizure duration, location of seizure initiation, description of unilateral or bilateral movement, and presence of incontinence. The family's reaction to the seizure is not included in documentation of a seizure.

The nurse is aware that absence (petit mal) seizures are difficult to detect for which reason(s)? (Select all that apply.) a. Lack of an aura b. Appearance as a brief moment of absentmindedness c. Brief loss of consciousness (LOC) d. Absence of patient memory of the event e. Absence of postictal signs

a b d e

To help prevent aspiration while feeding a patient who has a right-sided paralysis, the nurse should implement which intervention(s)? (Select all that apply.) a. Place the patient in high Fowler position. b. Instruct the patient to tilt the head and neck forward. c. Instruct the patient to drink liquids through a straw. d. Place food in the left side of the mouth. e. Avoid mixing foods with different textures.

a b d e

Which findings characterize peripheral vascular disease (PVD)? (Select all that apply.) a. Narrowed arteries b. Obstructed veins c. Involvement of all extremities d. Defective valve function e. Thrombophlebitis

a b d e

A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause

a b d e The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion.

The nurse is caring for a patient with Raynaud disease who is employed as a construction worker, has hypertension, and smokes one-half to one pack of cigarettes per day. What teaching points should the nurse include in discharge instructions? (Select all that apply.) a. Wear gloves when handling cold items. b. Drink plenty of warm beverages, such as coffee. c. Wear insulated socks when working in cool weather. d. Attend a smoking program. e. Use a heating pad to stay warm.

a c d e

The nurse is completing a care plan for a stroke patient who is at risk for impaired physical mobility. Which interventions should the nurse include in the care plan? (Select all that apply.) a. Assist the patient to stand. b. Remind the patient to ambulate as much as possible. c. Ensure that the call light is within reach. d. Coach the patient in active range-of-motion (ROM). e. Reinforce the use of a walker or cane.

a c d e

A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.

a c e The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done.

5.The nurse is instructing a client diagnosed with a brain tumor on symptoms to immediately report to her physician. Which of the following should be included in these instructions? (Select all that apply.) a. onset of seizures b. one sided weakness c. loss of balance d. problems with vision e. inability to talk f. loss of appetite

a, b, c, d, e Brain tumor symptoms that require immediate attention include new onset of seizures, slow progressing hemiparesis, gait or balance disturbances, visual problems, hearing loss, and aphasia. Loss of appetite is not a brain tumor symptom.

2.A client is at risk for coronary artery disease. Which of the following should the nurse instruct as modifiable risk factors for this health condition? (Select all that apply.) a. alcohol consumption b. diabetes mellitus c. family history d. gender e. low daily fruit intake f. psychosocial index

a, b, e, f

2.A client diagnosed with heart failure is prescribed furosemide (Lasix). Which of the following should this client be monitored for because of this medication? (Select all that apply.) a. dehydration b. rebound fluid volume overload c. hyponatremia d. hypokalemia e. hypernatremia f. hyperkalemia

a, c, d

5.A client is diagnosed with a venous stasis ulcer on the foot. Which of the following will be included in this clients plan of care? (Select all that apply.) a. administer oral antibiotics if infection is present b. keep the foot open to the air c. cover the foot with a hydrocolloidal dressing d. provide pain medication with debridement e. restric fluids f. instruct client to ambulate without shoes

a, c, d Nursing care of a client diagnosed with a venous stasis ulcer includes provide with oral antibiotics if infection is present, cover the wound with hydrocolloidal dressing if indicated to promote the formation of granulation tissue, provide pain medication with debridement. The wound should not be kept open to the air. The client does not need a fluid restriction. The client should be instructed to never ambulate without appropriate foot protection.

1.A client, being tested for a stroke, is not a candidate for tPA. Which of the following would be contraindicated for the use of tPA? (Select all that apply.) a. minor ischemic stroke within 30 days b. flucose level 120 c. blood pressure 190/120 d. lumbar puncture 2 days ago e. stroke onset 5 hours ago f INR 1.o

a, c, d, e

1.The nurse suspects a client is experiencing left-sided heart failure when which of the following is assessed? (Select all that apply.) a. decreased basilar lung sounds b. distended neck veins c. extra heart sounds d. lung crackles e. tachycardia f. weight gain

a, c, d, e Signs of left-sided heart failure are dysrhythmic heart rate, tachycardia, heart murmurs, extra heart sounds, lung crackles, and decreased basilar lung sounds. Distended neck veins and weight gain are symptoms of right-sided heart failure.

1.A client is diagnosed with tonic-clonic seizures. Which are the characteristics of these types of seizures? (Select all that apply.) a. progressing through all of the seizure phases b. beginning before age 5 c. lasting 2 to three minutes d. causing injury to the client e. occuring at any time day or night f. being highly variable

a, c, d, e, f

The nurse, caring for a client diagnosed with a brain tumor, is planning interventions to assist with swallowing and prevent aspiration. Which of the following would be appropriate for this client? (Select all that apply.) a. instruct the client to tuck the chin with each swallow b. instruct the client to turn the head toward the strong side to swallow c. instruct the client to turn the head toward the weak side to swallow d. instruct the client to hold the breath while swallowing e. instruct the client to eat in a reclining position f. instruct the client to sit in an upright position when eatings

a, c,d f

12.A client diagnosed with an embolic stroke is not a candidate for tPA. The nurse realizes that the client might be eligible for which of the following forms of treatment? a. carotid stenting b. antiarrhythmic medication c. IV fluid therapy d. carotid endarterectomy

a. In clients who are ineligible for tPA therapy, catheter-based treatment such as stenting may be an option. Carotid endarterectomy is used to prevent a stroke. Antiarrhythmic medication does not prevent a stroke. Intravenous fluid therapy does not prevent a stroke.

5.A client is experiencing a grand mal seizure. Which of the following should the nurse do during this seizure? a. protect the clients head b. leave the client alone c. give water to the client to avoid dehydration d. place a finger in the clients mouth to avoid swallowing the tongue

a. One of the most important interventions for a nurse to perform during a seizure is to protect the clients head from injury. Never give a client a drink during a seizure. Placing a finger in the clients mouth could be very dangerous to the client and the nurse. Do not leave the client unattended during a seizure

When instructing a client on ways to lower his cholesterol levels, which of the following should the nurse include? a. eat more meat and eggs b. consume less meat and eggs c. incorporate more vegetables d. limit fruits

b Cholesterol is located in animal sources, so decreasing meat and eggs will lower cholesterol levels. The client should not be instructed to eat more meat and eggs. Vegetables and fruits do not impact the cholesterol level.

14. A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching? a. the best way to lose weight is a high protein low carb diet b. you should balance weight loss with consuming necessary nutrients c. a nutritionist will provide you with information about your new diet d. if you exercise more frequently, you wont need to change your diet

b Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse should encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse should include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk.

A client is diagnosed with Raynauds disease. Which of the following will the nurse most likely assess in this client? a. elevated BP b. pain, cyanosis, and numb, cold extremeties c. absent peripheral pulses d. increase in varicose veins

b Clinical manifestations of Raynauds disease include venospasms; pain; cyanosis; redness; numb, cold extremities; and swelling. Elevated blood pressure, absent peripheral pulses, and varicose veins are not associated with this disorder.

The nurse is unable to insert an intravenous access line into a client who is currently experiencing a seizure. Which of the following routes can the nurse use to provide medication to the client at this time? a. oral b. intranasal c. rectal d. intramuscular

b For a client experiencing a seizure, oral medications and sharp objects can be dangerous and should not be used. Intranasally administered drugs are rapid and effective in treating a client experiencing an acute seizure. Intranasal delivery is more effective than rectal.

A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

b Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for.

A client is prescribed phenytoin (Dilantin) for a seizure disorder. Which of the following would indicate that the client is adhering to the medication schedule? a. the client is slepey b. the client is not expierencing seizures c. the client no longer has headaches d. the client is eating more food

b Phenytoin (Dilantin) is a medication to control seizures. The absence of seizures indicates that the client is adhering to the medication schedule. Sleepiness, lack of headaches, or improved appetite are not indications that the medication is being used as prescribed.

The nurse is assessing a client for risks in the development of varicose veins. Which of the following findings would increase this clients risk? a. normal weight b. prolonged stnading c. engages in golf three times a week d. eats several servings of fruits and vegetables each day

b Risk factors for the development of varicose veins include thrombophlebitis, obesity, prolonged standing, pregnancy, and liver or pancreas dysfunction. Normal weight, activity, and balanced diet are not risk factors for the development of varicose veins.

12.A client is prescribed Spironolactone (Aldactone) for blood pressure control. Which of the following should the nurse assess in this client as a potential side effect? a. hypokalemia b. hyperkalemia c. hyponatremia d. hypernatremia

b Spironolactone (Aldactone) is a potassium-sparing diuretic. Side effects include hyperkalemia. Hypokalemia and hyponatremia are side effects of the thiazide diuretics. Hypernatremia is not a known side effect of any antihypertensive medication.

A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commissions Core Measures outcomes? a. Obtain an electrocardiogram (ECG) now and in the morning. b. Give the client an aspirin. c. Notify the Rapid Response Team. d. Prepare to administer thrombolytics.

b The Joint Commissions Core Measures set for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG is vital, but getting another one in the morning is not part of the Core Measures set. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed.

13. A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery? a. adminstration of IV furosemide (lasix) b. initiation of an external pacemaker c. assistance with endotracheal intubation d. placement of central venos access

b The RCA supplies the right atrium, the right ventricle, the inferior portion of the left ventricle, and the atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing should be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node malfunction.

11. A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The clients health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take? a. schedule an electrocardiogram just before the MRI b. notify the health care provider before scheduling the MRI c. call the physician and request a laboratory draw for cardiac enzymes d. instruct the client to increase fluid intake the day before the mri

b The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health care provider and report that the client has a pacemaker so the provider can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids.

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema? a. i wake up to go to the bathroom at night b. my shoes fit tighter by the end of the day c. i seem to be feeling more anxious lately d. i drink at least eight glasses of water a day

b Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse should note whether the client feels that his or her shoes or rings are tight, and should observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.

3.A nurse is instructing a client regarding medications and substances contraindicated for the client with heart failure. Which of the following would not be contraindicated? a. alcohol b. forosemide c. metformin d. pioglitazone

b Loop diuretics (e.g., furosemide) are part of the recommended medications for heart failure. Alcohol, metformin, and pioglitazone (a thiazolidinedione) are contraindicated.

5.A client is being seen in the emergency department experiencing symptoms of a stroke. The nurse realizes that the administration of a medication to break clots, such as tPA, should be administered within how many minutes of the client presenting to the emergency department? a. 30 minutes b. 60 minutes c. 90 minutes d. 120 minutes

b Medications like tPA should be given within 60 minutes of the clients arrival to the emergency department. This is why health care teams must have a plan to deal with stroke clients quickly and efficiently.

6.A clients blood pressure has been measured at 130/86 mmHg on two separate occasions. The nurse realizes this clients blood pressure reading would be categorized as being: a. normal b. prehypertension c. stage 1 hypertension d. stage 2 hypertension

b Prehypertension is a new designation used to identify individuals at high risk for the development of hypertension. Systolic blood pressure of 120 to 139 and diastolic blood pressure of 80 to 90 are values for prehypertension. A normal blood pressure is less than or equal to 120 mmHg systolic and less than or equal to 80 mmHg diastolic. Stage 1 hypertension is a systolic blood pressure between 140 to 159 and a diastolic pressure between 90 to 99. Stage 2 hypertension is a systolic reading greater than or equal to 160 and a diastolic pressure of greater than or equal to 100 mmHg.

1. 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 exercises e. Teaching the client about surgical options

b c d The three Es of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure.

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Age b. Hypertension c. Obesity d. Smoking e. Stress

b c d e

The nurse is caring for a patient with peripheral vascular disease (PVD). The nurse understands that which age-related changes may cause PVD? (Select all that apply.) a. Decreasing blood viscosity b. Loss of elasticity in vessel walls c. Atherosclerotic changes in vessels d. Sedentary practices e. Weakened leg muscles

b c d e

The nurse is performing an initial assessment on a new patient with suspected right- sided heart failure. Which finding(s) is/are consistent with the patient's potential diagnosis? (Select all that apply.) a. Clammy skin b. Splenomegaly c. Abdominal distention d. Wheezing e. Dyspnea

b c e

An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath

b c e Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptomsindigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome.

A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.) a. Photophobia b. Dilated pupils c. Headache d. Widened pulse pressure e. Bradycardia

b d e Increased ICP is a complication of encephalitis. The nurse should monitor for signs of increased ICP, including dilated pupils, widened pulse pressure, bradycardia, irregular respirations, and less responsive pupils. Photophobia and headache are not related to increased ICP

Which intervention(s) is/are important for a patient with venous insufficiency? (Select all that apply.) a. Avoid swimming. b. Elevate feet to reduce edema. c. Wear tight clothing. d. Decrease fluid intake. e. Apply elastic compression wraps twice daily.

b e

4.A client asks the nurse to explain symptoms that would indicate the presence of a brain tumor. Which of the following should the nurse respond to this client? (Select all that apply.) a there are no symptoms specific to a brain tumor b. dizziness is a common symptom c. ringing or buzzin the ears can occur d. seizures may occur e. a headache that gets worse in the afternoon is specific to a brain tumor f. a headache is usually expierenced by fifty percent

b, c, d, f

for the client who is at risk for stroke, the most important guideline the nurse should teach is to a. increase drinks with caffiene b. monitor blood pressure c. increase amounts of sodium in the diet d. monitor weight and activity

b. monitoring weight and activity is important, but the highest priority is monitoring the BP.

11.A client is participating in cardiac rehabilitation and is currently engaging in supervised exercise, counseling, and education. The nurse realizes this client is in which phase of cardiac rehabilitation? a. phase I b. phase II c. phase III d. phase IV

c

4. A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 beats/min. Which action should the nurse take first? a. document the finding in the chart b. initiate external pacing c. assess the clients medications d. aminister 1 mg of atropine

c

5.A client is surprised to learn that she has high blood pressure. Which of the following should the nurse assess in this client? The presence or occurrence of: a. nausea b. pain c. headache d. fear

c

the nurse is determining nursing diagnoses appropriate for a client demonstrating productive cough with pink frothy sputum, shortness of breath, and crackles. Which of the following nursing diagnoses is of the most importance? a. activity intolerance b. anxiety c. impaired gas exchange d. risk for ineffective respiratory function

c

9. A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. urinary output less than intake b. bruising at the insertion site c. slurred speech and confusion d. discomfort in the left leg

c A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are expected at the site. If intake decreases, a client can become dehydrated because of dye excretion. The second intervention would be to increase the clients fluid status. Neurologic changes would take priority.

A client is admitted with abdominal aortic aneurysm. For which of the following complications should the nurse be concerned? a. hypotension b. cardiac arrhythmias c. aneurysm rupture d. loss of bowel sounds

c Aneurysm rupture is a life-threatening occurrence and the highest risk for the client until it can be repaired. Hypotension, cardiac arrhythmias, and loss of bowel sounds are all significant potential complications; however, they are not life threatening.

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met? a. Chooses preferred items from the menu b. Eats 75% to 100% of all meals and snacks c. Has clear lung sounds on auscultation d. Gains 2 pounds after 1 week

c Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.

A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect? a. excruciating pain on inspiration b. left lateral chest wall pain c. disorientation and confusion d. numbness and tingling of the arm

c In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the myocardial infarction. However, the nurse should be more concerned about the new onset of disorientation or confusion caused by decreased perfusion.

A client is diagnosed with acute peripheral arterial occlusion. The nurse should prepare to provide which of the following interventions for this client? a. administer oxygen b. assist with ambulation c. administer heparin d. restrict fluids

c In the treatment of acute peripheral arterial occlusion, intravenous heparin therapy is usually the first intervention. Oxygen is not the first intervention for this client. The client will most likely be on bed rest and will not ambulate. Restricting fluids would not be indicated for acute peripheral arterial occlusion.

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take? a. elevate the leg and apply a sandbag to the entrance site b. increase the flow rate of IV fluids c. assess the color and temp of leg d. document the finding as left pedal pulse of +1/4

c Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The pulse may be faint because of edema. The left pulse should be compared with the right, and pulses should be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider should be notified. Simply documenting the findings is inappropriate. The leg should be positioned below the level of the heart or dangling to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the clients problem.

3.The nurse measures a clients blood pressure to be 158/92 mmHg. The nurse recognizes that this blood pressure is classified as: a. normal b. prehypertnesion c. stage 1 hypertension d. stage II hypertension

c Normal blood pressure is SBP less than 120 mmHg and DBP less than 80 mmHg. A prehypertensive state is SBP of 120 to 139 mmHg or DBP of 80 to 90 mmHg. Stage I hypertension is SBP of 140 to 159 mmHg or DBP of 90 to 99 mmHg. Stage II hypertension is a SBP of 160 mmHg or higher or a DBP of 100 mmHg or higher.

2.A client has a blood pressure of 124/78 mmHg and a triglyceride level of 160 mg/dL. Based on these results, the nurse knows that the client has: a. an optimal blood pressure and trigyceride level b. a prehypertensive BP and optimal triglyceride level c. a prehypertensive BP and borderline high triglyceride level d. stage 1 hypertension and a high triglyceride level

c Prehypertensive blood pressure ranges systolically from 120 to 139 mmHg or diastolically from 80 to 90 mmHg. Stage I hypertension is systolic blood pressure (SBP) of 140 to 159 mmHg or a diastolic blood pressure (DBP) of 90 to 99 mmHg. Optimal triglyceride levels are less than 150 mg/dL. Triglyceride levels from 150 to 199 mg/dL are considered borderline high. Triglyceride levels at 200 to 499 mg/dL are considered high.

11.A client receiving a heparin infusion is demonstrating signs of acute bleeding. Which of the following should the nurse prepare to administer to this client? a. aspirin b. vitamin K c. protamine sulfate d. narcan

c Protamine sulfate is the heparin antagonist used for excessive bleeding. Vitamin K is the antagonist for warfarin. Aspirin and narcan are not used for bleeding associated with a heparin infusion.

8.A client is diagnosed with Buergers disease. Which of the following should the nurse instruct the client regarding this disorder? a. it is a common disease b. it appears in women more than women c. smoking exacerbates the disease d. more common in african americans

c Smoking cessation halts the disease progress, but continuation of smoking exacerbates the progression of the disease. Buergers disease is a rare disorder. It is more common in men than women. It is more common in Asians and rare among African Americans.

The nurse is instructing a client diagnosed with mild heart failure on dietary modifications. Which of the following client statements indicates that the instruction has been effective? a. i will avoid green beans b. i will avoid orange juice c. i will avoid soy sauce d. i will avoid apple sauce

c Soy sauce is a high-sodium food choice; all the other choices are low sodium. Treatment for mild symptoms of heart failure includes dietary restriction of salt.

4.A client is complaining of chest pain that occurs during exercise. This pain is relieved when the client rests. The nurse realizes that this client is experiencing which type of angina? a. prinzmetals variant angina b. silent angina c. stable angina d. unstable angina

c Stable angina is precipitated by factors that increase oxygen demand or reduce oxygen supply. Chest pain occurs predictably with the same onset, duration, and intensity and is relieved when the precipitating factor is removed or with nitroglycerin. Unstable angina is typified by an increase in frequency, duration, and intensity of symptoms at lower levels of activity and even at rest. Prinzmetals variant angina is a coronary artery spasm. Silent angina can occur with no pain at all and is common in diabetic patients.

A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease? a. an 86 year old man with hx of asthma b. a 32 year old asian american women with colorectal cancer c. a 45 year old american indiam women with diabetes d. a 53 year old post menopausal woman who is on hormone therapy

c The incidence of coronary artery disease and hypertension is higher in American Indians than in whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary artery disease in people of any race or ethnicity. Asthma, colorectal cancer, and hormone therapy do not increase risk for cardiovascular disease.

A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority? a. Administer pain medication. b. Assess the clients vital signs. c. Notify the Rapid Response Team. d. Raise the head of the bed.

c This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team, but getting immediate medical attention is the priority. Administering pain medication may not be warranted if the client must return to surgery. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning.

A client is having a diagnostic test that will evaluate the hearts structure and function using an ultrasound. The client is most likely having a(n): a. exercise electrocardiography b. electrocardiogram c. echocardiogram d. chest xray

c An echocardiogram is the evaluation of the hearts structure and function with images and recordings using ultrasound. Exercise electrocardiography is the use of exercise while assessing a clients 12-lead electrocardiogram. A 12-lead electrocardiogram is a standardized recording of the electrical activity of the heart. A chest x-ray provides information on the size of the heart and pulmonary circulation, lung disease, and abnormalities of the aorta.

A client is diagnosed with a normal ejection fraction. The nurse realizes that the clients ejection fraction is most likely between: a. 10 to 20 b. 30 to 40 c. 60 to 70 d. 80 to 90

c Ejection fraction is the percentage of blood that is emptied from the ventricle during systole. An ejection fraction of 60% to 70% is considered normal. Lower ejection fraction findings indicate damage to the ventricle. Ejection fractions are not usually as high as 80% to 90%.

A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.) a. Bleeding b. Infection c. Hoarseness d. Dysphagia e. Seizures

c d Complications of surgery to implant a vagal nerve stimulation device include hoarseness (most common), dyspnea, neck pain, and dysphagia. The device is tunneled under the skin with an electrode connected to the vagus nerve to control simple or complex partial seizures. Bleeding is not a common complication of this procedure, and infection would not occur during the recovery period.

The nurse is caring for a 60-year-old African American patient with hypertension. The patient is obese and a smoker. Which modifiable risk factors place this patient at an increased risk for heart disease? (Select all that apply.) a. Age b. Race c. Hypertension d. Obesity e. Smoking

c d e

A client diagnosed with arteriosclerosis is prescribed an anticoagulant. For which of the following should the nurse assess in this client? a. respiratory distress b. skin breakdown c. decreased urine output d. bruising and bleeding

d A client who is prescribed blood-thinning medication is at a greater risk of bleeding and bruising. Anticoagulant therapy does not increase a clients risk for developing respiratory distress, skin breakdown, or decreased urine output.

. An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first? a. a 42 year old female who describes her pain as a dull ache with numbness in her fingers b. a 49 year old male who reports moderate pain that is worse on inspiration c. a 53 year old male who reports substernal pain that radiates to her abdomen d. a 58 year old male who describes his pain as intensie stabbing that spreads across his chest

d All clients who have chest pain should be assessed more thoroughly. To determine which client should be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing, vise-like substernal pain that spreads through the clients chest, arms, jaw, back, or neck is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent cardiac cell death. A dull ache with numbness in the fingers is consistent with anxiety. Pain that gets worse with inspiration is usually related to a pleuropulmonary problem. Pain that spreads to the abdomen is often associated with an esophageal-gastric problem, especially when this pain is experienced by a male client. Female clients may experience abdominal discomfort with a myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal-gastric problems should be seen, they are not a higher priority than myocardial infarction.

A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find? a. blood pressure increased from 98/42 to 132/60 b. respiratory rate decreased from 25 bpm to 14 c. oxygen saturation increased from 99 to96 percent d. pulse decreased from 100 bpm to 80

d Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased HR.

9.A client tells the nurse that using nitroglycerin tablets causes a tingling sensation and a headache. The nurse knows that this is: a. an emergency b. an allergic reaction c. evidence of toxicity d. expected

d Nitroglycerin tablets will cause a tingling sensation and can cause feelings of the heart pounding, as well as flushing and headache. These symptoms are not an emergency, an allergic reaction, or evidence of toxicity. These symptoms are expected with nitroglycerin tablets.

13.A client is prescribed an ACE inhibitor for management of hypertension. Which of the following side effects should the nurse instruct the client as being expected with this medication? a. tachycardia b. constipation c. bizarre dreams d. persistent dry cough

d One side effect of ACE inhibitors that is expected with this medication is a persistent dry cough. Tachycardia, constipation, and bizarre dreams are not side effects associated with ACE inhibitors.

The nurse is assessing a client diagnosed with an abdominal aortic aneurysm. Which of the following sounds did the nurse auscultate during the assessment? a. pleural rub b. hyperactive bowel sounds c. crackles d. bruit

d The nurse may auscultate a bruit at the site of the aneurysm. Pleural rib and crackles are adventitious sounds heard during the assessment of the lungs. Hyperactive bowel sounds may be heard when assessing the abdomen.

4. A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset

d The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.

. A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder retention and/or incontinence. b. Listen to the clients lungs after eating or drinking. c. Prop the clients right side up when sitting in a chair. d. Rotate the clients meal tray when the client stops eating.

d This condition is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. The client may not see all the food on the tray, so the nurse rotates it so uneaten food is now within the visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.

in planning the care for a client diagnosed with heart failure, which of the following would be an appropriate goal? a. reduce myocradial contractility b. increase cardiac workload c. decrease ejection fraction d. increase activity levels

d An increase in activity levels would be an appropriate goal for the client diagnosed with heart failure. The other options would be a decrease in ability, function, or management of the heart failure patient.

10. A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? a. clients level of anxiety b. ability to turn self in bed c. cardiac rhythm and heart rate d. allerges to iodine-based agents

d Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. Second, it is important for the nurse to assess anxiety, mobility, and baseline cardiac status.

12.A client is scheduled for a cardiac catheterization. The nurse realizes that the indications for this diagnostic test would be: a. hypertension b. peripheral edema c. CVA d. diagnose coronary artery disease

d Clinical implications for cardiac catheterization are to diagnose coronary artery disease and assess for atherosclerotic lesions. Hypertension, peripheral edema, and cerebral vascular accident are not indications for a cardiac catheterization.

15. A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond? a. i will consult the provider to prescribe a sleep study to determine the problem b. you become hypoxic while sleeping, oxygen therapy via nasal cannula will help c. a continous positive airway pressure or cpap breathing mask will help you breathe at night d. use pillows to elevate your head and chest while you are sleeping

d The client is experiencing orthopnea (shortness of breath while lying flat). The nurse should teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea.