Fundamentals Final
The nurse is caring for a patient who was admitted to the telemetry unit with a diagnosis of rule/out acute MI. The patient's chest pain began 3 hours ago. Which of the following laboratory tests would be most helpful in confirming the diagnosis of a current MI? a) Creatinine kinase-myoglobin (CK-MB) level b) CK-MM c) Troponin C level d) Myoglobin level
a) Creatinine kinase-myoglobin (CK-MB) level
The nurse is preparing to assess a patient's newly created stoma. Which of the following findings would the nurse include in the documentation of a healthy stoma? a) Dry in appearance b) Pink color c) Pain d) Black color
b) Pink color
Which of the following arterial blood gas (ABG) results would the nurse anticipate for a patient with a 3-day history of vomiting? a) pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34 b) pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 c) pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 d) pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21
b) pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 (metabolic alkalosis)
The nurse is reviewing the laboratory data of a patient admitted for evaluation of a fluid and electrolyte imbalance. The lab results show Na+ 132 mEq/L, BUN 5 mg/dL, and HCT 33%. What does the nurse infer from these findings? a) Hyperkalemia b) Hypernatremia c) Excess fluid volume d) Deficient fluid volume
c) Excess fluid volume
(EMS) diagnosed a man with a myocardial intarction (MI) based on his presentation and electrocardiogram (ECG). The patient has been identified as a candidate for percutaneous transluminal coronary angioplasty (PTCA). The nurse who is providing care for this patient should recognize that the extent of cardiac damage will primarily depend on: a) The patient's previous use of antiplatelets and anticoagulants b) The particular risk factors that contributed to the patient's MI c) The duration of oxygen deprivation to the patient's cardiac cells d) The patient's high- and low-density lipoprotein (LDL, HDL) levels prior to MI
c) The duration of oxygen deprivation to the patient's cardiac cells
When caring for a patient who has risk factors for fluid and electrolyte imbalances, which of the following assessment findings is the highest priority for the nurse to follow up? a) Blood pressure 96/53 mm Hg b) Weight loss of 4 lb c) Mild confusion d) Irregular heart rate
d) Irregular heart rate
A patient's gradual decline in activity tolerance and increased shortness of breath have prompted her health care provider to assess the structure and size of her heart. Which of the following diagnostic tests is most likely to yield these assessment data? A) Echocardiography B) Electrocardiography (ECG) C) Cardiac catheterization D) Angiography
A) Echocardiography
A team of public health nurses are strategizing around a new initiative that will address screening, education, and management of hypertension in residents of the community. Which of the following facts surrounding hypertension should underlie the nurses' design of this health initiative? A) Many of the pathophysiological effects of hypertension are poorly understood in the health literature. B) Hypertension is difficult to identify in many of the individuals who are at highest risk of the problem. C) Hypertension tends to be inadequately managed in many of the people who have been diagnosed with the problem. D) Hypertension is among the health problems that are most difficult to treat successfully.
C) Hypertension tends to be inadequately managed in many of the people who have been diagnosed with the problem.
A patient presents to the Emergency Department experiencing a severe anxiety attack and is hyperventilating. The nurse would expect the patient's pH value to be which of the following? a) 7.50 b) 7.30 c) 7.45 d) 7.35
a) 7.50 (respiratory alkalosis)
The nurse is performing a physical assessment on a patient suspected of being in heart failure. During auscultation, heart failure would be suggested by: a) An S3 heart sound b) Crackles c) Wheezing d) An S4 heart sound
a) An S3 heart sound
Which of the following would the nurse expect to find when reviewing the laboratory test results of a client with renal failure? a) Increased serum creatinine level b) Decreased serum potassium level c) Increased red blood cell count d) Increased serum calcium level
a) Increased serum creatinine level
A hospitalized patient with heart failure suddenly develops dyspnea at rest, disorientation, crackles midway up in all lung fields with a pulse oximetry reading of 87% on Room Air. What interventions would be appropriate? Select all that apply: a) Insertion of a Foley catheter b) Monitor strict I & O c) Administer a 500cc bolus of normal saline d) Place the client in trendelenburg position e) Administer a rapid acting diuretic f) Administer oxygen
a) Insertion of a Foley catheter b) Monitor strict I & O e) Administer a rapid acting diuretic f) Administer oxygen
The nurse is conducting a service project for a local elderly community group on the topic of hypertension. The nurse will relay that risk factors and cardiovascular problems related to hypertension include which of the following? Select all that apply. a) Obesity (BMI ≥ 30 kg/m2) b) Age ≥55 in men c) Decreased low-density lipoprotein (LDL) levels. d) Elevated high-density lipoprotein (HDL) cholesterol e) Smoking
a) Obesity (BMI ≥ 30 kg/m2) b) Age ≥55 in men e) Smoking
A patient has been admitted for dehydration. What is a priority nursing intervention? a) Perform daily weights. b) Reorient the patient hourly. c) Restrict sodium intake to 2 grams per day. d) Provide continuous oxygen saturation monitoring.
a) Perform daily weights.
A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with that diagnosis? Select all that apply. a) Crackles on auscultation b) Cyanosis c) Hypertension d) Shoulder pain e) Dyspnea f) Tachycardia
b) Cyanosis d) Shoulder pain e) Dyspnea f) Tachycardia
For both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish accurate baseline data. Which of the following data is necessary to collect if the patient is experiencing chest pain? a) Blood pressure in the left arm b) Description of the pain c) Sound of the apical pulses d) Pulse rate in upper extremities
b) Description of the pain
A patient presents to the ED complaining of severe coughing episodes. The patient states the "episodes are more intense at night." The nurse should suspect which of the following conditions based on the patient's primary complaint? a) Bronchitis b) Left-sided heart failure c) Emphysema d) Chronic obstructive pulmonary disorder (COPD)
b) Left-sided heart failure
The nurse is teaching the Benson Relaxation Response to a patient for stress reduction. The nurse instructs the patient to do which of the following? a) Practice the technique daily b) Select a focus word c) Maintain an active demeanor d) Think of a comforting scene
b) Select a focus word
A patient is brought to the emergency department by ambulance. He has hematemesis and alteration in mental status. The patient has tachycardia, cool clammy skin, and hypotension. The patient has history of alcohol abuse. What would the nurse suspect the patient has? a) Hemolytic jaundice b) Hepatic insufficiency c) Bleeding esophageal varices d) Portal hypertension
c) Bleeding esophageal varices
When the nurse is assessing the older adult patient, what gerontologic changes in the respiratory system should the nurse be aware of? (select all that apply) a) Decreased alveolar duct diameter b) Increased presence of mucus c) Decreased gag reflex d) Increased presence of collagen in alveolar walls e) Decreased presence of mucus
c) Decreased gag reflex d) Increased presence of collagen in alveolar walls e) Decreased presence of mucus
The nurse is assessing the respiratory status of a patient who is experiencing an exacerbation of heremphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate? a) Absence of breath sounds b) Wheezing with discontinuous breath sounds c) Faint breath sounds with prolonged expiration d) Faint breath sounds with fine crackles
c) Faint breath sounds with prolonged expiration
One hour after IV Furosemide is given to a patient in heart failure a short burst of Ventricular Tachycardia (VT or VTach) appears on the monitor. Which electrolyte imbalance should the nurse suspect? a) Hypocalcemia b) Hypermagnesemia c) Hypokalemia d) Hypernatremia
c) Hypokalemia
The nurse anticipates the client with right sided heart failure will exhibit which of the following? a) Adequate urine output b) Polyuria c) Oliguria d) Polydipsia
c) Oliguria
A patient is being treated with loop diuretics; gastric suctioning has been initiated. The nurse understands the patient is at risk for developing which of the following electrolyte imbalances? a) Hypocalcemia b) Hyponatremia c) Hypomagnesium d) Hypokalemia
d) Hypokalemia
The nurse is working with a patient who has uncontrolled hypertension. The patient asks the nurse what can happen if the blood pressure is not brought under control. What are potential consequences of uncontrolled HTN? Select all that apply: A) Transient ischemic attack B) CVA C) Retinal hemorrhage D) Venous insufficency E) Right ventricular hypertrophy
A) Transient ischemic attack B) CVA C) Retinal hemorrhage
A 45-year-old adult male patient is admitted to emergency department after he developed unrelieved chest pain that was present for approximately 20 minutes before he presented to the emergency department. The patient has been subsequently diagnosed with a myocardial infarction (MI). To minimize cardiac damage, what health care provider's order will the nurse expect to see for this patient? A) Thrombolyties, oxygen administration, and bed rest B) Morphine sulfate, oxygen administration, and bed rest C) Oxygen administration, anticoagulants, and bed rest D) Bed rest, albuterol nebulizer treatments, and oxygen administration
B) Morphine sulfate, oxygen administration, and bed rest
A 40-year-old man newly diagnosed with hypertension is discussing risk factors with the nurse. The nurse talks about lifestyle changes with the patient and advises that the patient should avoid tobacco use. What is the rationale behind that advice to the patient? A) Smoking directly causes high blood pressure. B) Smoking increases the risk of heart disease. C) Smoking causes obesity, which exacerbates hypertension. D) Smoking increases cardiac output.
B) Smoking increases the risk of heart disease.
A 56-year-old man has sought care because the automated blood pressure machine in his pharmacy indicated a blood pressure reading of 146/96 mm Hg. He has said to the nurse, "My pressure has never been this high. Will I need to take medication to reduce it? Which of the following responses by the nurse would be best? A) "Yes. Hypertension is prevalent among males; it's fortunate we caught this during your routine examination." B) "Quite likely, because your age places you at high risk for hypertension." C) "A single elevated blood pressure doesn't confirm hypertension. You'll need to have your blood pressure reassessed several times before a diagnosis can be made." D) "You have no necd to worry. Your pressure was probably elevated because of your anxiety."
C) "A single elevated blood pressure doesn't confirm hypertension. You'll need to have your blood pressure reassessed several times before a diagnosis can be made."
A patient has been placed on telemetry following treatment for a non-ST wave elevation myocardial infarction (NSTEMI). Which of the patient's following statements indicates that the nurse should perform further patient teaching? A) "The nurse said that I can be up and around the unit while I'm hooked up to telemetry." B) "Ive been told that telemetry gives a longer-term view of my heart's electrical activity than an eclectrocardiogram (ECG)." C) "If I get chest pain or shortness of breath, it will show up on my telemetry monitor." D) "I will let someone know if one of the leads gets detached from my chest."
C) "If I get chest pain or shortness of breath, it will show up on my telemetry monitor."
The staff educator is talking to a group of new emergency department nurses about hypertensive crises. The nurse educator is aware that hypertensive urgency differs from hypertensive emergency in what way? A) The patient's blood pressure (BP) is always higher in a hypertensive emergency. B) Close hemodynamic monitoring is required during treatment of hypertensive emergencies. C) Hypertensive urgency is treated with rest and tranquilizers to lower BP. D) Hypertensive emergencies are associated with evidence of target organ damage.
D) Hypertensive emergencies are associated with evidence of target organ damage.
A nurse who works in a busy emergency department provides care for numerous patients who present with complaints of chest pain. Which of the following questions is most likely to help the nurse differentiate between chest pain that is attributable to angina and chest pain due to myocardial infarction (MI)? a) "Does resting and remaining still help your chest pain to decrease?" b) "Have you ever bcen diagnosed with high blood pressure or diabetes?" c) "When was the first time that you recall having chest pain?" d) "Does your chest pain make it difficult to move around like you normally would?"
a) "Does resting and remaining still help your chest pain to decrease?"
A patient has been newly diagnosed with heart failure (HF) and has come to the meet with the nurse at the clinic for health education. What lifestyle recommendation should the nurse provide to this patient when discussing dietary modifications? a) "It's in your best interests to avoid excessive fluids and sodium in your diet." b) "Try to replace as many of the complex carbohydrates in your diet with simple sugars." c) "I will teach you some good sources of potassium, which you should try to eat regularly." d) "Many people with HF find that small, frequent meals allow them to manage their diet effectively
a) "It's in your best interests to avoid excessive fluids and sodium in your diet."
The nurse has completed a head-to-toe assessment of a patient who was admitted for the treatment of heart failure (HF). Which of the following assessment findings should signal to the nurse a possible exacerbation of the patient's condition? a) Crackles are audible on chest auscultation. b) The patient's blood pressure (BP) is 144/99. c) The patient has put out 600 mL of dilute urine over the past 8 hours. d) Blood glucose testing reveals a glucose level of 158 mg/dL
a) Crackles are audible on chest auscultation.
A patient has cirrhosis. The nurse recognizes the risks of fluid imbalances that accompany this health problem. Scheduled assessments of this patient's fluid balance should include: a) Daily weights and abdominal girth measurements b) Asking the patient to track his food intake and estimated sodium intake c) Assessing the patient's skin turgor and skin tone each morning d) Frequent blood pressure (BP) monitoring and sputum analysis
a) Daily weights and abdominal girth measurements
A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition? a) Dehydration b) Hypervolemia c) Hypercalcemia d) Hyperkalemia
a) Dehydration
The nurse is caring for a patient with heart failure. What assessment data indicates the patient is at risk for developing fluid volume excess? a) Full, bounding pulse b) Flattened neck veins c) Low blood pressure d) Easily obliterated pulse
a) Full, bounding pulse
A nurse is completing an assessment on a patient with suspected fluid volume excess. Which cardiovascular changes would support this diagnosis? Select all that apply. a) Full, bounding pulse b) Distended neck veins c) Orthostatic hypotension d) Increase in the heart rate e) Presence of an S3 heart sound
a) Full, bounding pulse b) Distended neck veins e) Presence of an S3 heart sound
The nurse is assessing a patient for local complication of IV therapy. Local complications include which of the following? Select all that apply. a) Hematoma b) Air embolism c) Extravasation d) Phlebitis e) Infection
a) Hematoma c) Extravasation d) Phlebitis
The nurse is educating a patient with COPD about the technique for performing pursed lip breathing. What does the nurse inform the patient is the importance of using this technique? a) It prolongs exhalation. b) It increases the respiratory rate to improve oxygenation. c) It will assist with widening the airway. d) It will prevent the alveoli from overexpanding.
a) It prolongs exhalation.
The nurse is aware that hemorrhage is a common complication of peptic ulcer disease. Therefore, assessment for indicators of bleeding is an important nursing responsibility. Which of the following are indicators of bleeding? Select all that apply. a) Melena b) Polyuria c) Bradycardia d) Tachypnea e) Thirst f) Mental confusion
a) Melena e) Thirst f) Mental confusion
A patient on the medical unit has told the nurse that he is experiencing significant dyspnea, despite thathe has not recently performed any physical activity. What assessment question should the nurse ask the patient while preparing to perform a physical assessment? a) On a scale from 1 to 10, how bad would rate your shortness of breath? b) When was the last time you ate or drank anything? c) Are you feeling any nausea along with your shortness of breath? d) Do you think that some medication might help you catch your breath?
a) On a scale from 1 to 10, how bad would rate your shortness of breath?
A 58-year-old patient's electrocardiogram (ECG) and presentation are suggestive of a myocardial infarction (MI), and treatment has been promptly initiated. The nurse who is part of the patient's care team should anticipate and facilitate which of the following interventions? Select all that apply. a) Providing the patient with supplementary oxygen b) Administering morphine by IV c) Administering oral warfarin (Coumadin) d) Administering a bolus of 0.9% NaCI e) Teaching the patient deep breathing and coughing techniques
a) Providing the patient with supplementary oxygen b) Administering morphine by IV
The nurse assesses the patient and records the data collected. What would lead the nurse to anticipate that the patient will experience a decrease in cardiac output? a) An order for the patient to receive digoxin b) A heart rate of 54 beats per minute c) A pulse oximetry reading of 98% d) An increase in preload related to ambulation in the hall
b) A heart rate of 54 beats per minute
What is the most common cause of small-bowel obstruction? a) Neoplasms b) Adhesions c) Volvulus d) Hernias
b) Adhesions
The nurse is performing a respiratory assessment of a patient who has been experiencing episodes ofhypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend? a) An appropriate perfusion:diffusion ratio b) An adequate ventilation:perfusion ratio c) Adequate diffusion of gas in shunted blood d) Appropriate blood nitrogen concentration
b) An adequate ventilation:perfusion ratio
A 70-year-old man has been living with a diagnosis of heart failure (HF) for several years and has been vigilant about monitoring the trajectory of disease and adhering to his prescribed treatment regimen. The man has scheduled an appointment with his primary care provider because he has noted a weight gain of 6 pounds over the past week. The nurse should anticipate that this patient may benefit from which of the following treatment measures? a) A further reduction in his dietary sodium intake b) An increase in the dose of his prescribed diuretic c) A decrease in his daily activity level d) Thoracentesis
b) An increase in the dose of his prescribed diuretic
A patient has been admitted to the medical unit because of an exacerbation of heart failure. Over the past hour, the patient has become increasingly restless, tachypneie, and short of breath, and pulse oximetry reveals SaO2, of 78%. Which of the following actions should the nurse prioritize? a) Providing reassurance to calm the patient and slow the patient's respiratory rate b) Protecting the patient's airway and taking measures to promote gas exchange c) Monitoring the patient's cardiac function d) Obtaining a complete set of vital signs
b) Protecting the patient's airway and taking measures to promote gas exchange
The nurse understands that an overall goal of hypertension management includes which of the following? a) There are no complaints of sexual dysfunction. b) There is no indication of target organ damage. c) There is no complaint of postural hypotension. d) The patient maintains a normal blood pressure reading.
b) There is no indication of target organ damage.
A patient arrives at the ED with an exacerbation of left-sided heart failure and complains of shortness of breath. Which of the following is the priority nursing intervention? a) Administer angiotensin-converting enzyme inhibitors b) Administer angiotensin II receptor blockers c) Assess oxygen saturation level d) Administer diuretics
c) Assess oxygen saturation level
A patient with chronic heart failure who is taking a diuretic and an ACE inhibitor tells the home health nurse about a 5lb weight gain in the past 3 days. What is the priority action? a) Have the patient share his dietary intake for 3 days b) Ask the patient about medication use c) Assess the patient for clinical manifestations of acute heart failure d) Teach the patient the importance of restricting dietary sodium
c) Assess the patient for clinical manifestations of acute heart failure
A patient is being treated in the ICU 24 hours after having a radical neck dissection completed. The patient's serum calcium level is 7.6 mg/dL. Which of the following physical examination findings is consistent with this electrolyte imbalance? a) Negative Chvostek's sign b) Slurred speech c) Presence of Trousseau's sign d) Muscle weakness
c) Presence of Trousseau's sign
The nurse is taking a respiratory history for a patient who has come into the clinic with a chronic cough. What information should the nurse obtain from this patient? (select all that apply) a) Financial ability to pay the bill b) Social support c) Previous history of lung disease in the patient or family d) Occupational and environmental influences e) Previous history of smoking
c) Previous history of lung disease in the patient or family d) Occupational and environmental influences e) Previous history of smoking
The nurse is analyzing the arterial blood gas (AGB) results of a patient diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis? a) pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L b) pH: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /L c) pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L d) pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L
c) pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L
A community health nurse is participating in a healthy-living workshop that has been sponsored by a local seniors' center. The discussion has turned to the problem of heart failure, and the nurse is emphasizing preventative measures. When teaching older adults to decrease their future risks of developing heart failure, the nurse should emphasize what action? a) Effective stress management b) A low-fat, high-protein diet c) Physical exercise and the importance of getting 30 to 60 minutes of activity each day d) Close blood pressure monitoring and vigilant adherence to hypertension therapy
d) Close blood pressure monitoring and vigilant adherence to hypertension therapy
The nurse is conducting a community education program on stress. The nurse includes which of the following? a) Effective stress adaptation is a disease precursor. b) Short-term stress increases susceptibility to disease. c) Stressors elicit a state of homeostasis. d) Excessive stress response increases susceptibility to illness.
d) Excessive stress response increases susceptibility to illness.
The nurse teaches the patient which of the following guidelines regarding lifestyle modifications for hypertension? a) Reduce smoking to no more than four cigarettes per day b) Stop alcohol intake c) Limit aerobic physical activity to 15 minutes, three times per week d) Maintain adequate dietary intake of fruits and vegetables
d) Maintain adequate dietary intake of fruits and vegetables
Which of the following findings indicates that hypertension is progressing to target organ damage? a) Urine output of 60 cc/mL over 2 hours b) Chest x-ray showing pneumonia c) Blood urea nitrogen (BUN) level of 12 mg/dL d) Retinal blood vessel damage
d) Retinal blood vessel damage