Illness 2 Exam 3
A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Which of the following is the priority nursing action? A. Monitor vaginal bleeding B. Administer glucocorticoids C. Insert an Foley catheter D. Apply an external fetal monitor
D
A client is in the emergency department with an esophageal trauma. The nurse palpates subcutaneous emphysema in the mediastinal area and up into the lower part of the clients neck. What action by the nurse takes priority? A. Assess the client's oxygenation B. Facilitate a STAT chest x-ray C. Prepare for immediate surgery D. Start 2 large bore IVs
A
A nurse is instructing a client diagnosed with coronary artery disease about care at home. The nurse determines that teaching is effective when the client states. Select all that apply. A. "If I have chest pain, I should contact my physician immediately." B. I should carry my nitroglycerin in my front pants pocket so it is handy" C. "If I have chest pain, I should stop activity and place one nitroglycerin tablet under my tongue" D. "I should always take 3 nitroglycerin tablets 5 minutes apart" E. "I plan to avoid being around people when they are smoking" F. "I plan on walking on most days of the week for at least 30 minutes"
A, C, E, F
A client is starting celecoxib to treat OA. The nurse should instruct the client to watch for and report which of the following adverse effects? a. black, tarry stool b. bone pain c. dry mouth d. polyuria
A
A nurse admits a client to the hospital and obtains a nursing history. The client tells the nurse that he had an endovascular repair of an abdominal aortic aneurysm found 1 year earlier during a routine screening. The nurse understands that this procedure consists of a. excision of the aneurysm and placement of a graft percutaneously b. an angioplasty with the placement of a stent around the outside of the aorta c. placement of a filter within the aneurysm to block clots from becoming emboli d. placement of a stent graft inside the aorta
D
A nurse is caring for a client who has developed gout. Which of the following medications should the nurse prepare to administer? A. Zolpidem B. Alprazolam C. Spironolactone D. Allopurinol
D
A Nurse, admitting a client who has a history of ongoing intravenous drug use, reviews the client's geology report. After considering the serology report, which conclusion by the nurse is correct? HBaAG= positive Anti HBc IgM= positive AST= 200 units/L ALT= 15 units/L A. The client has acute hep B and health care personnel needs to be cautioned to emphasize safe injection practices B. The client has had Hep B in the past and is currently immune C. The client has acute Hap A and contact precautions should be initiated D. The client is not currently infected with hepatitis, and no extra precautions are required
A
A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varies, and portal HTN. The nurse recognizes which of the following lab findings as indicating the clients GI tract is digesting and absorbing blood? A. Elevated BUN B. Elevated HbA1c C. Decreased chloride D. Decreased bilirubin
A
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's RR is 10 and deep tendon reflexes are absent. Which of the following actions should the nurse take? a. discontinue the medication infusion b. prepare for an emergency C-section birth c. assess maternal blood glucose d. place the client in Trendelenburg position
A
A nurse should anticipate instructing a client scheduled for a coronary artery bypass draft to... select all that apply. A. Discontinue taking aspirin prior to surgery B. Perform postop cardiac rehabilitation exercises and stress management strategies C. Wash with an antimicrobial soap the evening prior to surgery D. Shave the chest and legs and then shower to remove the hair E. Resume normal activities when discharged from the hospital F. Expect close monitoring after surgery, several IV lines, a urinary catheter, ETT, and chest tubes
A, B, F
A client admitted with a diagnosis of acute coronary syndrome calls for a nurse after experiencing sharp chest pains that radiate to the left shoulder. The nurse notes, prior to entering the client's room, that the client's rhythm is sinus tachycardia with a 10-beat run of premature ventricular contractions (PVCs). Admitting orders included all of the following interventions for treating chest pain. Which should the nurse implement first? A. Obtain a stat 12-lead ECG B. Administer oxygen by nasal cannula C. Administer sublingual nitroglycerin D. Administer morphine sulfate intravenously
B
A 28- year old pregnant client (G3P2) has just been diagnosed with gestational diabetes at 30 weeks The client asks what types of complications may occur with this diagnosis. Which complications should the nurse identify as being associated with gestational diabetes? Select all that apply A. Seizures B. Large for gestational age infant C. Low birth weight infant D. Congenital abnomalies E. Preterm Labor
B, D
A nurse assesses a client who has just returned to a telemetry unit after having a coronary angiogram using the left femoral artery approach. The client's baseline BP during the procedure was 130/72 and the cardiac rhythm was a normal sinus throughout. Which assessment finding should indicate to the nurse that the client may be experiencing a complication? a. BP 144/78 b. pedal pulses palpable at +1 c. left groin soft with 1 cm ecchymotic area d. apical pulse 132 beats per minute with an irregularly-irregular rhythm
D
A nurse assessing a client hospitalized following a MI, obtains the following vital signs: HR: 128, RR: 32, BP: 78/38. For which life-threatening complication should the nurse carefully monitor the client? A. PE b. Cardiac tamponade C. Cardiomyopathy D. Cardiogenic Shock
D
Angiography reveals an aneurysm with a shape as in the illustration. What type of aneurysm is this? (straight, bows out, and straight again) A. Saccular aortic aneurysm B. Fusiform aortic aneurysm C. Aortic dissection D. False aortic aneurysm
B
An office nurse is evaluating a 32-weeks-pregnant client. The client presents for her routine visit with an elevated BP of 142/89. Her urine is negative for protein and hwe weight gain is 2 pounds since her last routine visit at 30 weeks. She has trace pedal edema. Based on this information, the nurse should conclude that the client is most likely experiencing: a. gestational HTN b. chronic HTN c. preeclampsia d. eclampsia
A
The nurse is teaching the partner of a client who had an acute MI about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzyme studies? A. These tests help determine the degree of damage to the heart tissues B. Cardiac enzymes will identify the location of the MI C. These tests will enable the provider to determine the heart structure and mobility of the heart valves D. Cardiac enzymes assist in diagnosing the presence of pulmonary congestion
A
A nurse in a clinic is caring for a 16-year-old mother and her baby. The mother seems anxious about her new role as a mother. She looks at the nurse and says, "I don't think I can do this." What are some conclusions that the nurse might make about this situation? Select all that apply. A. There may be a concern for postpartum depression B. This mother may be at risk for abandoning her baby C. An intervention could be providing information for the nearest safe house for the baby D. The mother should have been taught how to deal with this situation in prenatal classes E. The mother should be encouraged to give up the infant for adoption
A, B, C
A nurse is providing teaching to a client who has RA and a new prescription for methotrexate. Which of the following instruction should the nurse include? Select all that apply A. Expect to feel the medication's effects immediately B. Do not drink alcoholic beverages while taking this medication C. Report unexplained bruising to the provider D. Avoid people who have infections E. Take NSAIDs to help minimize the adverse effects fo the medications
B, C, D
A client who has a history of MI is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? a. analgesic b. anti-inflammatory c. antiplatelet aggregate d. antipyretic
C
A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching? A. Avoid eating at fast food restaurants B. Avoid serving raw foods C. Practice effective hand hygiene D. Wear barrier protection during vaginal intercourse
C
A nurse plans teaching for a 20 year-old newly diagnosed with hypertrophic cardiomyopathy. The client is on the college soccer team. Which information should be the nurse's priority when teaching the client? a. provide pamphlets on genetic testing to avoid passing on an inherited disease b. reinforce the need to continue exercise with soccer to strengthen the heart c. provide information about CPR to persons living with the client d. counsel on foods for consuming on a low-fat, low-cholesterol diet
C
An emergency department nurse is assessing a pediatric client suspected of having acute pericarditis. Which assessment finding should the nurse conclude supports the diagnosis of acute pericarditis? A. Bilateral lower extremity pain B. Pain on expiration C. Pleural friction rub D. Pericardial friction rub
D
The nurse assessing the client hospitalized following an MI obtains these VS: BP 78/38, HR: 128, RR: 32. The nurse notifies the HCP concerted that the client may be experiencing which most life threatening complication? A. Pulmonary embolism B. Cardiac Tamponade C. Cardiomyopathy D. Cardiogenic shock
D
Which statement is not true about limited systemic scleroderma? a. the onset is rapid b. it involves the trunk c. internal organ in involvement is unlikely d. it involves the occurrence of Raynaud's phenomenon after the diagnosis
C
A nurse is caring for a client with facial trauma. Which actions of the nurse are most beneficial in promoting wound healing? select all that apply a. keeping wire cutters near the client at all times b. providing oral humidification c. encouraging the client to consume adequate nutrition d. providing frequent mouth care by rinsing the mouth after meals e. administering antibiotics to the client
C, D, E
The nurse is teaching a client about risk factor for osteoarthritis. Which of the following factors should the nurse include in the teaching? Select all that apply. A. Bacteria B. Diuretics C. Aging D. Obesity E. Smoking
C, D, E
The nurse is caring for a 12 kg child following cardiac surgery. The chest tube drainage totals 200 mL for the past hour. Which is the nurses best action? A. Check to be sure that the connections are secure B. Document the drainage and continue to monitor C. Tip and tilt the tube to promote adequate drainage D. Notify the health care provider immediately
D
The primary health-care provider referred a client with liver cancer to a radiologist for cannulation. Which method is most suitable for cannulation? A. Cryotherapy B. Radiofrequency ablation C. Hepatic arterial infusion D. Transcatheter arterial chemoembolization
D
The nurse is caring for a client with a PA catheter. The nurse understands that the SVO2 will most likely be which of the following if the client in in cardiogenic shock a. increased b. decreased c. normal d. not significant
B
Which is true regarding diffuse systemic scleroderma? Select all that apply A. It is a chronic systemic auto-immune disease B. It shows an insidious onset C. It involves the skin of the extremities and the trunk D. It is most likely to affect organs, generally within 2 years of onset E. Raynaud's phenomenon may proceed disea
A, C, D
A nurse is caring for a client following a coronary artery bypass graft. Which assessment finding in the immediate postoperative period should be most concerning to the nurse? a. no chest tube output for 1 hour when previously it was copious b. client temperature of 99.1 c. arterial blood gad results show pH: 7.32; Pco2: 48; HCO3: 28; Po2: 80 d. urine output of 160 mL in the last 4 hours
A
A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematous (SLE). Which of the following finings should the nurse expect? A. A grey collared, non purpuric papular rash B. A dry, red fresh across the bridge of the nose and on the cheeks C. Pitting edema of the hands and fingers D. Subcutaneous nodules on the ulnar side of the arm
B
A nurse is managing the care of an infant with an unrepaired heart defect. Which health promotion strategy should the nurse recommend to the parent in planning for discharge? A. Vaccinate against RSV monthly during the RSV season B. Restrict the child's level of physical activity C. Encourage weight loss by restricting caloric intake D. Delay immunizations as the child's immune system may be too impaired
A
A nurse is teaching a client who has RA about self-care strategies for managing the disease. Which of the following activities should the nurse include in the teaching? a. press warm water from a sponge rather than wringing it b. turn doorknobs using a clockwise motion c. finish weekly household tasks within 1 or 2 days d. engage in repetitive tasks, even when joints are inflamed, to keep the joint mobile
A
A nurse's laboring client suddenly experiences a dramatic drop in the fetal heart rate (FHR) from the 150s to the 110s. A vaginal exam reveals the presence of the fetal cord that has protruded through the cervix. What is the initial step the nurse should take? A. Provide continuous pressure to hold the presenting part of the card B. Place the client in Trendelenburg position C. Inset and fill a foley catheter D. Continue to monitor the FHR
A
A patient learns of having a 1 cm abdominal aortic aneurysm. What should the nurse emphasize when discussing the health problem with this patient? a. stop smoking b. increase physical activity c. engage in stress management d. reduce the intake of saturated fat
A
The husband of a postpartum client, who has been diagnosed with postpartum depression (PPD), is concerned and asks the nurse what kind of treatment his wife will require. The nurse's response should be based on the knowledge that the collaborative plan of care for PPD includes which of the following? a. antidepressant medications and psychotherapy b. psychotherapy alone c. removal of the infant from the house d. hypnotic agents and psychotherapy
A
The nurse caring for a client with cariogenic shock would expect the pulmonary capillary wedge pressure to be which of the following? A. Increased B. Decreased C. Normal D. Unchanged
A
The nurse completes an assessment of the 2-month-old infant during a well-child checkup. The nurse should report which finding to the HCP? A. Split S2 heart sound B. Apical heart rate of 140 bpm C. Oxygen saturation of 97% D. Femoral pulse 3+ and brachial pusle 2+
A
The nurse is assessing a client who complains of chest pain. Which lab parameter may differentiate between myocardial infarction and angina pectoris? a. troponin b. myoglobin c. fibrinogen d. C-reactive protein
A
The nurse is caring for a client who has had a myocardial infarction. Upon his visit to cardiac rehabilitation, he tells the nurse that he does not understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response? a. cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely b. it's not unusual to feel that way at first, but ince you learn the routine, you'll enjoy it c. exercise id good for you and good for your heart d. your doctor is the expert here, and I'm sure he would only recommend what is best for you
A
A new nurse is preparing the pediatric client for a cardiac catheterization under the supervision of the experienced nurse. Which information identified by the new nurse demonstrates understanding of the information that can be collected during cardiac catheterization? select all that apply a. oxygen saturation of blood within the heart chambers b. pressure of blood flow within the heart chambers c. cardiac output d. anatomical abnormalities e. ankle brachial index (ABI) d. ejection fraction
A, B, C, D, F
A nurse in an emergency department is preparing to administer alteplase accelerated therapy to a client who is having an MI. Which of the following actions should the nurse plan to take? Select all that apply. A. Administer the medication within 30 min of the client's arrival to the department B. Reconstitute the medication with sterile water C. Administer a 15 mg IV bolus D. Tell the client that the purpose of the medication is to keep a new clot from forming E. Assess the client for back pain
A, B, C, E
While diagnosing a client with oral trauma, the nurse finds ineffective airway clearance. Which characteristic fingers are likely observed? Select all that apply. A. Respiratory stridor B. Impaired ability to eat or drink C. Swelling in and around the mouth D. Increased vascularity of the face and mouth E. Difficult in managing oral secretions
A, C
A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? Select all that apply. A. Administer furosemide B. Administer warfarin C. Implement a low-sodium diet D. Measure the client's abdominal girth E. Encourage weight lifting during physical therapy
A, C, D
A nurse is preparing a client for a thoracic aneurysm repair. Which assessment findings lead the nurse to suspect that a rupture has occurred? Select all that apply. A. Severe chest pain radiating to the back B. Abdominal distention C. Hypotension D. Dyspnea E. Oliguria
A, C, D, E
Which actions are most appropriate when caring for a client with liver cancer? select all that apply a. administer nerve blocks locally and directly into the nerves of the abdomen b. include plenty of fluids and protein-rich foods in the diet c. administer antibiotics and antipyretics to the client d. keep the lower extremities at a lower level e. administer nonsteroidal anti-inflammatory drugs to the client
A, C, E
Which statement is not true about limited systemic scleroderma? a. the onset is rapid b. it involves the trunk c. internal organ in involvement is unlikely d. it involves the occurrence of Raynaud's phenomenon after the diagnosis
A, D
A nurse receives a serum lab report for 6 different clients with admitting diagnoses of chest pain. After reviewing all of the lab reports, in which order should the nurse address each lab value? Prioritize the order in which the nurse should address each of the client's results A. Troponin T 42 ng/mL (0-0.4 ng/mL) B. WBC 11,000 K/microL (normal 3.9-11.9) C. Hgb 7.2 g/dL D. SCr 2.2 mg/dL E. K 2.2 mEq/L F. Total cholesterol 430 mg/dL
A, E, C, D, F, B
A nurse is preparing a presentation at a community center about osteoarthritis. The nurse should plan to include which of the following information? Select all that apply A. Affects weight- bearing joints B. Crepitus can occur in affected joints C. Affects bilateral, symmetrical joints D. Causes joint stiffness E. Causes joint pain
A,B,D,E
A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension and possible preeclampsia. Which of the following actions should the nurse expect to implement. Select all that apply A. Administer magnesium sulfate IV B. Provide a dark, quiet environment C. Assess respiratory status every 4 hours D. Evaluate neurologic status every 8 hr E. Ensure that calcium gluconate is readily available
A,B,E
A hospitalized preterm infant diagnosed with tetralogy of Fallot s experiencing a hypercyanotic spell. Which actions should be taken by the nurse? select all the apply A. Place the infant in a knee-chest position B. Administer 2 L of Oxygen via nasal cannula C. Administer intramuscular morphine D. Use a calm and comforting approach E. Administer oral propranolol F. Prepare for emergency surgery
A,C,D,E
As part of discharge education for a postpartum client, a nurse suggests prevention strategies for postpartum depression. Which prevention strategies should the nurse include when educating the client on postpartum depression? select all that apply A. Attending a postpartum support group B. Using the baby's nap time to complete household chores C. Keeping a journal of feelings during the postpartum period D. Notifying the health care provider if feelings of being overwhelmed to not subside quickly E. Setting a daily schedule and following it F. Completing major life changes within the first year after the birth
A,C,D,E
A family notices that their father, who has been diagnosed with cirrhosis, has become increasingly irritable and restless. A practitioner orders a protein-restricted diet. A nurse should explain to the client and family that this dietary change will: a. help to restore their father's liver function b. help reduce the amount of ammonia in their father's blood c. giver their father's liver a chance to rest, since proteins in the diet make the liver work harder d. prevent fluid from leaking into their father's abdomen
B
A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption? a. cocaine use b. HTN c. blunt force trauma d. cigarette smoking
B
A nurse is assessing clients in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing Hep C? A. A client who eats raw fish B. A client two has multiple tattoos C. A client who works in a child care center D. A client who has recently traveled to an underdeveloped country
B
A nurse is caring for a child who has liver enlargement and JVD secondary to infectious endocarditis. For which associated cardiac condition should the nurse assess the client? a. left-sided HF b. right-sided HF c. myocardial infarction d. Tetralogy of Fallot
B
A nurse is providing discharge teaching to a client who has SLE. Which of the following instructions should the nurse include? a. avoid using moisturizing lotions on the skin b. wash the hair with mild protein shampoo c. apply powder liberally to sensitive skin areas d. use a sun-blocking agent with a sun protection factor of at least 15
B
A nurse is providing teaching to a client who is postoperative following CABG surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? A. It decreases the client's level of anxiety B. It facilitates the client's deep breathing C. It enhances the client's ability to sleep D. It reduces the client's BP
B
A nurse is teaching a client how to follow a low-purine diet as prescribed bu the provider for the management of gout. Which of the following statements indicates the client understands the teaching? a. I will need to limit the number of fruit servings each day b. I should avoid eating liver and onions c. I can drink only white wine d. I should choose red meat instead of poultry
B
A nurse is teaching a client who has a new prescription for colchicine to treat gout. Which of the following instructions should the nurse include? A. "Take this medication with food if nausea develops" B. "Monitor for muscle pain" C. "Expect to have increased bruising" C. "Increase your intake of grapefruit juice"
B
A nurse is teaching a client who has a new prescription of allopurinol for the treatment of gout. Which of the following instructions should the nurse include? A. Take the medication on an empty stomach B. Drink 2 liters of fluid each day while taking the medication C. Take a 650 mg dose of aspirin for joint pain D. Do not crush the medication before taking it
B
A nurse on the obstetric unit is caring for a client who experienced abrupt placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications? A. Anaphylactoid syndrome of pregnancy B. Disseminated intravasucalr coagulation C. Preeclampsia D. Puerperal infection
B
A patient is diagnosed with an abdominal aneurysm measuring 5 cm. Which teaching material should the nurse prepare for this patient? A. Dietary changes B. Preoperative and postoperative care C. Actions to reduce high BP D. Activities to prevent aneurysm rupture
B
An older adult hospitalized with chest trauma following an MVA has a right femoral arterial line. Because the client has been thrashing about in bed, a physician writes an order for wrist restraints to be applied. Based on this information, which action by a nurse is correct? A. Apply the wrist restraints as ordered B. Request an order for a right ankle restraint also C. Request an order for sedation instead of restraints D. Question the order b/c restraints will increase the client's agitation
B
The client is hospitalized for HF secondary to alcohol-induced cardiomyopathy. The client is started on milrinone and placed on a transplant waiting list. The client has been curt and verbal aggressive in expressing dissatisfaction with the medications, overall care, and the need for energy conservation. Which nursing interpretation of the client's behavior is most appropriate? A. The client is denying the illness B. The client is experiencing fear C. Alcohol abuse is affecting behavior D. A reaction to milrinone is affecting behavior
B
The nurse is caring for the pediatric client with congenital heart disease. The nurse should monitor the client for which specific complications? A. Congestive HF and pulmonary hypotension B. Congestive HF and hypoxemia C. Hypoxemia and pulmonary hypotension D. Pulmonary hypotension and cyanosis
B
The nurse is managing the care of a patient with an arterial line. Which assessment finding warrants immediate intervention by the nurse? a. a dampened or flat waveform on the monitor b. tubing disconnected from the arterial line c. IV medications being infused into an arterial line d. redness at the arterial insertion site
B
The nurse is preparing to administer a dose of lactulose to a client who as cirrhosis. The client states, "I do not need this medication, I am not constipated." The nurse should explain that in clients who have cirrhosis, lactulose is used to decrease levels of which of the following components in the bloodstream? a. glucose b. ammonia c. potassium d. bicarbonate
B
The nurse is providing care to a patient who presents tp the ED with an abdominal stab injury. Which should the nurse assess for based on the current data? A. Spleen injury B. Liver laceration C. Intestinal obstruction D. TBI
B
The nurse is reviewing the ECG of the patient admitted for acute pericarditis. Which ECG change does the nurse anticipate? A. Normal ECG B. ST segment elevation C. Peaked t waves D. Wide QRS complex
B
The nurse received a change-of-shift report on 4 clients. Which client should the nurse assess first? A. The 29-year-old client with HF who is experiencing anxiety r/t scheduling of a valvuloplasty later today B. The 40-year-old client with restrictive cardiomyopathy who developed severe dyspnea just before the shift change C. The 48-year-old client who had a coronary angioplasty 1 day ago and has had occasional pain at the right groin puncture site since the procedure D. The 58-year-old client who transferred from the ICU 1 day ago after coronary artery bypass graft surgery and has a temperature of 100.6F
B
Which nursing intervention should a nurse take when caring for a client before heart catheterization? A. Obtain an ECG test B. Delay administering diabetic medications C. Restrict the client from performing any activity D. Monitor peripheral pulses of the affected extremity
B
Which statement about complications of PPD is accurate? a. children of mothers treated for PPD will develop language delays b. newborns of mothers untreated for PPD may fail to thrive c. mothers treated for PPD will develop chronic depression
B
Which statement by the patient indicates a need for further teaching? A. I will report any fever greater than 100F B. I will avoid heavy lifting for 3 more weeks C. I will call my doctor right away if i notice redness or swelling at the incision D. I will look for color changes in my feet and lower legs
B
During the postoperative period after an aneurysmectomy, the nurse will implement which actions? select all that apply a. keep the HOB elevated at 60 degrees b. keep firm pressure on the abdominal incision during coughing exercises c. change dressings as orders with aseptic technique d. monitor peripheral pulses of both lower extremities e. use the bed's knee gatch to allow for knee flexion during bed rest
B, C, D
Cyclosporine and methotrexate are prescribed for a client with severe RA. Which points should a nurse address when teaching the client about these medications? Select all that apply. A. Drinking grapefruit juice is best b/c the meds effects are enhanced B. Keep well hydrated to maximize the therapeutic effects of methotrexate C. Avoid use of St. John's wort, echinacea, and melatonin as they interfere with immunosuppression D. These medications are administered weekly by subcutaneous injection E. Both methotrexate and cyclosporin suppress the immune system
B, C, E
A 77-year-old client is diagnosed with an abdominal aortic aneurysm measuring 3.5 cm, which was discovered on a routine health physical. The client has a 30 pack-year history of cigarette smoking. Which learning need should a nurse identify as most important for the client? A. Understand the importance and begin the process of smoking cessation. B. Understand and follow a reduced-sodium and low-saturated-fat diet C. Follow through with medical supervision so the size of the aneurysm can be monitored at regular intervals D. Verbalize understanding of preoperative and postoperative care following surgical repair of the aneurysm
C
A nurse in the postanesthesia care unit (PACU) is monitoring a client who has had a repair of an aortic aneurysm with graft surgery. The nurse is unable to palpate the posterior tibial pulse of one leg that was palpable 15 minutes earlier. The most appropriate initial action for the nurse is to a. recheck the pulse in 15 minutes b. reposition the leg c. notify the surgeon d. remove the surgical dressing
C
A nurse is admitting a client who has acute heart failure following MI. The nurse recognizes that which of the following prescriptions by the provider requires clarification? a. morphine sulfate 2 mg IV blues every 2 hr PRN pain b. lab testing of srum potassium upon admission c. 0.9% NS IV at 50 ml/hr continuous d. bumetanide 1 mg IV bolus every 12 hours
C
A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the fowling findings is the highest priority for the nurse to report to the provider? A. Client report of feeling of depression B. Dry, raised rash on the face C. Presence of peripheral edema D. Joint pain in hands and knees
C
A nurse is caring for a client who received a diagnosis of systemic scleroderma 5 years ago. The nurse plans to assess the client to document the diseases progression. In addition to the skin changes which of the following findings should nurse expect? A. Periorbital edema B. Excessive salivation C. Finger contractures D. Thinning of the skin
C
A nurse is interpreting an ECG rhythm strip for a 2 year-old child with HF secondary to a congenital heart defect. In analyzing the rhythm, the nurse notes the measurements of PR interval is 0.26 seconds, the QRS is 0.08 seconds, and the QT is 0.28. The ventricular rate is 128 bpm. A nurse interprets the rhythm as: a. sinus bradycardia b. sinus rhythm with a bundle branch block c. sinue rhythm with a first-degree AV block d. sinus tachycardia with a first degree AV block
C
The 6 month old infant being seen in the clinic has an HR of 167 bpm, RR of 5, and SpO2 of 98%. The mother states the infant gets very tired with feedings, eating about 2 ounces every 4 hours. Which action should be the nurse's priority? A. Check peripheral capillary refill time B. Auscultate for bowel sounds C. Auscultate for a heart murmur D. Attempt to bottle-feed the infant
C
The nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? A. Check the client's BP B. Auscultate heart tones C. Perform a 12 lead ECG D. Determine if pain radiated to the left arm
C
The nurse is caring for a client with a central venous catheter located in the subclavian vein. The provider has ordered the catheter to be discontinued, The nurse will place the client is which position for removal of the catheter? A. Semi- Fowlers B. Prone C. Trendelenburg D. Head of bed at 15-30 degrees
C
The nurse is examining a client in the ED who has just sustained blunt force trauma to the abdomen. The nurse notes ecchymosis located on the flank region of the client. The nurse notes this is which of the following? a. Blue's sign b. Cullen' sign c. Turner's sign d. Melon's sign
C
The nurse is planning care for the infant with tetralogy of Fallot. Which intervention should the nurse include to best promote adequate nutrition? A. Administer prostaglandin E1 to keep fetal ducts open B. Provide rest periods to allow adequate digestion C. Administer fortified breast milk every 3 hours D. Encourage sips of water between feedings
C
The nurse is teaching a group of clients about osteoarthritis. Which of the following recommendation should the nurse include in the teaching? A. Use Echinacea to manage joint pain B. Apply ice to the joint before exercising C. Maintain a recommended body weight D. Reduce the amount of purine in the diet
C
The patient is admitted for pericarditis. In order to assess and help the patient to feel more comfortable, what does the nurse instruct the patient to do? a. sit in a semi-Fowler's position with pillows under the arms b. lie on their side in the recovery position c. sit up and lean forward d. lie down in the supine and bend the legs at the knees
C
Which statement about postpartum psychosis is accurate? A. The clinical features appear a few weeks after childbirth B. A family history of schizophrenia is a significant risk factor C. A women with a history of bipolar disorder is at risk for postpartum psychosis
C
The nurse is beginning a shift on a cardiac step-down unit receives shift report for four clients. Prioritize the order, from most urgent to least urgent, that the nurse should assess the clients a. the 56 year-old client who was admitted 1 day ago with chest pain receiving IV heparin and has a PTT due back in 30 minutes b. the 62 year-old client with end-stage cardiomyopathy, BP of 78/50, 20 ml/hr urine output, and DNR order; whose family has just arrived c. the 72 year-old client who was transmitted 2 hours age from the ICU following a coronary artery bypass graft and has a new-onset atrial fibrillation whit rapid ventricular response d. the 38 year-old postoperative client who had an aortic valve replacement 2 days ago, BP 114/72, HR 100, RR 28, and temp 101.2F
C, D, A, B
A nurse in an emergency department is assessing a client who is having a suspected acute MU Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI. Select all that apply. A. Orthopnea B. Headache C. Nausea D. Tachycardia E. Diaphoresis
C, D, E
A nurse is caring for a client with hepatitis B. Which of the following interventions should the nurse include in the plan? a. administer antibiotics b. provide a diet high in fat c. restrict fluids d. encourage short periods of ambulation
D
A nurse is caring for a patient who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 minutes. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action? a. examination to determine cervical status b. a magnesium sulfate infusion c. initiation of pushing d. preparation for cesarean birth
D
A nurse is completing the admission assessment of a client who is at 38 weeks gestation and has severe preeclampsia. Which of the following is an expected finding? A. Tachycardia B. Absence of clonus C. Polyuria D. Report of headache
D
An LPN is discussing liver trauma with student nurses. Which statement made by a student nurse indicated a need for further discussion? a.liver trauma is more common in male clients than their female counterparts b. a common finding with liver trauma is a tense, firm abdomen due to bleeding into the peritoneal cavity c. decreased urinary output is an important sign or symptom of a client with liver trauma d. the left lobe of the liver is more susceptible to injury than the right lobe because of the proximity of the ribs
D
The nurse is caring for 4 clients. Which client may be at risk for developing scleroderma? A. A 29-year-old Caucasian male B. A 50-year-old Caucasian female C. A 40-year-old African American male D. A 25-year-old African American female
D