Med Surg 5
1) The client enters the outpatient clinic and states to the triage nurse, "I think I have the flu. I'm so tired, I have no appetite, and everything hurts." The triage nurse assesses the client and finds a butterfly rash over the bridge of nose and on the cheeks. Which diagnosis does the nurse expect? A) Systemic lupus erythematosus B) Fibromyalgia C) Lyme disease D) Gout
A
4) The nurse is caring for a client who is hospitalized due to an exacerbation of systemic lupus erythematosus (SLE). The nurse is reviewing the client's lab work and finds the white blood cell count (WBC) is shifted to the left. Based on this information, which is a priority nursing diagnosis for this client? A) Ineffective Protection B) Ineffective Health Maintenance C) Ineffective Individual Coping D) Risk for Impaired Skin Integrity
A
5. A nurse is providing discharge teaching for a client who has a prescription for furosemide 40 mg PO daily. The nurse should instruct the client to take this medication at which of the following times of day? A. Morning B. Immediately after lunch C. Immediately before dinner D. Bedtime
A
9) The nurse is providing care for a newly married woman with systemic lupus erythematosus (SLE). Which client statement indicates plan of care understanding? A) "I will take birth control pills while I am taking cytotoxic medications." B) "I do not need to contact the doctor if I develop a fever or rash." C) "I plan to go to the movies this weekend so that I get out of the house." D) "I can take ibuprofen as indicated for pain."
A
A cardiac nurse educator is reviewing the use of the fixed rate mode pacemaker with a group of newly hired nurses. Which of the following statements by a newly hired nurse indicates understanding of the review? A. "This means the pacemaker fires in an asynchronous pattern." B. "This means the pacemaker fires only when the heart rate is below a certain rate." C."The pacemaker can automatically adjust to a client's increased activity level." D."The pacemaker activity is triggered by heart muscle activity."
A
A nurse in a clinic is caring for a client who has been on long‐term NSAID therapy to treat myocarditis. Which of the following laboratory findings should the nurse report to the provider? A. Platelets 100,000/mm3 B. Serum glucose 110 mg/dL C. Serum creatinine 0.7 mg/dL D. Amino alanine transferase (ALT) 30 IU/L
A
A nurse is admitting a client who has a suspected myocardial infarction (MI) and a history of angina. Which of the following findings will help the nurse distinguish angina from an MI? A. Angina can be relieved with rest and nitroglycerin. B. The pain of an MI resolves in less than 15 min. C. The type of activity that causes an MI can be identified. D. Angina can occur for longer than 30 min.
A
A nurse is assessing a client who has splinter hemorrhages in her nail beds and reports a fever. The nurse should identify these findings as manifestations of which of the following disorders? A. Infective endocarditis B. Pericarditis C. Myocarditis D. Rheumatic endocarditis
A
A nurse is caring for a client who asks why her provider prescribed a daily aspirin. Which of the following is an appropriate response by the nurse? A. "Aspirin reduces the formation of blood clots that could cause a heart attack." B. "Aspirin relieves the pain due to myocardial ischemia." C."Aspirin dissolves clots that are forming in your coronary arteries." D."Aspirin relieves headaches that are caused by other medications."
A
A nurse is caring for a client who has a prescription for an afterload‐reducing medication. The nurse should identify that this medication is administered for which of the following types of shock? A. Cardiogenic B. Obstructive C. Hypovolemic D. Distributive
A
A nurse is caring for a client who has heart failure and asks how to limit fluid intake to 2,000 mL/day. Which of the following is an appropriate response by the nurse? A. "Pour the amount of fluid you drink into an empty 2 liter bottle to keep track of how much you drink." B. "Each glass contains 8 ounces. There are 30 milliliters per ounce, so you can have a total of 8 glasses or cups of fluid each day." C. "This is the same as 2 quarts, or about the same as two pots of coffee." D. "Take sips of water or ice chips so you will not take in too much fluid."
A
A nurse is caring for a client who will undergo an endarterectomy due to severe peripheral vascular disease (PVD). When reviewing this procedure with the client, which statement will the nurse include? a The plaque from your occluded vessel will be surgically removed b The plaque from your occluded vessel will be removed by heat c This is considered a nonsurgical procedure that treats your occluded vessel d This procedure re-routes blood flow around your occluded vessel
A
A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client indicates understanding of the teaching? A. "I will notify the airport screeners about my pacemaker." B. "I will expect to have occasional hiccups." C."I will have to disconnect my garage door opener." D."I will take my pulse every 2 to 3 days."
A
A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan? A) Avoiding tight-fitting socks. B) Limit activity whenever possible. C) Sleep with legs in a dependent position. D) Avoid the use of pressure stockings.
A
A nurse is instructing a client who is scheduled for a transurethral resection of the prostate (TURP) about his postoperative care. Which of the following information should the nurse include in the teaching? A. "you may have a continuous sensation of needing to void even though you have a catheter." B. "you will be on bed rest for the first 2 days after the procedure." C."you will be instructed to limit your fluid intake after the procedure." D."your urine should be clear yellow the evening after the surgery."
A
A nurse is providing discharge teaching for a client who has a prescription for furosemide 40 mg PO daily. The nurse should instruct the client to take this medication at which of the following times of day? A. Morning B. Immediately after lunch C. Immediately before dinner D. Bedtime
A
A nurse is providing discharge teaching for a client who has heart failure and is on a fluid restriction of 2,000 mL/day. The client asks the nurse how to determine the appropriate amount of fluids he is allowed. Which of the following statements is an appropriate response by the nurse? A. "Pour the amount of fluid you drink into an empty 2‐liter bottle to keep track of how much you drink." B. "Each glass contains 8 ounces. There are 30 milliliters per ounce, so you can have a total of 8 glasses or cups of fluid each day." C. "This is the same as 2 quarts, or about the same as two pots of coffee." D. "Take sips of water or ice chips so you will not take in too much fluid."
A
A patient who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day? A) Assess pulse of affected extremity every 15 minutes at first. B) Palpate the affected leg for pain during every assessment. C) Assess the patient for signs and symptoms of compartment syndrome every 2 hours. D) Perform Doppler evaluation once daily.
A
A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patient's lower extremities? A) Ensure that the patient's heels are protected and supported. B) Closely monitor the patient's serum albumin and prealbumin levels. C) Perform gentle massage of the patient's lower legs, as tolerated. D) Perform passive range-of-motion exercises once per shift.
A
The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several blocks. The patient has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide what instruction about long-term care to the client? A) "Be sure to practice meticulous foot care." B) "Consider cutting down on your smoking." C) "Reduce your activity level to accommodate your limitations." D) "Try to make sure you eat enough protein."
A
The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the patient takes oral contraceptives. Consequently, the nurse's postoperative plan of care should include what intervention? A) Early ambulation and leg exercises B) Cessation of the oral contraceptives until 3 weeks postoperative C) Doppler ultrasound of peripheral circulation twice daily D) Dependent positioning of the patient's extremities when at rest
A
The nurse is caring for a patient who returned from the tropics a few weeks ago and who sought care with signs and symptoms of lymphedema. The nurse's plan of care should prioritize what nursing diagnosis? A) Risk for infection related to lymphedema B) Disturbed body image related to lymphedema C) Ineffective health maintenance related to lymphedema D) Risk for deficient fluid volume related to lymphedema
A
The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection? A) Provide a high-calorie, high-protein diet. B) Apply a clean occlusive dressing once daily and whenever soiled. C) Irrigate the wound with hydrogen peroxide once daily. D) Apply an antibiotic ointment on the surrounding skin with each dressing change.
A
When assessing venous disease in a patient's lower extremities, the nurse knows that what test will most likely be ordered? A) Duplex ultrasonography B) Echocardiography C) Positron emission tomography (PET) D) Radiography
A
a cardiac nuse educator is reviewing the use of the fixed rate modepacemaker with a group of newly hired nurses. which of the following statements by a newly hired nurse indicates understanding of the review a. this means the pacemaker fires in an asynchronous pattern b. this means the pacemaker fires only when the heart rate is below a certain level c. the pacemaker can automatically adjust to a clients increased activity level d. the pacemaker activity is triggered by heart muscle activity
A
a nurse in a clinic is caring for a client who has been on long term nsaid therapy to treat myocarditis. which lab should be reported a. platelets 100,000 b. serum glucose 110 c. serum creatine 0.7 d. ALT 30
A
a nurse is admitting a client who has complete heart block as demonstrated by ecg. the clients pulse rate is 34/min and BP 83/48. he is lethargic and unable to complete sentences. what should the nurse do first a. clean the skin with soap and water b. prepare the client for insertion of permanent pacemaker c. obtain signed informed consent form for a pacemaker d. apply transcutaneous pacemaker pads
A
a nurse is assessing a client who has splinter hemorrhages in her nail beds and reports a fever. for which of the following conditions is the client at risk a. infective endocarditis b. pericarditis c. myocarditis d. rheumatic endocarditis
A
a nurse is caring for a client and reviewing a new presription for an afterload reducing med. the nurse should recognize that this med is administered for which of the following types of shock a. cardiogenic b. obstructive c. hypovolemic d. distributive
A
a nurse is caring for a client in a clinic who askes the nurse why her provider prescribed 1 aspirin per day. which of the following is appropriate response a. aspirin reduces formation of blood clots that could cause a heart attack b. aspirin relieves the pain due to myocardial ischemia c. aspirin dissolves clots forming in coronary arteries d. aspirin relieves headaches that are caused by other meds
A
a nurse is caring for a client who has a new diagnosis of htn and a new prescription for spironolactone 25 mg.day. which of the following statements by the client indicates a need for further teaching. a. i should eat a lot of fruits and vegetables especially bananas and potatoes b. i will report any changes in HR or rhythm c. i should use a salt substitute that is low in potassium d. i will continue to take this med even if I am feeling better
A
a nurse is caring for a client who has heart failure and asks how to limit fluid intake to 2000ml.day. which of the following is an appropriate response by the nurse a. pour the amount of fluid you drink into an empty 2 liter bottle to keep track b. each glass contains 8 ounces. there are 30 milliliters per ounce, so you can have a total of 8 glasses or cups of fluid each day c. this is the same as 2 quarts, or the same as two pots of coffee d. take sips of water or ice chips so you will not take in too much fluid
A
a nurse is caring for a client who has severe PAD. the nurse should expect that the client will sleep most comfortably in which of the following positions a. affected limb hanging from bed b. affected limb elevated on pillows c. hob raised d. side lying recumbent position
A
a nurse is providing discharge teaching for a client who has a prescription for furosemide 40 mg po daily. what time of day should they take this med a. morning b. immediately after lunch c. immediately before dinner d. bedtime
A
a nuse is admitting a client who has a suspected MI and a history of angina. which finding helps distinguish MI from angina a. angina relieved with rest and nitro b. pain of MI resolves in less than 15 min c. type of activity that causes MI can be identified d. angina can occur for longer than 30 mins
A
11) A nurse caring for a client with SLE on immunosuppressive therapy understands that careful teaching is required to make sure both clients and family members understand appropriate precautions against the threat of infection. Teaching points should include: Select all that apply. A) Avoid large crowds and situations that increase exposure to infection. B) Report difficulty breathing or cough to the physician if taking cyclophosphamide. C) Use ibuprofen instead of acetaminophen if fever develops. D) Women may develop heavy menstrual bleeding during therapy.
A, B
4. A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. Avoid the consuming grapefruit while taking this medication. B. Monitor for the presence of black, tarry stools. C. Use an electric razor when shaving. D. Schedule a weekly PT test. E. Limit food sources containing vitamin K while taking this medication.
A, B
A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. Avoid the consuming grapefruit while taking this medication. B. Monitor for the presence of black, tarry stools. C. Use an electric razor when shaving. D. Schedule a weekly PT test. E. Limit food sources containing vitamin K while taking this medication.
A, B
a nurse is teaching a client who has a new prescription for clopidogrel. what should be included in teaching. select all that apply a. effects may not be apparent for several weeks b. monitor for the presence of black tarry stools c. instruct the client to use electric razor d. schedule weekly PT test e. advise about food sources containing vitamin k
A, B
A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary artery bypass grafting with a group of nurses. Which of the following statements should the nurse include in the discussion? (Select all that apply.) A. "The client's demand for oxygen is lowered." B. "Motion of the heart ceases." C."Rewarming of the client takes place." D."The client's metabolic rate is increased." E. "Blood flow to the heart is stopped."
A, B, C
a nurse educator is reviewing the use of CABG with a group of nurses. which of the following should be included in the discussion. select all that apply a. the cliets demand for oxygen is lowered b. motion of the heart ceases c. rewarming of the client takes place d. the clients metabolic rate is increased e. blood flow to the heart is stopped
A, B, C
a nurse is admitting a client to the coronary care unit following placement of a temporary pacemaker. which of the following actions should the nurse use to promote client safety? select all that apply a. wear gloves when handling pacemaker leads b. verify the use of three pronged grounding plugs c. minimize clients shoulder movements d. keep the lead wires taut when turning the client e. additional batteries should be kept at the nurses station
A, B, C
A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should be consumed in limited quantities? (Select all that apply.) A. Cheddar cheese, 2 oz B. Hot dog C. Canned tuna, 3 oz D. Roast chicken breast, 3 oz E. Baked ham, 3 oz
A, B, C, E
a nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2000mg daily. which of the following should be consumed in limited quantities. select all that apply a. cheddar cheese 2 oz b. hot dog c. canned tuna 3 oz d. roasted chicken breats 3 oz e. baked ham 3 oz
A, B, C, E
a nurse is caring for a client who had a surgical placement of an synthetic graft to repair an aneurysm. which interventions included in the plan of care a. assess pedal pulses b. monitor for increase in pain below graft site c. maintain client in high fowlers d. admin prescribed antiplatelet agents e. report hourly urine output of 60ml/hr
A, B, D
3. A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? (Select all that apply.) A. Diuretic use B. Obesity C. Deep sleep deprivation D. Depression E. Cardiovascular disease
A, B, E
A nurse educator is reviewing expected findings in a client who has right‐sided valvular heart disease with a group of nurses. Which of the following findings should the nurse include in the discussion? (Select all that apply.) A. Dyspnea B. Client report of fatigue C. Bradycardia D. Pleural friction rub E. Peripheral edema
A, B, E
A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? (Select all that apply.) A. Follow‐up ECG B. Energy settings used C. IV fluid intake D. Urinary output E. Skin condition under electrodes
A, B, E
A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following are expected findings? (Select all that apply.) A. Tachypnea B. Persistent cough C. Increased urinary output D. Thick, yellow sputum E. Orthopnea
A, B, E
A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following manifestation are expected findings? (Select all that apply.) A. Tachypnea B. Persistent cough C. Increased urinary output D. Thick, yellow sputum E. Orthopnea
A, B, E
The nurse is evaluating a patient's diagnosis of arterial insufficiency with reference to the adequacy of the patient's blood flow. On what physiological variables does adequate blood flow depend? Select all that apply. A) Efficiency of heart as a pump B) Adequacy of circulating blood volume C) Ratio of platelets to red blood cells D) Size of red blood cells E) Patency and responsiveness of the blood vessels
A, B, E
a nurse educator is reviewing expected findings in a client who has right sided valvular heart disease with a group of nurses. which of the following she be in the discussion. select all that apply a. dyspnea b. client report fatigue c. bradycardia d. pleural friction rub e. peripheral edema
A, B, E
a nurse is caring for a client who experienced defibrillation. which of the following should be included in the documentation of this procedure. select all that apply a. follow up ecg b. energy settings used c. iv fluid intake d. urinary output e. skin condition under electrodes
A, B, E
a nurse is completing the admission assessment of a client who has suspected pulmonary edema. which is expected. select all that apply a. tachypnea b. persistent cough c. increased urinary output d. thick yellow sputum e. orthopnea
A, B, E
a nurse is reviewing clinical manifestations of a thoracic aortic aneurysm with a newly hired nurse. which of the following should the nurse include in the discussion. select all that apply a. cough b. SOB c. upper chest pain d. diaphoresis e. altered swallowing
A, B, E
A nurse at a provider's office is reviewing the laboratory test results for a group of clients. The nurse should identify that which of the following results indicates the client is at risk for heart disease? (Select all that apply.) A. Cholesterol (total) 245 mg/dL B. HDL 90 mg/dL C. LDL 140 mg/dL D. Triglycerides 125 mg/dL E. Troponin I 0.02 ng/mL
A, C
A nurse is admitting a client to the coronary care unit following placement of a temporary pacemaker. Which of the following nursing actions should the nurse use to promote client safety? (Select all that apply.) A. Wear gloves when handling pacemaker leads. B. Ensure electronic equipment has three‐pronged grounding plugs. C. Minimize the client's shoulder movements. D. Hold the lead wires taut when turning the client. E. Keep extra pacemaker batteries at least 300 ft away from the client.
A, C
A nurse is caring for a client following the insertion of a temporary venous pacemaker via the femoral artery that is set as a VVI pacemaker rate of 70/min. Which of the following findings should the nurse report to the provider? (Select all that apply.) A. Cool and clammy foot with capillary refill of 5 seconds B. Observed pacing spike followed by a QRS complex C. Persistent hiccups D. Heart rate 84/min E. Blood pressure 104/62 mm Hg
A, C
a nurse is caring for a client following the insertion of a temporary venous pacemaker via the femoral artery that is set at 70/min. which of the following findings should the nurse report to the provider. select all that apply a. cool and clammy foot with cap refill of 5 seconds b. observed pacing spike followed by a qrs complex c. twitching of intercostal muscle d. HR of 84/min e. BP of 104/62
A, C
A nurse is planning care for a client who has a PICC line in the right arm. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Use a 10 mL syringe to flush the PICC line. B. Apply gentle force if resistance is met during injection. C. Cleanse ports with alcohol for 15 seconds prior to use. D. Maintain a transparent dressing over the insertion site. E. Flush with 10 mL heparin before and after medication administration.
A, C, D
A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should the nurse recommend for the client? (Select all that apply.) A. 1 slice cheddar cheese B. 1 medium beef hot dog C. 3 oz Atlantic salmon D. 3 oz roasted chicken breast E. 2 oz lean baked ham
A, C, D
1. A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate? (Select all that apply.) A. Positive ANA titer B. Increased hemoglobin C. 2+ urine protein D. Increased serum C3 and C4 E. Elevated BUN
A, C, E
A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. The nurse should recognize which of the following data as risk factors for this condition? (Select all that apply.) A. Surgical repair of an atrial septal defect at age 2 B. Measles infection during childhood C. Hypertension for 5 years D. Weight gain of 10 lb in past year E. Diastolic murmur present
A, C, E
a nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. what are risk factors. select all that apply a. surgical repair of an atrial septal defect at age 2 b. measles infection during childhood c. htn for 5 years d. weight gain of 10 lbs in past year e. diastolic murmur present
A, C, E
6) A nurse is caring for a client with systemic lupus erythematosus (SLE). The client begins to cry and tells the nurse that she is afraid that her skin will be disfigured with lesions. Which intervention does the nurse plan to teach this client to minimize skin infections associated with SLE? Select all that apply. A) Use sunscreen with an SPF of 15 or greater. B) Remain indoors on sunny days. C) Avoid swimming in a pool or the ocean. D) Avoid sun exposure between 10:00 a.m. and 3:00 p.m. E) Decrease sun exposure between 3:00 p.m. and 5:00 p.m.
A, D
A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? (Select all that apply.) A. A client who has metabolic alkalosis B. A client who has a serum potassium level of 4.3 mEq/L C. A client who has an SaO2 of 96% D. A client who has COPD E. A client who underwent stent placement in a coronary artery
A, D, E
A nurse is performing a nursing assessment on a client with peripheral vascular disease (PVD). Which findings will the nurse anticipate during the health history portion of the nursing assessment? (Select all that apply.) a Complaints of pain b Current diet c Presence of skin discoloration d History of coronary artery disease (CAD) e Current medications
A,B,C,E
a nurse is caring for a client who is receiving hemodynamic monitoring and has the following hemodynamic readings: PAS 34 mm Hg, PAD 21 mm Hg, PAWP 16 mm Hg, and CVP 12 mm Hg. for which of the following is the client at risk? a. heart failure b. cor pulmonale c. hypovolemic shock d. pulmonary hypertension e. peripheral edema
A,B,D,E
a nurse is reviewing a new prescription to administer NS IV at 50ml/hr to a client who is receiving hemodynamic monitoring and has an indwelling IV catheter in the left hand. which of the following sites can be used for administering this solution. select all that apply a. peripheral saline lock b. port on the arterial line c. port on proximal lumen of pulmonary artery catheter d. port on distal lumen of pa catheter e. balloon inflation port
A,C
A community health nurse is educating a group of adults about the risk factors associated with peripheral vascular disease (PVD) and chronic venous insufficiency (CVI). Which factors will the nurse include as those factors that increase the risk for developing CVI or PVD? (Select all that apply.) a. Excess body weight b. Male gender c. Physical inactivity d. Increased cholesterol levels e. Age 45 or older
A,C, D
5) A client with SLE is being treated with immunosuppressant drugs and corticosteroids. Which precautions should the nurse provide this client? Select all that apply. A) Avoid large crowds. B) Don't get a flu shot. C) Use contraception to prevent pregnancy D) Refrain from taking aspirin or ibuprofen. E) Report signs of infection to the physician.
A,C, D, E
The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurses assessment should include which of the following components? Select all that apply. A) Location and type of pain B) Apical heart rate C) Bilateral comparison of peripheral pulses D) Comparison of temperature in the patients legs E) Identification of mobility limitations
A,C,D, E
a nurse on a cardiac unit is caring for a group of clients. the nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia. select all that apply a. has metabolic acidosis b. has a serum potassium level of 4.3 c. has SaO2 of 96 d. has COPD e. underwent stent placement in a coronary artery
A,D, E
1. A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh-high compression stockings. Which of the following actions should the nurse take? A. Massage both legs firmly with lotion prior to applying the stockings. B. Apply the stockings in the morning upon awakening and before getting out of bed. C. Roll the stockings down to the knees to relieve discomfort on the legs. D. Remove the stockings while out of bed for 1 hr, four times a day, to allow the legs to rest.
B
4. A nurse is providing teaching for a client who has a new diagnosis of hypertension and a new prescription for spironolactone 25 mg/day. Which of the following statements by the client indicates an understanding of the teaching? A. "I should eat a lot of fruits and vegetables, especially bananas and potatoes." B. "I will report any changes in heart rate to my provider." C."I should replace the salt shaker on my table with a salt substitute." D."I will decrease the dose of this medication when I no longer have headaches and facial redness."
B
5. A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate? A. Swelling of joints of the fingers B. Pallor of toes with cold exposure C. Feet that become reddened with ambulation D. Client report of intense feeling of heat in the fingers
B
7) The nurse is caring for a client who has been diagnosed with discoid lupus erythematosus. The nurse is collaborating with the client to set goals for the nursing plan of care. What is an appropriate goal for this client? A) Work through the stages of death and dying. B) Comply 100% of the time with a sun protection plan. C) Gain weight to within 10 pounds of normal for height. D) Report pain no higher than four on a scale of 1-10.
B
A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. What is the most appropriate intervention for this diagnosis? A) Elevate his legs and arms above his heart when resting. B) Encourage the patient to engage in a moderate amount of exercise. C) Encourage extended periods of sitting or standing. D) Discourage walking in order to limit pain.
B
A nurse in a cardiac unit is assisting with the admission of a client who is to undergo hemodynamic monitoring. Which of the following actions should the nurse anticipate performing? A. Administer large volumes of IV fluids. B. Assist with insertion of pulmonary artery catheter. C. Obtain Doppler pulses of the extremities. D. Gather supplies for insertion of a peripheral IV catheter.
B
A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication? A) Aoritis B) Deep vein thrombosis C) Thoracic aortic aneurysm D) Raynaud's disease
B
A nurse is assessing a client with peripheral vascular disease (PVD). Which clinical manifestation will the nurse expect to find on assessment? a Spoon-shaped toenails b Hairless lower extremities c Pallor in lower extremities when in the dependent position d Dark red color to extremities when elevated
B
A nurse is caring for a 72‐year‐old client who is to undergo a percutaneous balloon valvuloplasty. The client's daughter asks the nurse to explain the expected outcome of this procedure. Which of the following responses should the nurse give? A. "This will improve blood flow in your mother's coronary arteries." B. "This will permit your mother to resume her activities of daily living." C. "This will prolong your mother's life." D. "This will reverse the effects to the damaged area."
B
A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh‐high compression stockings. Which of the following actions should the nurse take? A. Massage both legs firmly with lotion prior to applying the stockings. B. Apply the stockings in the morning upon awakening and before getting out of bed. C. Roll the stockings down to the knees to relieve discomfort on the legs. D. Remove the stockings while out of bed for 1 hr, four times a day, to allow the legs to rest.
B
A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the client's oxygen per protocol. Which of the following actions should the nurse take first? A. Obtain the client's weight. B. Assist the client into high‐Fowler's position. C. Auscultate lungs sounds. D. Check oxygen saturation with pulse oximeter.
B
A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the oxygen per protocol. Which of the following actions should the nurse take first? A. Obtain the client's weight. B. Assist the client into high-Fowler's position. C. Auscultate lung sounds. D. Check oxygen saturation with pulse oximeter.
B
A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting (CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, then refuses to cough because he is tired and it hurts too much. Which of the following actions should the nurse take? A. Allow the client to rest, and return in 1 hr. B. Administer IV bolus analgesic, and return in 15 min. C. Document the 200 mL as an appropriate inspired volume. D. Tell the client that he must try to cough if he does not want to get pneumonia.
B
A nurse is caring for a client with chronic venous insufficiency (CVI) who has a past medical history of thrombophlebitis. Why is a client with a history of thrombophlebitis at greater risk for developing CVI? a. Thrombophlebitis may increase nitric oxide concentration, which damages veins. b. Thrombophlebitis may damage valves of deep veins. c. Thrombophlebitis may alter coagulation that damages deep veins. d. Thrombophlebitis may create a toxin that damages veins.
B
A nurse is caring for four clients. Which of the following clients should the nurse identify as being at risk of acquiring rheumatic endocarditis? A. Older adult who has chronic obstructive pulmonary disease B. Child who has streptococcal pharyngitis C. Middle‐age adult who has lupus erythematosus D. Young adult who recently received a body tattoo
B
A nurse is completing discharge teaching to a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following statements by the client indicates understanding of the teaching? A. "I will consume more white rice." B. "I will eat more baked potatoes." C. "I will drink more grape juice." D. "I will use more powdered cocoa mixes."
B
A nurse is completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. Which of the following statements by the client indicates understanding of the teaching? A. "I will be glad to get back to my exercise routine right away." B. "I will have my prothrombin time checked on a regular basis." C."I will talk to my dentist about no longer needing antibiotics before dental exams." D."I will continue to limit my intake of foods containing potassium."
B
A nurse is completing discharge teaching with a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following food selections should the nurse include as having the highest source of potassium? A. 1 medium apple B. 1 medium baked potato C. 1 slice toast with 1 tbsp peanut butter D. 1 large scrambled egg
B
A nurse is planning care for a client who has septic shock. Which of the following actions is the priority for the nurse to take? A. Maintain adequate fluid volume with IV infusions. B. Administer antibiotic therapy. C. Monitor hemodynamic status. D. Administer vasopressor medication.
B
A nurse is planning care for a client with peripheral vascular disease (PVD) who is hospitalized due to increased pain associated with intermittent claudication. Which independent nursing intervention will the nurse implement to help the client's condition? A. Administer pain medications as ordered B. Teach the client guided imagery C. Assess client pain every 12 hours using standard scale D. Encourage the client to walk the halls, regardless of pain
B
A nurse is providing teaching for a client who has a new diagnosis of hypertension and a new prescription for spironolactone 25 mg/day. Which of the following statements by the client indicates an understanding of the teaching? A. "I should eat a lot of fruits and vegetables, especially bananas and potatoes." B. "I will report any changes in heart rate to my provider." C."I should replace the salt shaker on my table with a salt substitute." D."I will decrease the dose of this medication when I no longer have headaches and facial redness."
B
A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/min and notifies the provider. The nurse should anticipate that which of the following management strategies will be used for this client? A. Defibrillation B. Pacemaker insertion C. Synchronized cardioversion D. Administration of IV lidocaine
B
A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patient's left leg is visibly swollen and reddened. What is the nurse's most appropriate action? A) Administer a PRN dose of subcutaneous heparin. B) Inform the physician that the patient has signs and symptoms of VTE. C) Mobilize the patient promptly to dislodge any thrombi in the patient's lower leg. D) Massage the patient's lower leg to temporarily restore venous return.
B
An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. What should the nurse suggest as a proactive preventative measure for varicose veins? A) Sit with crossed legs for a few minutes each hour to promote relaxation. B) Walk for several minutes every hour to promote circulation. C) Elevate the legs when tired. D) Wear snug-fitting ankle socks to decrease edema.
B
The nurse is caring for a 72-year-old patient who is in cardiac rehabilitation following heart surgery. The patient has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day. The patient states that he is having a cramp-like pain in the legs every time he walks and that the pain gets "better when I rest." The patient's care plan should address what problem? A) Decreased mobility related to VTE B) Acute pain related to intermittent claudication C) Decreased mobility related to venous insufficiency D) Acute pain related to vasculitis
B
The nurse is caring for a patient who is admitted to the medical unit for the treatment of a venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment. What is the nurse most likely to find during an assessment of this patient's wound? A) Hemorrhage B) Heavy exudate C) Deep wound bed D) Pale-colored wound bed
B
The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? A) Numbness and tingling in the distal extremities B) Unequal peripheral pulses between extremities C) Visible clubbing of the fingers and toes D) Reddened extremities with muscle atrophy
B
The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left lower leg and foot when walking. This pain is relieved with rest. The nurse notes that the left lower leg is slightly edematous and is hairless. When planning this patient's subsequent care, the nurse should most likely address what health problem? A) Coronary artery disease (CAD) B) Intermittent claudication C) Arterial embolus D) Raynaud's disease
B
While assessing a patient the nurse notes that the patient's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best respond to this assessment finding? A) Assess the patient's use of over-the-counter dietary supplements. B) Implement interventions relevant to arterial narrowing. C) Encourage the patient to increase intake of foods high in vitamin K. D) Adjust the patient's activity level to accommodate decreased coronary output.
B
You are caring for a patient who is diagnosed with Raynaud's phenomenon. The nurse should plan interventions to address what nursing diagnosis? A) Chronic pain B) Ineffective tissue perfusion C) Impaired skin integrity D) Risk for injury
B
a nurse in a cardiac unit is assisting with the admission of a client who is to undergo hemodynamic monitoring. which of the following actions should the nurse anticipate performing a. administer large volumes of IV fluids b. assist with insertion of pulmonary artery catheter c. obtain doppler pulses of the extremities d. gather supplies for insertion of a PIV catheter
B
a nurse is caring for a client who has chronic venous insufficiency. prescribed thigh high compression socks. the nurse should instruct the patient to a. massage both legs firmly with lotion prior to applying the stockings b. apply the stockings in the morning upon awakening and before getting out of bed c. roll the stockings down to the knees if they will not stay up on the thighs d. remove the stockings while out of bed for 1 hr four times a day to let the legs res
B
a nurse is caring for a client who has heart failure and reports increased SOB. the nurse increases the oxygen per protocol. which of the following actions should the nurse take first a. obtain the weight b. assist the client into high fowlers c. auscultate lung sounds d. check 02 sats with pulse oximeter
B
a nurse is caring for a client who is 4 hr postop following CABG. he is able to inspire 200ml with the IS, then refuses to cough because he is tired and it hurts too much. which of the following is an appropriate intervention a. allow the client to rest, and return in 1 hr b. administer iv bolus analgesic and return in 15 min c. document the 200 ml as an appropriate inspired volume d. tell the client that he must try to cough if he does not want to get pneumonia
B
a nurse is caring for a client who is 72 and about to undergo a percutaneous balloon valvuloplasty. the clients daughter asks the nurse to explain the expected outcome of this procedure. what is appropriate response a. this will improve blood flow in your mothers coronary arteries b. this will permit your mother to resume her activities of daily living c. this will prolong your mothers life d. this will reverse the effects to the damaged area
B
a nurse is completing discharge teaching to a client who has heart failure and is encouraged to increase potassium in his diet. which of the following statements by the client indicates understanding a. i will consume more white rice b. i will eat more baked potatoes c. i will drink more grape juice d. i will use more powdered cocoa mixes
B
a nurse is completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. which indicates understanding a. i will be glad to get back to my exercise routine right away B. i will have my prothrombin time checked on a regular basis c. i will talk to my dentist about no longer needing antibiotics before dental exams d. i will contine to limit my intake of foods containing potassium
B
a nurse is planning care for a client who has septic shock. which of the following is priority action a. maintaining adequate fluid volume with iv infusion b. administering antibiotic therapy c. monitoring hemodynamic status d. administering vasopressor med
B
a nurse on a cardiac unit is caring for a client who is on telemetry. the nurse recognizes the clients HR is 46/min and notifies the provider. the nurse should anticipate that which of the following management strategies will be used for this client a. defibrillation b. pacemaker insertion c. synchronized cardioversion d. administration of iv lidocaine
B
which of the following clients has the greatest risk of acquiring rheumatic endocarditis a. an older adult who has copd b. a child who has upper resp strep infection c. a middle age adult who has lupus erythematosus d. a young adult who is at 24 weeks gestation
B
A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following findings pose an immediate concern? (Select all that apply.) A. Trace of bloody drainage on dressing B. Capillary refill of affected limb of 6 seconds C. Mottled appearance of the limb D. Throbbing pain of affected limb that is decreased following IV bolus analgesic E. Pulse of 2+ in the affected limb
B, C
a nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. which finding poses an immediate concern. select all that apply a. trace of bloody drainage on dressing b. cap refill of affected limb of 6 seconds c. mottled appearance of the limb d. throbbing pain of the affected limb that is decreased following IV bolus analgesic e. pulse of 2+ in affected limb
B, C
A nurse in the emergency department is completing an assessment on a client who is in shock. Which of the following findings should the nurse expect? (Select all that apply.) A. Heart rate 60/min B. Seizure activity C. Respiratory rate 42/min D. Increased urine output E. Weak, thready pulse
B, C, E
A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a CVP of 7 mm Hg and a PAWP of 17 mm Hg. Which of the following findings should the nurse expect? (Select all that apply.) A. Poor skin turgor B. Bilateral crackles in the lungs C. Jugular vein distension D. Dry mucous membranes E. Hepatomegaly
B, C, E
a nurse in the ED is completing an assessment of a client who is in shock. which of the findings are expected. select all that apply a. HR 60/min b. seizure activity c. respiratory rate 42/min d. increased urine output e. weak, thready pulse
B, C, E
1. A nurse is screening a male client for hypertension. The nurse should identify that which of the following actions by the client increase his risk for hypertension? (Select all that apply.) A. Drinking 8 oz nonfat milk daily B. Eating popcorn at the movie theater C. Walking 1 mile daily at 12 min/mile pace D. Consuming 36 oz beer daily E. Getting a massage once a week
B, D
A nurse is screening a male client for hypertension. The nurse should identify that which of the following actions by the client increase his risk for hypertension? (Select all that apply.) A. Drinking 8 oz nonfat milk daily B. Eating popcorn at the movie theater C. Walking 1 mile daily at 12 min/mile pace D. Consuming 36 oz beer daily E. Getting a massage once a week
B, D
a nurse is screening a client for htn. which increases risk. select all that apply a. drinking 8 oz of nonfat milk per day b. eating popcorn at the movie theater c. walking 1 mile daily at 12 min/mile pace d. consuming 36 oz of beer daily e. getting a message once a week
B, D
a nurse is caring for a client following a CABG. hemodynamic monitoring has been initiated. which of the following actions by the nurse facilitate correct monitoring readings? select all that apply a. place the client in high fowlers position b. level the transducer to phlebostatic axis c. zero transducer to room air d. observe trends in readings e. compare readings to physical assessment
B,C, D, E
A nurse is providing discharge instructions to a client who is postoperative following a TURP. Which of the following instructions should the nurse include? (Select all that apply.) A. Avoid sexual intercourse for 3 months after the surgery. B. If urine appears bloody, stop activity and rest. C. Avoid drinking caffeinated beverages. D. Take a stool softener once a day. E. Treat pain with ibuprofen.
B,C,D
The prevention of VTE is an important part of the nursing care of high-risk patients. When providing patient teaching for these high-risk patients, the nurse should advise lifestyle changes, including which of the following? Select all that apply. A) High-protein diet B) Weight loss C) Regular exercise D) Smoking cessation E) Calcium and vitamin D supplementation
B,C,D
A nurse in a provider's office is obtaining a history from a client who is undergoing an evaluation for benign prostatic hyperplasia (BPH). The nurse should identify that which of the following findings are indicative of this condition? (Select all that apply.) A. Backache B. Frequent urinary tract infections C. Weight loss D. Hematuria E. Urinary incontinence
B,D,E
10) A nurse is caring for a client with systemic lupus erythematous (SLE) who is taking hydroxychloroquine (Plaquenil). The nurse understands that the primary concern with this drug is: A) Pulmonary fibrosis. B) Cushingoid effects. C) Retinal toxicity. D) Renal toxicity.
C
2) A female client asks the nurse if there are any conditions that can exacerbate systemic lupus erythematosus (SLE). Which is the best nurse response? A) "Conditions that cause hypotension can often exacerbate SLE." B) "GI upset is often associated with SLE exacerbation." C) "Pregnancy is often associated with an SLE exacerbation." D) "Fever is a known trigger for an SLE exacerbation."
C
2. A nurse in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the second time in 2 weeks that the client experienced hypoglycemia. Which of the following client data should the nurse report to the provider? A. Takes psyllium daily as a fiber laxative B. Drinks skim milk daily as a bedtime snack C. Takes metoprolol daily after meals D. Drinks grapefruit juice daily with breakfast
C
2. A nurse is teaching a client who has SLE about self-care. Which of the following statements by the client indicates an understanding of the teaching? A. "I should limit my time to 10 minutes in the tanning bed." B. "I will apply powder to any skin rash." C."I should use a mild hair shampoo." D."I will inspect my skin once a month for rashes."
C
3. A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports a headache and double vision. The client states that she ran out of her diltiazem 3 days ago, and is unable to purchase more. Which of the following actions should the nurse take first? A. Administer acetaminophen for headache. B. Provide teaching regarding the importance of not abruptly stopping an antihypertensive. C. Obtain IV access and prepare to administer an IV antihypertensive. D. Call social services for a referral for financial assistance in obtaining prescribed medication.
C
5. A nurse is caring for a client who has a deep-vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin. The client asks the nurse about receiving both heparin and warfarin at the same time. Which of the following statements should the nurse give? A. "I will remind your provider that you are already receiving heparin." B. "Your laboratory findings indicated that two anticoagulants were needed." C."It takes 3 to 4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued." D."Only one of these medications is being given to treat your deep-vein thrombosis."
C
A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the patient has a history of what health problem? A) Raynaud's phenomenon B) CAD C) Arterial insufficiency D) Varicose veins
C
A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would assessment of ankle-brachial index (ABI) be most clearly warranted? A) A patient who has peripheral edema secondary to chronic heart failure B) An older adult patient who has a diagnosis of unstable angina C) A patient with poorly controlled type 1 diabetes who is a smoker D) A patient who has community-acquired pneumonia and a history of COPD
C
A nurse in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the second time in 2 weeks that the client experienced hypoglycemia. Which of the following client data should the nurse report to the provider? A. Takes psyllium daily as a fiber laxative B. Drinks skim milk daily as a bedtime snack C. Takes metoprolol daily after meals D. Drinks grapefruit juice daily with breakfast
C
A nurse in the emergency department is caring for a client who had an allergic reaction related to a bee sting. The client is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first? A. Methylprednisolone IV bolus B. Diphenhydramine subcutaneously C. Epinephrine IV D. Albuterol inhaler
C
A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority health education for this patient? A) The lack of exercise, which is the main cause of PAD. B) The likelihood that heavy alcohol intake is a significant risk factor for PAD. C) Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. D) Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.
C
A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. Which of the following findings should the nurse suspect? A. Retroperitoneal bleeding B. Cardiac tamponade C. Bleeding from the incisional site D. Heart failure
C
A nurse is caring for a client who has a deep‐vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin. The client asks the nurse about receiving both heparin and warfarin at the same time. Which of the following statements should the nurse give? A. "I will remind your provider that you are already receiving heparin." B. "Your laboratory findings indicated that two anticoagulants were needed." C."It takes 3 to 4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued." D."Only one of these medications is being given to treat your deep‐vein thrombosis."
C
A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports a headache and double vision. The client states that she ran out of her diltiazem 3 days ago, and is unable to purchase more. Which of the following actions should the nurse take first? A. Administer acetaminophen for headache. B. Provide teaching regarding the importance of not abruptly stopping an antihypertensive. C. Obtain IV access and prepare to administer an IV antihypertensive. D. Call social services for a referral for financial assistance in obtaining prescribed medication.
C
A nurse is caring for a client with peripheral vascular disease (PVD) who complains of intermittent claudication, decreased exercise tolerance, and occasional pain in the lower extremities at rest. The client's healthcare provider has prescribed cilostazol (Pletal) for the collaborative treatment of the client's condition. Which statement will the nurse include in the client teaching about this medication? a. "This medication is used to increase your energy so that you can exercise more efficiently." b. "This medication is used to decrease your risk of developing a blood clot." c. "This medication is used to improve blood flow to your legs, decreasing incidence of cramping pain in your legs." d. "This medication is used to increase flexibility of red blood cells, improving your condition.
C
A nurse is caring for a client with peripheral vascular disease (PVD) who presents to the primary care clinic complaining of a burning pain in the legs, which occurs at night in bed. What is the best response from the nurse? A ."This is known as intermittent claudication. Wearing compression socks to bed may help your pain." B ."This is known as rest pain. Elevating your legs may help your pain." C. "This is known as rest pain. Dangling your legs off your bed may help your pain." D. "This known as intermittent claudication. Elevating your legs may help your pain."
C
A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patient's aneurysm? A) Sudden increase in blood pressure and a decrease in heart rate B) Cessation of pulsating in an aneurysm that has previously been pulsating visibly C) Sudden onset of severe back or abdominal pain D) New onset of hemoptysis
C
A nurse is completing the admission physical assessment of a client who has a history of mitral valve insufficiency. Which of the following findings should the nurse expect? A. S4 heart sound B. Petechiae C. Crackles in lung bases D. Splenomegaly
C
A nurse is planning care for a client with peripheral vascular disease (PVD) who is scheduled to have revascularization surgery to improve circulation to the lower extremities. Which independent nursing intervention will the nurse implement to promote client tissue perfusion? a Warm lower extremities using heating pad b Elevate lower extremities above the heart c Encourage regular exercise d Administer medication as ordered
C
A nurse is presenting a community education program on recommended lifestyle changes to prevent angina and myocardial infarction. Which of the following changes should the nurse recommend be made first? A. Diet modification B. Relaxation exercises C. Smoking cessation D. Taking omega‐3 capsules
C
A nurse on a cardiac unit is reviewing the laboratory findings of a client who has a diagnosis of myocardial infarction (MI) and reports that his dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the MI occurred 14 days ago? A. CK‐MB B. Troponin I C. Troponin T D. Myoglobin
C
A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis. When reviewing this patient's medication administration record, the nurse should anticipate which of the following? A) Coumadin (warfarin) B) Lasix (furosemide) C) An antibiotic D) An antiplatelet aggregator
C
A patient presents to the clinic complaining of the inability to grasp objects with her right hand. The patient's right arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with her left arm. The nurse should expect that the primary care provider may diagnose the woman with what health problem? A) Lymphedema B) Raynaud's phenomenon C) Upper extremity arterial occlusive disease D) Upper extremity VTE
C
A student nurse is observing a cardioversion procedure and hears the team leader call out, "Stand clear." The student should recognize the purpose of this action is to alert personnel that A. the cardioverter is being charged to the appropriate setting. B. they should initiate CPR due to pulseless electrical activity. C. they cannot be in contact with equipment connected to the client. D. a time‐out is being called to verify correct protocols.
C
The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal insufficiency. How will this patient's renal status affect heparin therapy? A) Heparin is contraindicated in the treatment of this patient. B) Heparin may be administered subcutaneously, but not IV. C) Lower doses of heparin are required for this patient. D) Coumadin will be substituted for heparin.
C
The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the patient's warfarin is at therapeutic levels? A) Partial thromboplastin time (PTT) within normal reference range B) Prothrombin time (PT) eight to ten times the control C) International normalized ratio (INR) between 2 and 3 D) Hematocrit of 32%
C
a nurse in the ED is assisting with the admission of a clientwho has a possible dissecting abdominal aortic aneurysm. which is primary intervention a. administer pain med as prescribed b. ensure a warm environment c. administer IV fluids as prescribed d. initiate a 12 lead ECG
C
a nurse in the ED is caring for a client who has an allergic reaction to a bee sting. the client is experiencing wheezing and swelling of the tongue. which med should the nurse administer first a. methylprednisone IV bolus b. diphenhydramine subq c. epinephrine IV d. albuterol inhaler
C
a nurse in urgent care clinic is obtaining a history from a client who has DM2 and a recent diagnosis of htn. this is the second time in two weeks that the client experienced hypoglycemia. which should the nurse report a. take psyllium hydrophilic muccilloid daily b. drink skim milk daily c. takes metoprolol daily d. drinks grapefruit juice daily
C
a nurse is admitting a client with a suspected occlusion of a graft of the abdominal aorta. which of the following is an expected finding a. increased urine output b. bounding pedal pulse c. increased abdominal girth d. redness of lower extremities
C
a nurse is caring for a client following an angioplast that was inserted through the femoral artery. while turning, the nurse discovers blood underneath the clients lower back. the nurse should suspect a. retroperitoneal bleeding b. cardiac tamponade c. bleeding form the incisional site d. heart failure
C
a nurse is caring for a client who has a dvt and has been taking unfractionated heparing for one week. two days ago, the provider also prescribed warfarin. the client questions the nurse about recieving both heparin and warfarin at the same time. which of the following is appropriate response a. i will remind your provider that you are already on heparin b. lab findings indicated that two anticoagulants were needed c. it takes three or four days befor ethe effects of wafating are achieved and the heparin can be discontinued d. only one of these meds is being given to treat your dvt
C
a nurse is caring for a client who is admitted to the ED with a bp of 266/147. the client reports a headach and states that she is seeing double. the client states that she ran out of her diltizem 3 days ago and she has not been able to purchase more. which of the following interventions first a. administer acetaminophen for the headachee b. provide teaching in regard to the importance of not abruptly stopping and antihtn c. obtain iv access and prepare to administer iv antihtn d. call social services for a referral for financial assistance in obtaining prescribed meds
C
a nurse is coleting the admission physical assessment of a client w ho has a history of mitral valve insufficiency. which of the following is expected a. hoarseness b. petechiae c. crackles inlung bases d. splenogmeagly
C
a nurse is completing discharge teaching with a client who has a permanent pacemaker. which of the following statements by the client indicates a need for further teaching a. i will notify the airport security about my pacemaker b. i will call my doctor about hiccups c. i will have to disconnect my garage door opener d. i will take my pulse every morning when i wake up
C
a nurse is presenting a community education program on reccommended lifestyle changes to prevent angina and MI. which of the following changes should the nurse recommend be made first a. diet modification b. relaxation exercises c. smoking cessation d. taking omega 3s
C
a nurse on a cardiac unit is reviewing the lab findings of a client who has a diagnosis of MI and reports that his dyspnea began 2 weeks ago. which of the following cardiac enzymes would confirm MI 14 days ago a. ckmb b. trop i c. trop t d. myoglobin
C
a student nurse is observing a cardioversion procedure and hears the team leader call out stand clear. the student should recognize the purpose of this action is to alert personnel that a. the cardoverter is being charged to the appropriate setting b. they should initiate cpr due to pulseless electrical activity c. they cannot be in contact with equipment connected to the client d. a time out is being called to verify correct protocols
C
A home health nurse is caring for a client with peripheral vascular disease (PVD). When educating the client regarding foot and leg care, which statements will the nurse include? (Select all that apply.) a "Buy shoes in the morning, when feet are largest." b "Avoid using powder on your feet." c "Dry between your toes after showering." d "Apply moisturizing cream to feet and legs daily.". e "When swimming, ensure the water is cool, not warm."
C,D
2. A nurse is assessing a client who has chronic peripheral arterial disease (PAD). Which of the following findings should the nurse expect? A. Edema around the ankles and feet B. Ulceration around the medial malleoli C. Scaling eczema of the lower legs with stasis dermatitis D. Pallor on elevation of the limbs, and rubor when the limbs are dependent
D
3) The nurse is providing health education to a diverse group at a neighborhood community center. Why does the nurse plan to include signs and symptoms of systemic lupus erythematosus (SLE)? A) The neighborhood is composed of many young female children. B) The audience has asked the nurse to include the information. C) The audience is mainly composed of Caucasian women. D) The audience is mainly females of Asian-American descent.
D
3. A nurse is teaching a client who has been a new diagnosis of severe peripheral arterial disease. Which of the following instructions should the nurse include? A. Wear tightly fitted insulated socks with shoes when going outside. B. Elevate both legs above the heart when resting. C. Apply a heating pad to both legs for comfort. D. Place both legs in dependent position while sleeping.
D
4. A nurse is assessing a client who has SLE. Which of the following findings should the nurse expect? A. Weight loss B. Petechiae on thighs C. Systolic murmur D. Alopecia
D
8) The nurse is planning care for an adolescent client who has systemic lupus erythematosus (SLE). The nurse knows that the treatment plan implemented by the healthcare team is appropriate for the situation when the client: A) Refuses to attend school. B) Does not want to attend any social functions. C) Discusses skin changes with the healthcare personnel. D) Discusses skin changes with a good friend.
D
A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation following an MI. The nurse's plan of care calls for the patient to walk for 10 minutes 3 times a day. The patient questions the relationship between walking and heart function. How should the nurse best reply? A) "The arteries in your legs constrict when you walk and allow the blood to move faster and with more pressure on the tissue." B) Walking increases your heart rate and blood pressure. Therefore your heart is under less stress." C) "Walking helps your heart adjust to your new arteries and helps build your self-esteem." D) "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart."
D
A nurse is admitting a client who has suspected rheumatic endocarditis. The nurse should anticipate a prescription from the provider for which of the following laboratory tests to assist in confirmation of this diagnosis? A. Arterial blood gases B. Serum albumin C. Liver enzymes D. Throat culture
D
A nurse is admitting a client who has complete heart block as demonstrated by ECG. The client's heart rate is 34/min and blood pressure is 83/48 mm Hg. The client is lethargic and unable to complete sentences. Which of the following actions should the nurse perform first? A. Transport the client to the cardiovascular laboratory. B. Prepare the client for insertion of a permanent pacemaker. C. Obtain a signed informed consent form for a pacemaker. D. Apply transcutaneous pacemaker pads.
D
A nurse is assessing a client who has chronic peripheral arterial disease (PAD). Which of the following findings should the nurse expect? A. Edema around the ankles and feet B. Ulceration around the medial malleoli C. Scaling eczema of the lower legs with stasis dermatitis D. Pallor on elevation of the limbs, and rubor when the limbs are dependent
D
A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patient's left foot. How should the nurse proceed with assessment? A) Have the primary care provider order a CT. B) Apply a tourniquet for 3 to 5 minutes and then reassess. C) Elevate the extremity and attempt to palpate the pulses. D) Use Doppler ultrasound to identify the pulses.
D
A nurse is caring for a client who has a new diagnosis of benign prostatic hyperplasia (BPH). The nurse should anticipate a prescription for which of the following medications? A. Oxybutynin B. Diphenhydramine C. Ipratropium D. Tamsulosin
D
A nurse is caring for a client who has pericarditis. Which of the following findings should the nurse expect? A. Petechiae B. Murmur C. Rash D. Friction rub
D
A nurse is caring for a client with peripheral vascular disease (PVD) who asks the nurse, open double quoteIs there anything other than medication to help slow this disease?close double quote What is the nurse's best response? a A diet high in protein has been shown to slow the progression of PVD b Aromatherapy has been shown to slow the progression of PVD c Yoga has been shown to slow the progression of PVD d Garlic supplements have been shown to slow the progression of PVD
D
A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following findings should the nurse expect? A. Rubor of the affected leg when elevated B. 3+ dorsal pedal pulse in left foot C. Thin, peeling toenails of left foot D. Report of intermittent claudication in the affected leg
D
A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching? A. "Air should be instilled into the monitoring system prior to the procedure." B. "The client should be positioned on the left side during the procedure." C."The transducer should be level with the second intercostal space after the line is placed." D."A chest x‐ray is needed to verify placement after the procedure."
D
A nurse is performing an assessment on a client with peripheral vascular disease (PVD). The nurse notes that the client's blood pressure is 142/86 mmHg. What additional manifestation, unique to PVD, will the nurse find upon physical examination of the nursing assessment of this client? A. Dilated blood vessels in the eye B. Decreased sensation of the upper extremities C. Wheezing upon auscultation of the lungs D. Delayed capillary refill in the lower extremities
D
A nurse is reviewing the physiological factors that affect a patient's cardiovascular health and tissue oxygenation. What is the systemic arteriovenous oxygen difference? A) The average amount of oxygen removed by each organ in the body B) The amount of oxygen removed from the blood by the heart C) The amount of oxygen returning to the lungs via the pulmonary artery D) The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood
D
A nurse is teaching a client who has angina about a new prescription for metoprolol. Which of the following statements by the client indicates understanding of the teaching? A. "I should place the tablet under my tongue." B. "I should have my clotting time checked weekly." C. "I will report any ringing in my ears." D. "I will call my doctor if my pulse rate is less than 60."
D
A nurse is teaching a client who has been a new diagnosis of severe peripheral arterial disease. Which of the following instructions should the nurse include? A. Wear tightly fitted insulated socks with shoes when going outside. B. Elevate both legs above the heart when resting. C. Apply a heating pad to both legs for comfort. D. Place both legs in dependent position while sleeping.
D
A nurse is teaching a client who is scheduled for an angiography. Which of the following statements should the nurse include in the teaching? A. "You should have nothing to eat or drink for 4 hours prior to the procedure." B. "You will be given general anesthesia during the procedure." C. "You should not have this procedure done if you are allergic to eggs." D. "You will need to keep your affected leg straight following the procedure."
D
A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the resident's feet, the nurse notes that she appears to have early evidence of gangrene on one of her great toes. The nurse knows that gangrene in the elderly is often the first sign of what? A) Chronic venous insufficiency B) Raynaud's phenomenon C) VTE D) PAD
D
A patient comes to the walk-in clinic with complaints of pain in his foot following stepping on a roofing nail 4 days ago. The patient has a visible red streak running up his foot and ankle. What health problem should the nurse suspect? A) Cellulitis B) Local inflammation C) Elephantiasis D) Lymphangitis
D
An older adult patient has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan? A) Use of supplementary oxygen to aid tissue oxygenation B) Daily use of normal saline compresses on the lower limbs C) Daily administration of prophylactic antibiotics D) A high-protein diet that is rich in vitamins
D
Graduated compression stockings have been prescribed to treat a patient's venous insufficiency. What education should the nurse prioritize when introducing this intervention to the patient? A) The need to take anticoagulants concurrent with using compression stockings B) The need to wear the stockings on a "one day on, one day off" schedule C) The importance of wearing the stockings around the clock to ensure maximum benefit D) The importance of ensuring the stockings are applied evenly with no pressure points
D
How should the nurse best position a patient who has leg ulcers that are venous in origin? A) Keep the patient's legs flat and straight. B) Keep the patient's knees bent to 45-degree angle and supported with pillows. C) Elevate the patient's lower extremities. D) Dangle the patient's legs over the side of the bed.
D
The nurse caring for a patient with a leg ulcer has finished assessing the patient and is developing a problem list prior to writing a plan of care. What major nursing diagnosis might the care plan include? A) Risk for disuse syndrome B) Ineffective health maintenance C) Sedentary lifestyle D) Imbalanced nutrition: less than body requirements
D
The nurse is assessing a woman who is pregnant at 27 weeks' gestation. The patient is concerned about the recent emergence of varicose veins on the backs of her calves. What is the nurse's best response? A) Facilitate a referral to a vascular surgeon. B) Assess the patient's ankle-brachial index (ABI) and perform Doppler ultrasound testing. C) Encourage the patient to increase her activity level. D) Teach the patient that circulatory changes during pregnancy frequently cause varicose veins.
D
a nurse is admitting a client who has suspected rheumatic endocarditis. the nurse should anticipate a prescription from the provider for which of the following labs to assist in confirming this diagnosis a. abgs b. albumin c. liver enzymes d. throat culture
D
a nurse is caring for a client who has pericarditis. what expected finding a. petechiae b. murmur c. rash d. friction rub
D
a nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. what is expected finding a. rubor of the affected leg when elevated b. 3+ dorsal pedal pulse in the left foot c. thin, peeling toenails of the left foot d. report of intermittent claudication in affected leg
D
a nurse is discussing anew diagnosis of an aneurysm with a client. the client asks the nucse to explain what causes an aneurysm to rupture. which of the following is appropriate response a. the wall of an artery becomes thin and flexible b. it is due to turbulence in blood flow in the artery c. it is due to abdominal enlargement d. it is due to htn
D
a nurse is instructing a client who has angina about a new prescription for metoprolol tartrate. which of the following statements by the client indicates understanding of the teaching a. i should place the tablet under my tongue b. i should have my clotting time checked weekly c. i will report and ringing in my ears d. i will call my doctor if my pulse is less than 60
D
a nurse is orienting a newly licensed nurse on the care of a client who is receiving hemodynamic monitoring. which of the following statements by the newly licensed nurse indicates the teaching was effective? a. air should be instilled into the monitoring system b. the client should be in the prone position c. the transducer should be level with the 2nd intercostal space d. a chest xray is needed to verify placement
D
a nurse is performing a physical assessment of a client who has chronic peripheral arterial disease. what is expected a. edema around the clients ankles and feet b. ulceration around the clients medial malleoli c. scaling eczema of the clients lower legs ans stasis dermatitis d. pallor on elevation of the clients limbs and rubor when his limbs are dependent
D
a nurse is teaching a client the importance of remaining still following angiography. which of the following is an appropriate statement by the nurse? a. moving in bed raises your blood pressure b. too much activity increases your risk for infection c. moving in bed increases your risk of a complication due to anesthesia d. too much activity places you at risk for bleeding
D
