Med Surg Final Review
20. A nurse assess a 66-year-old client who is attempting to quit smoking. The client states i started smoking at age 13 and smoked one pack each day until 10 years ago..
48 pack-years
19. ARF occurs with the PaO2 fall less than______mmHg (hypoxemia) and PaCO2 rises to greater than ____mmhd (hypercapnia)
50 to 50
36. The nurse hangs a 1000ml IV solution at 9am and sets the infusion controller device to administer 100 gtt/min via micro drip infusion set. On assessment of the IV infusion the nurse expect that the remaining
500 mL
55. Prophylactic isoniazid (INH) drug treatment is necessary for how many months?
6 to 12 months
14. The nurse is assessing clients in the ER. Which is at highest risk for septic shock?
68-year-old woman who is being treated with chemotherapy
28. A nurse assess patients on a cardiac unit. Which patient would the nurse identify as the greatest risk for developing left-sided heart failure?
A 36-year-old woman with aortic stenosis
44. A patient has had a tracheostomy for 5 day and is having difficulty communicating with their family. Name 4 other methods of communication that the nurse should teach to the patient and family that would better aid in communication
A board with pictures and letters Writing tablet Hand signals Call light within reach Yes/no questions Communication flashcards
18. Order: 25,000 units of heparin IV in 250 mL 0.9% NS to infuse at 20units/kg/hr. The client weights 165 lb.
A. Weight in kg B. Units/Hour A: 75, B: 1500
47. Esmolol is ordered for a client. The solution available is 2.5g in 250mL D5W. The order is to infuse 32 mL/hr.
A. mg/hr B. mg/min Answer is A-320 mg/hr B-5
9. A nurse assesses a patient who has a history of HF. Which question would the nurse ask to assess the extent of their HF?
"Are you able to walk upstairs without fatigue like usual?"
10. The nurse is caring for a client who has had an anaphylactic event. Which priority question does the nurse ask to determine whether the client is experiencing distributive shock.
"Are you usually this swollen?"
11. A nurse teaches a patient recovering from a heart transplant who is prescribed cyclosporine. Which statement would the nurse include in this patient's discharge teaching?
"Avoid large crowds and people who are sick"
5. A nurse is teaching a patient with HF who has been prescribed enalapril (vasotec). Which statement would the nurse include in this teaching?
"Avoid using salt substitutes"
41. A client admitted for pneumonia has been tachypneic for several days. When the nurse starts in IV to give fluids the client questions the action by saying "I have been drinking plenty of fluids how can I be dehydrated?"
"Breathing so quickly can cause dehydration"
41. The nurse is teaching a client who is given a calcium channel blocking agent after a percutaneous transluminal coronary angioplasty. What side effect should she tell the client about the medication?
"Change position slowly.
18. A client recovering from septic shock is preparing for discharge home. What priority information does the nurse include in the teaching plan for this client?
"Clean your toothbrush with laundry bleach daily"
46. A nurses teaches a patient who is prescribed digoxin therapy. Which statement would the nurse include in this patient's teaching?
"Do not take this medication within 1 hour of taking an antacid"
5. The nurse observes that a client's anteroposterior chest diameter is the same as his lateral chest diameter. Which question is most important for the nurse to ask the client in response to the finding?
"Do you have any chronic breathing problems?"
22. A nurse is teaching a client who has Cystic Fibrosis (CF) which statement should the nurse include in the teaching?
"Eat a well-balanced, nutritious diet"
43. The nurse is teaching a client prescribed sublingual Nitro for chest pain. Which statement indicates the client needs further teaching?
"I carry my medicine around in a clear plastic bag so that I can get to it easily if I have chest pain"
36. A nurse assess a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided HF?
"I must stop halfway up the stairs to catch my breath"
46. The clients bp is being taken at a screening clinic. Which client statement to the nurse demonstrates the awareness of having a risk factor for hypertension?
"I plan to get my blood pressure checked more often, as I am an African American."
19. After teaching a pt who is being discharged home after a mitral valve replacement surgery the nurse assesses the ots understanding which pt statement indicates the need for further teaching
"I will have my teeth cleaned by my dentist in 2 weeks"
19. After teaching a client about their prescribed long acting beta 2 agonist medication, a nurse assess the client's level of understanding. Which statement by the client indicates they understood the teaching?
"I will take this medication every morning to help prevent an acute attack"
20. After teaching a client who is prescribed salmeterol (serevent), the nurse assesses the client's understanding. Which statement indicates the client needs additional teaching?
"I will use the drug when i have an asthma attack."
36. The nurse is teaching a client about his fenestrated trach tube. Which statement by the client indicates an understanding of teaching?
"I'm glad I will still be able to talk with this tube in place."
28. A community health nurse assess clients at a health fair. Which statement assists the nurse to identify modifiable risk factors in clients with coronary artery disease?
"In what activities do you participate on a daily basis?"
25. Which statement by the nurse about bacterial or infective endocarditis is most accurate?
"It is an infection of the valves and inner lining of the heart"
21. A student nurse asks what essential hypertension is. What response by the nurse is best?
"It is hypertension with no specific cause"
18. A student nurse asks for an explanation of "refractory hypoxia". What is the best answer
"It is hypoxemia that persists even with 100% oxygen administration"
10. A patient is on a mechanical vent and the patient's spouse wonders why ranitidine (Zantac) is needed since the patient only has lung problems. What is the best response
"It will prevent ulcers from the stress of mechanical ventilation."
14. Which client statement alerts the nurse to the possibility of rhinitis medicamentosa?
"My nose doesn't stay open even though im using nasal spray every hour"
39. A nurse assess a patient admitted to the cardiac unit. WHich statement b the patient laters the nurse to the possibility of right-sided HF?
"My shoes fit really tight lately"
22. A patient is taking warfarin and asked if taking St John's wort is acceptable. What response should he get
"No, it may interfere with the warfarin"
1.The intensive care nurse is educating the spouse of a client who is being treated for shock. The spouse states, "the doctor said she has shock. What's that?" What is the nurse's best response?
"Shock occurs when oxygen to the body's tissue and organ is impaired
27. A nurse cares for a female client who has a family history of cystic fibrosis (CF). The client asks, "will my children have CF?" How should the nurse respond?
"Since you have a family history of CF, I would encourage you and your partner to be tested"
3. A patient has a PE and is started on O2. The student nurse asks why the patients SpO2 is not improving. The best response is?
"The blood clot interferes with perfusion in the lungs"
40. A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over. What instructions should the nurse give?
"Try warm, moist heat packs on your face"
38. A nurse cares for a pt with right sided HF, the patient asks, "why do I need to weigh myself everyday?"
"Weight is the best indication that you are gaining or losing fluid."
43. A client has been admitted for suspected inhalation anthrax infection. What questions by the nurse is most important?
"What is your occupation?"
39. Which statement by a client indicates an accurate understanding of home self-care of a trach?
"While showering, I need to keep water out of my airway."
30. A nurse cares for a patient with end-stage heart failure who is awaiting a transplant. The patient appears depressed and states "I know a transplant is my last chance, but I don't want to become a vegetable." How would the nurse respond?
"Would you like information about advance directives?"
34. A nurse cares for an older adult with HF. The patient states that he "doesn't know what to do because he doesn't wanna be a burden to his daughter but I can't do it alone," What is the best response by the nurse?
"Would you like to talk more about this?"
29. The nurse teaches a client who is newly diagnosed with CAD. Which instructions does the nurse include to minimize complications of the disease?
"You should talk to your provider about medications to help you quit smoking"
39. A client has a TB skin test as a pre-employment physical assessment. Which statement by the nurse is best made to the client who has the best result seen in the photograph given.
"You will need further testing, such as a chest x-ray./"
26. A nurse cares for a client who test positive for alpha 1 antitrypsin deficiency. The client ask, "what does this mean?" How should the nurse respond?
"Your risk for COPD is higher, especially if you smoke."
40. Which statement made by a parent indicates an understanding about the genetic transmission of cystic fibrosis?
- "both parents are carriers of the cystic fibrosis gene"
32. What is the best nursing response to the parent of a child with asthma who asks if his child can still participate in sports?
- Children can usually play any type of sport if asthma is controlled
1. A nurse answers a call light and finds a patient anxious, SOB, reporting chest pain, and BP of 88/52. What action is priority
- Notify the rapid response team
2. A patient is admitted with a PE. The patient is young, healthy, and active and has no known risk factor for PE. What action by the nurse is most appropriate?
- Teach the patient about factor V Leiden testing
42. The nurse caring for mechanically ventilated patients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice?
- adherence to proper hand hygiene, administering antiulcer meds, elevating head of bed, providing oral care per protocol
37. The home health nurse is planning a follow-up visit to the parents after their first-born and only child died from SIDS. Which action is most important for the nurse to include in the initial visit?
- allow time for listening to the parents and explore their concerns
43. A nurse is caring for a patient who is on mechanical ventilation. What actions will promote comfort in this patient?
- allow visitors at the bedside, ensure pt. Can communicate if awake, turn patient every 2 Hours, back and hand massages
26. Which type of croup is always considered a medical emergency?
- epiglottitis
30. What is a common trigger for asthma attacks in children?
- exercise
. When working with women who are taking hormonal birth control, which health promotion measures does the nurse teach to prevent possible pulmonary embolism?
- exercise on a regular basis, maintain a healthy weight, stop smoking cigs
27. Which intervention is appropriate for the infant hospitalized with bronchiolitis?
- give cool, humidified 02
24. Which statement made by a parent indicates an understanding about treatment of streptococcal pharyngitis?
- i should give penicillin 3 times a day for 10 days
. What explanation should the nurse give to a parent of a child with asthma about using a peak flow meter?
- it is used to monitor the child's breathing capacity
38. What is the earliest recognizable clinical manifestation of CF?
- meconium ileus
25. A 5-year-old child is brought to the emergency department with copious drooling and a croaking sound on inspiration. Her mother states that the child is very agitated and only wants to sit upright. What should be the nurses first action?
- prepare intubation equipment and call physician
44. The nurse is planning care for the child diagnosed with RSV. Which intervention should the nurse plan to implement?
- promotes rest by grouping activities, assess skin turgor and mucous membranes q4hr, gave oxygen to maintain >95%
23. The nurse expects the initial plan of care for a 9-month-old child with an acute otitis media infection to include:
- symptomatic treatment and observation for 48-72 hours after diagnosis
36. The nurse is closely monitoring the hospitalized infant who has acute Upper Respiratory Infection. The nurse's close monitoring is based on knowing that the infant has an increased risk for severe consequences due to which factor?
- the tracheal airway is narrower in an infant
50. Calculate the hourly rate of heparin. 40 units/kg/hr. The client weights 50 kg
-2000 units per hour
45. The nurse is assessing a client who has a serum potassium level of 4.5 mEq/L after CABG. Which action does the nurse take?
-Document the finding
40. After administering a new prescribed captopril (Capoten) to a patient with HF, the nurse implements interventions to decrease complications. Which priority intervention would the nurse implement for this patient?
-Instruct the patient to ask for assistance when rising from bed
42. What is the QRS complex in an ECG normally?
-Less than 0.12 seconds
45. The nurse should implement which interventions for an infant experiencing apnea?
-Maintain a neutral thermal environment, stimulate the infant by gently tapping the foot, have resuscitative equipment available
25. A nurse evaluates laboratory results for a pt. With HF. Which results would the nurse expect?
-Proteinuria, Serum sodium: 130 mEq/L, Hematocrit 32.8%, Microalbuminuria
48. The nurse is monitoring client undergoing an exercise electrocardiography (stress test). Which assessment finding necessitates that the test be stopped ?
-Significant ST EKG changes
21. A client is being discharged with oxygen therapy via nasal cannula. Which of the following instructions should the nurse give to the client and family
-Wear cotton clothes to prevent static electricity
49. A nurse cares for a client who is recovering from an MI the client states : i will need to stop eating so much chili to keep that indigestion pain from returning" how should the nurse respond?
-What do you understand about what happened to you?
49. A nurse assesses a pt with pericarditis which assessment finding would be expected?
-friction rub at the left lower sternal border
21. What is the normal measurement of the PR interval in an ECG?
0.12-0.2 seconds
Calculate the following children's dosage. Epinephone 2.5mg IV stat. Available is IV epinephrine 0.1mg/mL.
2.5 mL
1. A child is given 0.5mg/kg/day of prednisone divided into two doses. The child weights 10kg. How much is given in each dose?
2.5 mg
15. A 52 yo client with a history of hypertension has just had surgery. The physician orders hydrochlorothiazide 35 mg oral solution PO. The bottle for the hydrochlorothiazide reads 50mg/5ml. How many mL should the nurse give the patient.
3.5 mL
29. The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur?
4,2,1,3,5,6,7
29. What is the most common symptom in a client with an abdominal aortic aneurysm?
Abdominal pain
50. The nurse is monitoring the ECG of a client who has a MI. which changes does the expect to see in the ECG tracing?
Abnormal Q wave St-segment elevation T-wave inversion
6. A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?
Absent breath sounds
17. The nurse is assessing a client at risk for shock. The clients systolic BP is 20 mm hg lower than baseline, which intervention should the nurse perform first?
Administer O2
23. A nurse assesses a patient after administering isosorbide mononitrate(Imdur). The patient reports a headache, which action should the nurse take?
Administer PRN acetaminophen
7. The nurse is caring for a client who has hypovolemic shock. After administering O2, what is the priority intervention for this client?
Administer crystalloid fluids
40. The nurse is caring for a client who had an MI. The client develops increased pulmonary congestion and an increase in heart rate from 80-102 bpm, and cold, clammy skin. Which action does the nurse implement before notifying the HCP?
Administer oxygen
45. A nurse admits a client from the ED, client data is listed below. (picture) Which action by the nurse is the priority?
Administer oxygen at 4 liters/NC
36. The nurse is administering thrombolytic therapy to a client who had a MI. Which intervention does the nurse implement to reduce the risk of complications in this patient?
Administer prescribed heparin
18. The client who had a synthetic valve replacement a year ago is hospitalized with unstable angina, IV heparin and nitro infusions were started but then nitro was discontinued after the client's pain resolved. The HCP prescribes to start oral warfarin 5 mg at 1900 hours. Which is the nurses best action?
Administer the warfarin as prescribed
44. A nurse is interested in providing community education and screening on hypertension. IN order to reach a priority population, to what target audience would the nurse provide this service?
African-American churches
6. A client has undergone a nasal septoplasty 2 hours ago. It is a priority for the nurse to assess for which factor?
Airway patency
13. The nurse is preparing client for cardiac cath, which assessment is priority before the procedure
Allergies to iodine and shellfish
14. A patient in the ER has several broken ribs. What care measure will best promote comfort
Allowing the patient to choose the position in bed
15. A patient has been diagnosed with a very large PE and has a dropping BP. What meds should the nurse anticipate the patient will need as a priority
Alteplase (Activase)
49. The nurse is assessing a client whois displaying one of the earliest signs of carcinogenic shock. The nurse would document this assessment finding as:
Altered level of consciousness
17. Which description best defines the cardiac description afterload?
Amount of pressure or resistance ventricles overcome to eject blood in to peripheral blood vessels
46. A hospital nurse is participating in a drill which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering?
Amoxicillin (amoxil) Doxycycline (vibramycin) Ciprofloxacin (cipro)
45. A nurse assesses patients on a cardiac unit. Which patients would the nurse identify as the greatest risk for the development or acute pericarditis?
An 88 year old woman with a stage II sacral ulcer, An 36 year old with systemic lupus erythematosus, a 42 year old man recovering from coronary artery bypass graft surgery
A client is ordered to start receiving digoxin o.25 mg opo. What is the priority assessment y the nurse before administering the medication
Apical pulse
7. The nurse observes sinus tachycardia with new-onset ST segment elevation on the ECG monitor of the client reporting chest pain.
Apply 4 liters of oxygen via nasal cannula
40. During observation of a child who has undergone cardiac catheterization, the nurse notes significant bleeding from the percutaneous femoral catheterization site. Which action should be taken first?
Apply direct continuous pressure to the site
8. A patient had a femoral popliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection
Appropriate hand hygiene before giving care
48. A nurse is working with a patient who takes a Statin. Patient labs are elevated BUN of 33 and Ck of 2.8. What is the best action
Ask if the patient eats grapefruit.
7. A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first?
Ask the client to gargle with mouthwash containing lidocaine
10. Which of the following techniques will help a nurse with heart sounds during an assessment? Select all that apply
Ask the client to sit and lean forward Feel the radial pulse while listening to the heart sounds Turn the client to the left side lying position
3. A client reports waking up feeling tired even after 8 hours of good sleep. What is the nurses best action?
Ask the client whether he or she has ever been evaluated for sleep apnea.
13. A client was admitted two days ago with early stages of septic shock. Today the nurse notes that the client's systolic blood pressure, pulse pressure and cardiac output are decreasing rapidly. Which intervention does the nurse do?
Ask the clients family to come to the hospital because death is near initiate prescribed dobutamine IV drip
47. It is suspected that a client has bacterial pharyngitis. What is the best intervention?
Assess a rapid antigen test (RAT)
18. A client has returned from a cardiac angiography via the left femoral artery..... Left pedal pulse is weak. What is priority?
Assess color and temp of left leg
13. A patient is four hours post-op after a femoral popliteal bypass, the pt reports throbbing leg pain on the affected side rated a 7/10. Which action by the nurse takes priority?
Assess distal pulses and skin color
1. A high school athlete has suffered a nasal fracture. What is the priority action of the nurse caring for the client?
Assess for airway patency.
15. A nurse assistant reports to the nurse that an African-American clients pulse ox reading is 93%
Assess for other signs of respiratory adequacy
14. While assessing a pt on a cardiac unit a nurse identifies the presence of an S3 gallop what action would the nurse take next
Assess for symptoms on left-sided heart failure
8. A nurse is caring for a patient on a mechanical vent and finds the patient is agitated and thrashing about. What action by the nurse is most appropriated
Assess the cause of agitation
31. 8 hours after presentation to the ED with reports of substernal chest pain. A clients lab results demonstrate myoglobin levels of 55 mg/dl. What does the nurse do next?
Assess the client to identify another potential cause of the chest pain
8. The nurse is administering sodium nitroprusside IV to client who is in shock. What is the priority intervention?
Assess the client's blood pressure every 15 minutes
4. The nurse is caring for an older adult client with a pulmonary infection. Which nursing action is a priority with this client?
Assess the client's level of consciousness
26. A unlicensed assistive personnel was feeding a client with a tracheostomy. Later that day, the UAP reports that the client has a coughing spell. What is the nurse's priority action?
Assess the client's lung sounds
42. A client who is post percutaneous transluminal coronary angioplasty reports severe chest pain. Which action does the nurse take first?
Assess the client's vital signs and notify the health care provider
9. A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next?
Assess the clients gag reflex before giving any food or water
12. A nurse admits a patient who is experiencing an exacerbation of heart failure. What action would the nurse take first?
Assess the patient's respiratory status
50. What is the priority nursing intervention when caring for a client with severe acute respiratory syndrome (SARS)?
Assessing oxygenation
10. A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing up stairs.
Assistance with Activities of Daily Living
41. A client has a reduced serum high density lipoprotein and an elevated low density lipoprotein level. Which of the following medications does the nurse expect to be ordered for the client?
Atorvastatin
What does the P wave stand for in a EKG
Atrial depolarization
1. A nurse assesses a patient who has mitral valve regurgitation. For which cardiac dysrhythmia would the nurse assess?
Atrial fibrillation
32. A client's heart rate and rhythm is regular. What does the nurse assume from this finding?
Automaticity of the cells in the heart is normal
19.A client has a HR averaging 56 beats.min with no adverse symptoms. What activity modifications does the nurse suggest to avoid further slowing of the HR?
Avoid bearing down or straining while having a BM
13. A client with an MI has received a thrombolytic agent. What is the most important intervention by the nurse?
Avoid puncture wounds
24. Which of the following rhythms can be treated with synchronized cardioversion
B (Ventricular tachycardia)
42. The nurse is evaluating a three day diet history with a patient who has an elevated lipid panel. What meal selection indicates that the patient is managing this condition well with diet?
Baked chicken breast, broccoli, tomatoes
44. The nurse is assessing a client who had percutaneous transluminal coronary angioplasty 1 hour ago. Which complication does the nurse monitor for?
Bleeding
7. A nurse cares for a pt recovering from prosthetic valve replacement surgery the pt asks why will i need to take anticoagulants for the rest of my life? what is the best response for the nurse to make
Blood clots form more easily in artificial replacement valves
20. The nurse is assessing the client who just arrived by ambulance following a MVA. Which assessment finding should the nurse associate with possible pulmonary contusion
Bloody sputum
23. The nurse is caring for a pt. On a medical surgical unit and has suddenly become unresponsive and has no pulse. The cardiac monitor shows as below: What action does the nurse take next?
CPR
18. A post op client has a O2 saturation of 96% but is pale and dyspneic and says "I can't get enough air". What should the nurse do
Call the physician and request a hemoglobin and hematocrit level
12. Which assessment finding in a pt who has had a cardiac cath does the nurse report immediately to the provider
Cath extremity is dusky with decreased peripheral pulses
50. A patient is receiving warm and humidified oxygen. The RT informs the nurse that several patients on the unit have developed hospital infections Pseudomonas aeruginosa and has been identified as the organism. What is the priority action of the nurse?
Change the humidifier every 24 hours
48. The nurse assess a client with pneumonia and notes decreased lung sounds on the left side and decreased lung expansion what is the nurse's best action?
Check O2 saturation and notify the health care provider
46. The nurse is assessing a client who is 6 hour postoperative from CABG surgery. The clients mediastinal tubes are not draining, what does the nurse do next?
Check for kinks in the tubing
8. Two days ago the client underwent femoral-popliteal artery bypass graft surgery. What should the nurse's priority at this time be?
Check pedal and post- tibial pulses bilaterally every 4 hours
The nurse is taking the history of a client with suspected coronary artery disease. Which situation correlates with stable angina?
Chest discomfort when mowing the lawn and subsiding with rest.
35. The nurse is caring for a client with CAD, what assessment finding does the nurse expect is the client's MAP decreases below 60 mmHG?
Chest pain
28. A nurse administers medications to a client who has asthma. Which medication class is paired correctly?
Cholinergic antagonist- causes bronchodilation by inhibiting the parasympathetic nervous system
13. A student nurse is preparing to administer lovenox to a pt. that action by the student requires immediate intervention by the supervising nurse
Choosing an 18 gauge, 2 inch (5cm0 needle
35. Two diseases common to the etiology of COPD are:
Chronic bronchitis and emphysema
2. The nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?
Client has reduced breath sounds and the nurse calls the DR (is dr doctor?) immediately
13. A client develops epistaxis. Which conditions in the client's history could have contributed to this problem?
Cocaine use Hypertension
2. After facial trauma a client has a nasal fracture and is reporting constant nasal drainage, headache difficulty with vision. What is the nurse's priority action?
Collect the nasal drainage on a piece of filter paper
16. A patient who was in a MVA and sustained laryngeal trauma is being greater in the ER with humidified oxygen and is being monitored every 15 to 30 mins for respiratory distress. Which assessment finding indicates the urgent need for further intervention?
Confused and disoriented, difficulty producing sounds, pulse oximetry 80%
27. A nurse is assessing a patient with L sided HF. for which clinical manifestations would the nurse assess? Select all that apply?
Confusion, restlessness Pulmonary crackles Cough that worsens at night
33. A client has a new trach and is receiving 60% oxygen by a trach collar. Which assessment finding requires immediate action by the nurse?
Constant, non productive coughing
35. Client who presented with an acute MI is prescribed thrombolytic therapy. The client had a stroke 1 month ago. Which action does the nurse take?
Contact the health care provider to discontinue the prescribed therapy
8. While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse complete?
Contact the provider and prepare for intubation
54. After being discharged from the hospital the client is then diagnosed with TB at the outpatient client. What is the correct procedure regarding public health policy in this case?
Contract the public health nurse so that all individuals who have come in contact with the patient can be screened.
14. In a hypovolemic pt stretch receptors in the blood vessels since a reduced volume or pressure and send fewer impulses to the CNS as a result which s/s are present
Cool, pale skin and tachycardia
47. In caring for a client with cardiac problems the nurse knows that the condition most likely for an MI is ?
Coronary artery thrombosis
34. The most frequent symptom of lung cancer is
Coughing
4. A nurse is assessing a patient with peripheral artery disease. The patient states that walking five blocks is possible without pain. What question asked next by the nurse will give the best information?
Could you walk further than that a few months ago?
23. While assessing a client who is 12 hours post op after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first?
Cover the insertion site with sterile petrolatum gauze
24. The nurse is caring for a client with a new trach. Which assessment finding requires the nurses immediate action?
Crackling sensation around the neck when skin is palpated
26. A client has a consistently regular heart beat of 128 BPM, which related physiologic alterations does the nurse assess for?
Decrease CO, decrease in BP
31. The client is being given a drug that blocks the action of the sympathetic nervous system which finding does the nurse expect
Decreased HR
5. The nurse determines that a client at risk for the development of carcinogenic shock would present with which of the following?
Decreased cardiac index
34. A client has a consistently regular heart rate of 158 bpm. Which related physiologic alteration does the nurse assess for?
Decreased cardiac output, Decreased blood pressure
28. A client is wearing a venturi mask to deliver their oxygen during dinner. Which intervention is best
Determine if the client can switch to a nasal cannula during the meal
34. The hospitalized child with severe asthma has ABG's of pH= 7.30, PaCO2=49 mm Hg, and HCO3= 24 mEq/L. Which signs and symptoms noted during the assessment should the nurse associate with the results?
Diaphoresis, headache, tachycardia, confusion, restlessness, apprehension, flushed face
30. The emergency department nurse is assessing an 82-year-old client for a potential MI. Which clinical manifestation does the nurse monitor for?
Disorientation or confusion
37. A patient had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates that a priority outcomes for this patient has been met?
Distal pulse on affected extremity 2+/4+
21. A client who has a local infection of Rt arm is getting discharged. what Teachings should to seek care if what happens
Dizziness on changing position
27. The nurse is assessing a client with stable angina, client talked about recent increase in attacks and intensity of pain. Which question should the nurse ask?
Do you have pain when you are resting
29. The nurse hears a splitting of s1 on auscultation of a young adult client. Which is the nurses best action?
Document the finding
37. The client's heart rate increases slightly during inspiration and decreases slightly during expiration. What action will the nurse take?
Document the finding as the only action
22. A nurse prepares a patient who is scheduled for a bronchoscopy procedure at 9:00 am the actions would the nurse take? (select all that apply)
Document the patient's allergies Verify that the informed consent was obtained Review laboratory results
31. Which possible complications and hazards of home oxygen therapy will the nurse plan to teach the client prior to their discharge to home?
Dried mucous membranes Absorption atelectasis Toxicity Combustion
51. A client is admitted with left lower lung pneumonia which assessment finding does the nurse correlate with this condition?
Dullness to percussion on the lower left side
2. A nurse assess a patient with mitral valve stenosis, what clinical manifestation would alert the nurse that the condition has progressed?
Dyspnea on exertion
37. The nurse is assessing the client who is in early stages of hypovolemic shock. Which manifestations does the nurse expect
Elevated heart rate Elevated diastolic blood pressure
22. The nurse is assessing a client who is in the early stages of hypovolemic shock. Which manifestations does the nurse expect?
Elevated heart rate, elevated diastolic blood pressure
24. A nurse assesses a client who is prescribed fluticasone (FloVent) and notes oral lesions. Which action should the nurse take?
Encourage oral rinsing after fluticasone administration
16. The nurse is planning to care for a client with late-phase septic shock. All of the following treatments have been prescribed. Which prescription should the nurse question?
Enoxaparin (Lovenox) 40 mg Subcutaneous twice daily
11. A patient has been brought to the ER with a life threatening chest injury. What action by the nurse is priority
Ensure a patent airway
9. A nurse is preparing to admit a patient on a mechanical vent from the ER. What action by the nurse takes priority
Ensuring that there is a bag-valve mask in the room
38. The nurse reads a client mantoux skin test as positive. The nurse notes that previous test were negative. The client becomes upset and asks the nurse what this means. The Nurse best response to the client is?
Exposure to TB
28. Truncus arteriosus a non cyanotic defect
False
12.Which of the following are symptoms of aortic stenosis? Select all that apply
Fatigue, palpitations, murmur
6. S1 and S2
First and second heart sounds
30. A home health nurse is visiting a new client who uses oxygen in the home. Which factor does the nurse assess when determining if the client is using the oxygen safely?
Flammable liquids are stored in appropriate containers in the garage Client does not allow smoking in the house Electrical cords are in good working order
22. The nurse is caring for the child who is postoperative tonsillectomy and adenoidectomy surgery. The nurse should further explore for signs of hemorrhage when obtaining which assessment finding?
Frequent swallowing and clearing of throat
26. The nurse is caring for 4 hypertensive patients. Which drug-laboratory value combination would the nurse report immediately to the healthcare provider?
Furosemide (lasix)/potassium: 2.1 mEq/L
16. A nurse teaches a patient with heart failure about energy conservation. Which statement would the nurse include in the patient's teaching?
Gather everything you need for a chore before you begin
31. The client with asthma has pronounced wheezing and sings of a possible impending asthma attack. Which intervention should the nurse implement first?
Give an inhaled beta-2 adrenergic agonist
34. A nurse is caring for a patient with CAD, the patient reports palpitations and chest discomfort and the nurse notes a tachydysrhythmia on the EC monitor, what does the nurse do next?
Give supplemental oxygen (O2)
28. Determine normal dosages range to the nearest tenth. 10kg is to get 0.5g in 100ml q6hr. Range is 100-200 mg/kg/day. What is the course of action?
Give the medication, the dosage is in the safe ranged
53. A patient who had sinus surgery has a surgical incision under the upper lip. The nurse intervenes when a well intentioned family member performs which cation in attempting to make the patient feel better?
Hands the patient a couple of tissues to blow their nose
42. The nurse assesses a client during suctioning. Which finding indicates that the procedure should be stopped?
Heart rate decreases from 78 to 40 beats/minute.
37. A client hospitalized for a severe case of pneumonia is asking a nurse why a sputum sample is needed. The nurse should reply that the primary reason is to
Help select the appropriate antibiotic
15. The nurse is caring for a client in the hyperdynamic phase of septic shock. Which medication does the nurse expect to be prescribed
Heparin sodium
23. Which condition is linked to more than 50% of client with abdominal aortic aneurysms?
Hypertension
What is the significance of a sodium level 130 meq/L for a patient with heart failure?
Hyponatremia due to excessive fluid and fluid retention
13. A nurse collaborates with a respiratory therapist to complete a PFT for a client. Which statement should the nurse include in his/her communications with the respiratory therapist prior to the start of the tests? (Select all that apply)
I held the client morning bronchodilator medication The client is alert and can follow your commands I advise the client to not smoke for 6 hours prior to the test
17. After teaching a pt with congestive HF, the nurse assesses the pts understanding. Which patient statement indicates a correct understanding of the teaching related to nutritional intake?
I'll read the nutritional labels on food items for salt content, I will eat oatmeal for breakfast instead of ham and eggs, Substituting fresh vegetables for canned ones will lower my salt intake"
43. A family member has been taught to provide oral care to a client with a trach which statement by the family member indicates accurate understanding of oral care?
I'll use water and a toothette
29. The nurse assess the client using the device pictured to deliver 50 % ox The nurse finds the mask fits snugly, the skin under the mask and straps in intact and the flow rate of the oxygen is 3L/min. What is the action by the nurse?
Immediately increase the O2 flow rate
19. The nurse is providing community education for clients at risk for dehydration. One client states, "we are not at risk because we live in a hot and dry climate." What is the nurse's best response?
In a hot and dry environment the body can lose an increased amount of water without your knowledge
33. The home health nurse is visiting a client whose chronic bronchitis has recently worsened due to not following previous instructions, which instruction should the nurse reinforce?
Increase fluid intake to 3 liters
6. The nurse is monitoring a client in hypovolemic shock who has been placed on a dopamine hydrochloride drip. Which manifestations is a desired response to this med?
Increase in cardiac output
4. The nurse is planning care for a client in cardiogenic shock. What is the priority goal?
Increase myocardial oxygen supply
25. A nurse cares for a client with a 40 year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this clients history and clinical manifestations?
Increase pulmonary pressure creating a higher workload on the right side of the heart
4. A patient is on IV heparin to treat a PE. The patient most recent PTT was 25 secs. What order should the nurse anticipate
Increase the heparin rate
40. The nurse has administered a drug that causes vasoconstriction, which finding indicates an expected response?
Increased blood pressure
33. A client's heart disease has resulted in a reduction of stroke volume. Which compensatory mechanism is expected?
Increased heart rate
23. A client has septic shock which hemodynamic diameters does the nurse correlate with this type of shock?
Increased serum lactate, increased blood pressure, and decrease cardiac output
3. The nurse is assessing a client who has hypovolemic shock. Which lab value indicates that the client is at risk for acidosis?
Increased serum lactic acid
49. The nurse is teaching a client with pneumonia way to clear secretions. Which intervention would be the most effective?
Increasing fluids to 2 L/day if tolerated
30. A nurse evaluates the following ABGs and vital sign results for a client with COPD: chart
Initiate oxygenation therapy to increase saturation to 92%
3. Which of the following drug classes should be administered to a client with heart failure ot maximise cardiac contractility performance ?
Inotropic agents
38. A client receiving high flow oxygen has new crackles and diminished breath sounds since the last assessment 1 hour ago. Which action by the nurse is most appropriate?
Instruct the client to use the spirometer and to cough and deep breath
46. The S1 sound is? Select all that apply.
Is best heard at the apex, is the closing of the tricuspid and mitral valves, Is the beginning of systole
25. What is the St segment in the ECG normally?
Isoelectric (flat)
44. The nurse performs an admission assessment on a 75 y/o pt with multiple chronic diseases the pts BP is 135/75 mmhg and oxygen
It is a picture of an EKG and the answer is 50 (determine the heart rate)
2. Which of the following la results should be reported to the provider indicating a heart attack
Lab chart - troponin T and CK-MB
47. After an anterior wall MI which problem is indicated by auscultation of crackles in the lungs?
Left sided heart failure
32. The client newly diagnosed with asthma is preparing for discharge. Which point should the nurse emphasis during the clients teaching?
Limit your exposure to sources that might trigger an attack
45. The nurse has prepared medication for a 75 year old patient with hypertension. The nurse notes that the client's potassium is 5.9 mg/dL. Which medication should the nurse administer?
Lisinopril
16. Where to listen for an aortic regurgitation?
Location A, top of sternum
23. Match the type of oxygen delivery device with the correct definition:
Look up O2 devices and what you need with each one, including O2 % or L
49. The nurse is administering oxygen to a patient who is hypoxic and has chronic high level of carbon dioxide. Which oxygen therapy prevents a respiratory complication for this patient?
Lower concentration of oxygen (1-2 L/min) per nasal cannula
1.The nurse obtains the health history of a client who was recently diagnosed with lung cancer. The nurse identifies that the patient has a 60 year pack history. What is the most important action when interviewing the client?
Maintain a non judgemental attitude to avoid causing the client to feel guilty
9. A client develops posterior nasal bleeding and has packing inserted. Which is the nurse's priority action?
Make sure the packing string is taped to the patient's cheek
10. A nurse teaches a client to use a room humidifier after a laryngectomy, which statement should the nurse include in this client's teaching?
Make sure you clean the humidifier to prevent infection
25. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?
Measure and compare cuff pressures
41. Which measure is most accurate when assessing a patient for fluid retention?
Measuring and monitoring daily patient weight
47. The nurse is caring for a 8- yr old who had a coronary artery bypass graft surgery. What is the priority.
Mental status
17. A client tells the nurse that he usually expectorates about 2 ounces of thin clear colorless sputum each day mostly in the morning after getting out of bed. What is the nurse's initial action after gaining this information?
Monitor for an increase in sputum production or a change in color
33. A patient has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What responses by the nurse is best?
Most people with hypertension do not have symptoms
3. An older pt with peripheral vascular disease is explaining the daily foot care regimen to the family practice nurse what statement by the pt may indicate need for further learning
My hands shake when i try to do things requiring coordination"
45. The nurse is assessing a client newly admitted to the medical unit. Which statement made by the client alerts the nurse to the presence of edema?
My shoes fit tighter by the end of the day"
16. A client's rhythm strip shows a regular rhythm with atrial and ventricular rates of 70 bpm, a PR interval of 0.28 seconds, and a QRS duration of 0.08 seconds. The nurse interprets this rhythm as:
Normal sinus rhythm with a first degree AV block
34. The nurse is providing care for a client admitted to the hospital with reports of chest pain. After receiving a total of three Nitroglycerin sublingual tablets, but the pain doesn't subside. What does the nurse do next?
Notify the health care provider
11. A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with cyanosis even with oxygen therapy. What action should the nurse take first?
Notify the rapid response team
49. The nurse is planning a community health promotion program for cardiovascular disease. Which risk factors of coronary artery disease does the nurse include in the education?
Obesity, cigarette smoking, hypertension
11. The nurse is assessing a client who is 6 hours post op for a nasal fracture. The client has facial pain 5/10 and nasal packing in place
Observe for clear drainage. Observe the client for frequent swallowing Assess for signs of bleeding
11. A client who has septic shock is admitted to the hospital. What priority intervention does the nurse implement first?
Obtain two sets of blood cultures
3. A nurse assesses a client's respiratory status. Which information is of highest priority for the nurse to obtain?
Occupation and hobbies
42. An older adult is brought to the Emergency Department by a family member who reports a moder change in mental status and a mild cough. The client is afebrile. The health care provider order a chest xray the family member questions why is is needed since the manifestations seem so vague. What is the best response by the nurse?
Older people often have vague symptoms so an x-ray is essential
26. A client with heart failure will exhibit which of the following?
Oliguria
38. The nurse is assisting a client to walk in the hall on the third day after an MI. Which clinical manifestation indicates to the nurse that the client is not ready to advance to the next level of activity?
Onset of chest pain
12. The nurse is assessing a client who was admitted for treatment of shock. Which manifestation indicates that the client's shock is caused by sepsis?
Oozing of blood at the IV site
6. A nurse assess a patient who is diagnosed with infective endocarditis. What findings would you expect?
Osler's nodes, cardiac murmur, night sweats
48. A patient has been receiving 100% oxygen by way of a nonrebreather mask for several days he complain of chest pain..
Oxygen toxicity
33. The client is admitted with an ACS. Which assessment finding should be the nurse's first priority?
Pain
35. A nursing student is caring for person with abdominal aneurysm. what cation caused RN to intervene?
Palpates the abdomen in four quadrants
43. A student nurse is assessing the peripheral vascular system of an older adult. WHich actions by the student would cause the faculty member to intervene?
Palpating both carotid arteries at the same time
10. A nurse is caring for 4 patients. Which should you see first?
Patient who had a 1st dose of captopril (capoten) and needs to use the bathroom
37. A client has been brought in to the ER. client is having a acute exacerbation of COPD and is SOB. on arrival the client is on 15 L of O2 via rebreather. What is the priority.
Perform a thorough respiratory assessment and attach pulse oximetry
31. The nurse is assessing a patient on admission to the hospital. The patient's leg is shown below. What action by the nurse is best?
Picture of a ugly ass foot with a burnt toe, but the answer is assess the patient ankle-brachial index and pulses
6. The nurse sees the following rhythms (Sinus tachycardia), first action is to?
Picture- Check for a pulse
40. The nurse is preparing to admit a post op client from surgery who just had a trach placed. Which action by the nurse is HIGHEST priority?
Place a second tracheostomy tube and obturator at the bedside
39. At 0745 hours the nurse in informed by the health care provider that a cardiac cath is to be completed on the client at 1400 hours which intervention should be the nurse priority?
Place the client on NPO status
11. A nurse is teaching a client about atherosclerosis. The nurse determines further teaching is necessary when?
Plaques obstruct the veins
6. A nurse is caring for 4 patients on IV heparin. Which value possibly indicates a serious side effect has occurred.
Platelet Count 82,000/ L
19. Lower lobe lung sounds are primarily heard in what area of the body?
Posterior back.
20. The nurse evaluates her teaching by asking the nursing student which term is used to describe the amount of stretch on the myocardium at the end of diastole. Which is the most accurate response?
Preload
21. The nurse assesses the client brought to the ER via ambulance after a motorcycle crash. The client has a paradoxical chest movement with resps, multiple bruises across the chest, torso, crepitus, and tachypnea. What should the nurse do next
Prepare for the clients imminent intubation
5. A patient is hospitalized with a second PE. Recent genetic testing reveals that the patient has an alteration in gene CYP2C19. What action by the nurse is best?
Prepare preoperative teaching for an inferior vena cava filter
17. A patient is brought to the ER after sustaining injuries in a MVA. The patient's chest wall does not appear to be moving normally with respirations, SpO2 is 82% and patient is cyanotic. What action by the nurse is the priority.
Prepare to assist with intubation
18. A nurse is helping a client with obstructive sleep apnea to apple a CPAP mask before going to sleep. The nurse knows that a CPAP is intended to
Prevent alveolar collapse
9. The nurse is preparing to administer sodium nitroprusside (Nipride) to a client. Which important action related to the administration of this drug does the nurse implement?
Protect the medication from light with an opaque bag.
12. A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this client's plan of care?
Provide a diet high in protein and vitamins Avoid places that have crowds of people Ambulate the client 3 times a day Encourage deep breathing a coughing
52. What is the best way for the nurse to decrease the risk of ventilator-associated pneumonia in a ventilator dependent client?
Provide frequent oral care Keep head of bed elevated Maintain good hand hygiene
7. A patient is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel.
Provide frequent oral care per protocol
32. A client is becoming frustrated because of an inability to communicate with a tracheostomy. Which intervention by the nurse most effectively enhances communication?
Provides the client with a communication board and call light within easy reach.
27. A patient with Afib suddenly develops shortness of breath, chest pain, hemoptysis and feeling of impending doom. What should the nurse recognize these symptoms as?
Pulmonary embolism
20. What is the total time required for ventricular depolarization and repolarization on the ECG?
QT interval
34. A client has been placed on 6 L of humidified oxygen via nasal cannula which action by the nurse is most appropriate?
Remove condensation in the tubing by disconnecting and emptying it appropriately
15. The nurse is assessing a patient with significant and obvious facial trauma after being stuck repeatedly in the face which finding is priority and requires immediate action?
Restlessness with high pitched respirations
30. The student nurse is looking at a patient's ECG and suspects a normal sinus rhythm. Which ECG criteria are included for NSR?
Rhythm: atrial and ventricular rhythms regular, p waves: present, consistent configuration one P wave before each QRS; QRS duration or width 0.04 to 0.10 seconds
31. A nurse is assessing a bedridden client and notes sacral edema. The nurse determines that the edema is most likely caused by what?
Right sided heart failure
5. A client who has acidosis resulting from hypovolemic shock has been prescribed intravenous fluid replacement. Which fluid does the nurse prepare to administer?
Ringer's lactate
2. The nurse is caring for multiple clients in the emergency department. The client with which condition is at highest risk for distributive shock?
Severe head injury from a motor vehicle accident
21. A nurse cares for a client with COPD. the client states that he no longer likes to go out with his friends. How should the nurse respond?
Share any thoughts and feelings that cause you to limit social activities
12. The client with which conditions requires immediate nursing interventions? (select all that apply)
Shortness of breath Stridor Sternal retraction Respiratory rate of 8 beats/min
38. The client presents with HR of 40 bpm. The nurses suspects that an elctro study will find a problem in what structure?
Sinoatrial (SA) node
3. A nurse assesses a patient's ECG and observes the reading below
Sinus rhythm w/PVCs
24. A nurse is caring for a patient with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure would the nurse implement?
Sit the patient up with a pillow to lean forward on
17. A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in the clients teaching? (Select all that apply).
Sleep in a semi fowler's position after surgery Eat six soft liquid meals each day after recovering You will need to cut the wires if you start vomiting Irrigate your mouth every 2 hours to prevent infection
21. A client has a baseline heart rhythm of A-FIB. What is the priority finding from the assessment that should be reported to the healthcare provider
Slurred speech
19. The client with a left anterior descending 90% blockage has crushing chest pain that is unrelieved by taking sublingual nitro. What ECG finding...
St segment elevation
29. A nurse cares for a patient with infective endocarditis. Which infection control precautions would the nurse use?
Standard precautions
27. The nurse assess a client who has a trach. The nurse notes that the trach tube is pulsating in synchrony with the clients heartbeat no other abnormal finding notes which is priorpity?
Stay with the client and have someone else call the provider immediately
12. A nurse is teaching a patient about warfarin . what assessment finding by the nurse indicates a possible barrier in self management
Strict vegetarian
41. The nurse is teaching a family member how to suction the client's tracheostomy at home. Which information does the nurse include in the teaching plan?
Suctioning with clean technique is acceptable
48. The nurse is discussing healthy lifestyle practices with the client who has chronic venous insufficiency. Which practices should be emphasized with this client?
Take rests and elevate the legs while sitting Wear graduated compression stockings, removing them at night Sleep with legs elevated above the level of the heart
48. The nurse is planning discharge education for a client after CABG surgery. Which instruction does the nurse include in the client's teaching?
Take your pulse before, midway through, and after exercising
39. A nurse prepares a client for coronary artery bypass graft surgery the client states "I am afraid I might die" how might the nurse reply?
Tell me more about your concerns about the surgery
24. Regular humulin insulin 10 units/hr IV available: 40 units of insulin in 100mL 0.9% NS what rate in mL
The answer is 2.5
33. While evaluating a client's ECG before surgery, the pre-op nurse identifies large, wide Q waves. What is the nurse's best interpretation of the findings?
The client had a myocardial infarction in the past
43. The nurse is caring for multiple clients. Which client would the nurse identify as having the greatest risk for developing a DVT?
The client post op hip arthroplasty who has venous insufficiency and immobile, platelet is 550,000
32. The client with Raynaud's disease is seen in a vascular clinic six weeks after nifedipine has been prescribed. The nurse evaluates that the mediation has been effective when which findings are noted?
The client's states experiencing less pain and numbness
35. The nurse assesses a client who is receiving oxygen via a partial rebreather mask. Which assessment finding does the nurse intervene to correct?
The oxygen flow rate is 2 L/min
8. A client has undergone a thoracentesis. Which assessment finding requires immediate action by the nurse?
The trachea is deviated toward the opposite side of the neck
4. A client who is scheduled for an echocardiography today asks
This is a noninvasive way to assess structure of heart
A client with acute pulmonary edema has been taking an angiotensin converting enzyme (ACE) inhibitor. The nurse teaches him that his medication has been ordered for which reason?
To reduce blood pressure
15. The nurse is reviewing the lipid panel of a male patient who has atherosclerosis. Which finding is most concerning?
Triglycerides: 198 mg/dL
22.What is the most significant and earliest lab marker in a patient who has had an MI?
Troponin T and I levels of 0.9 ng/mL
32. The nurse evaluates the diagnostic results for a client who has chest pain which lab test is most specific and quickest for acute coronary syndrome?
Troponin markers
17. One of the first treatments of coarctation of the aorta is administration of prostaglandin E
True
44. Most edema in tricuspid atresia is in the legs and abdomen
True
9. Hypoplastic left heart syndrome can cause brain abnormalities.
True
4 A client has open vocal cord paralysis. Which techniques does the nurse teach the client to do to prevent aspiration?
Tuck the chin down when swallowing
16. A key characteristic feature of ARDS is
Unresponsive arterial hypoxemia
39.a nurse is assessing a client who has left ventricular failure secondary to a MI. which clinical manifestation of poor organ perfusion does the nurse monitor for in this client?
Urine output of less than 30mL/hr
36. The client has a productive cough, fever, chills and a history of night sweats. The clients PPD test is negative. What is the nursers best intervention related to infection prevention?
Using a standard and airborne precautions until TB can be ruled out
7. A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?
Validate that informed consent has been given by the client
36. What does the T wave on an ECG represent
Ventricular Repolarization
38. The nurse sees the following rhythm she recognizes it to be _____ and knows the intervention is _____. It is a picture
Ventricular fibrillation and defibrillation
27. What defect is a hole in the wall separating the two lower chambers of the heart?
Ventricular septal defect
44. A client is being discharged on long term therapy for TB. What referral by the nurse is most appropriate?
Visiting nurses for directly observed therapy
50. Which statements by the patient indicate good understanding of foot care in peripheral vascular disease?
Washing my feet in room temperature water is best, Lotion is important to keep my feet smooth and soft, i will keep my feet dry especially between my toes
5. The nurse is observing thee client performing stoma care for a laryngectomy or the first time. Which action does the nurse reinforce?
Washing the stoma with soap and water
33. The nurse educates parents about the nutritional needs of their child with CF. Which response by a parent indicates an understanding of the child's nutritional needs?
We will need to prepare a lot of meat and carbohydrates, some fat
14. At what stage of fetal development does this heart defect happen?
Week 1-8
20. A nurse teaches a patient who has a history of heart failure. Which statement would the nurse include in the patient's discharge teaching?
Weigh yourself daily while wearing the same amount of clothing
4. A client brought to the ED after a motor vehicle accident is suspected of having internal bleeding. What question does the nurse ask to determine if the patient is in the early stages of hypovolemic shock?
What is your normal heart rate?"
14. The nurse is providing care after auscultating a client's breath sounds. Which assessment finding has been correctly link to the nurse's primary intervention for it?
Wheezes are heard in the central areas of the lungs. The nurse administers an inhaled bronchodilator
42. The nurse auscultates the first heart sound and interprets the first heart sound as occurring:
With the closure of the mitral and tricuspid valves
16. The nurse is caring for several clients on a respiratory unit. Which client does the nurse see first?
Young adult with an arterial oxygen level of for a 85%
41. After teaching a patient who is recovering from a heart transplant to change positions slowly, the patient asks "why is this important". how would the nurse respond?
Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes
Which statement indicates that a parent of a toddler needs more education about preventing foreign body aspiration?
my toddler loves to play with balloons
35. The mother of a 2-year-old telephones the clinic to ask advice. The child has a temperature of 104 degrees F (40 degrees C) and a sore throat and has been drooling for a few days. The child is now sleepy. Which is the best advice by the nurse?
take your child to a emergency department immediately
28. The nurse encourages the mother of a toddler with acute LTB to stay at the bedside as much as possible. The nurse's rationale for this action is primarily that
the mother's presence will decrease anxiety
39. Which vitamin supplements are necessary for children with cystic fibrosis?
vitamins A,D,E,K
37. The nurse is assessing a client who has been prescribed a non-selective beta blocking agent. Which adverse effect does the nurse monitor the client for?
wheezing
