Med surg2 exams
The nurse is caring for a client admitted with angina who is scheduled for cardiac catheterization. The client is anxious and asks the reason for this test. What is the best response?
"Cardiac catheterization is usually done to assess how blocked or open a client's coronary arteries are."
A mother calls the clinic asking for a prescription for amoxicillin for her 2-year-old son who has what the nurse suspects to be viral rhinitis. What should the nurse explain to this mother?
"I'll certainly inform the doctor, but if it is a cold, antibiotics won't be used because they do not affect the virus." Explanation: Antimicrobial agents (antibiotics) should not be used because they do not affect the virus or reduce the incidence of bacterial complications. In addition, their inappropriate use has been implicated in development of organisms resistant to therapy. It would be inappropriate to tell the client that the physician will not respond to her request.
A client's severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the client's statements suggests a need for further education?
"I'll make sure to use this each time I feel an asthma attack coming on."
The nurse is assessing a client whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this client?
A barrel chest
The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration?
A resident who suffered a severe stroke several weeks ago
A client is brought to the ED by ambulance after a motor vehicle accident in which the client received blunt trauma to the chest. The client is in acute respiratory failure, is intubated, and is transferred to the ICU. What assessment parameters should the nurse monitor most closely? Select all that apply.
Arterial blood gases Level of consciousness Vital signs
A perioperative nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication?
Atelectasis
A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma?
Bilateral wheezes
A clinic nurse is caring for a client who has just been diagnosed with chronic obstructive pulmonary disease (COPD). The client asks the nurse what he could have done to minimize the risk of contracting this disease. What should the nurse describe as the most significant risk factor?
Cigarette smoking
A nurse is caring for a client who is exhibiting ventricular tachycardia (VT). Because the client is pulseless, the nurse should prepare for what intervention?
Defibrillation
The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)?
Early ambulation
An asthma nurse educator is working with a group of adolescent asthma clients. What intervention is most likely to prevent asthma exacerbations among these clients?
Educating clients about recognizing and avoiding asthma triggers
A nurse is evaluating the diagnostic study data of a client with suspected cystic fibrosis (CF). Which of the following test results is associated with a diagnosis of cystic fibrosis?
Elevated sweat chloride concentration
The ED nurse is caring for a client who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform?
Ensure no one is touching the client at the time shock is delivered.
When planning the care of a client with an implanted pacemaker, what assessment should the nurse prioritize?
Heart rate and rhythm
The perioperative nurse has admitted a client who has just underwent a tonsillectomy. The nurse's postoperative assessment should prioritize which of the following potential complications of this surgery? Hemorrhage
Hemorrhage
The nurse is caring for a client whose recent unexplained weight loss and history of smoking have prompted diagnostic testing for cancer. What symptom is most closely associated with the early stages of laryngeal cancer?
Hoarseness Explanation: Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Alopecia is not associated with a diagnosis of laryngeal cancer.
The nurse is caring for a client who has just been diagnosed with sinus bradycardia. The client asks the nurse to explain what sinus bradycardia is. What would be the nurse's best explanation?
In many clients a heart rate slower than 60 beats per minute is considered to slow to maintain an adequate cardiac output.
The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis?
Incentive spirometry
A client visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the client to perform what action?
Increase fluid intake.
A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do?
Increase oral fluids unless contraindicated.
The nurse is planning the care of a client who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis?
Ineffective airway clearance related to airway alterations
The nurse is assessing a client who had a pacemaker implanted 4 weeks ago. During the client's most recent follow-up appointment, the nurse identifies data that suggest the client may be socially isolated and depressed. What nursing diagnosis is suggested by these data?
Ineffective coping related to pacemaker implantation
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily?
Intubate the client and control breathing with mechanical ventilation
The case manager for a group of clients with COPD is providing health education. What is most important for the nurse to assess when providing instructions on self-management to these clients?
Knowledge about self-care and their therapeutic regimen
During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where should the nurse best palpate the PMI?
Left midclavicular line of the chest at the fifth intercostal space
The physical therapist notifies the nurse that a client with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a client with CAD may result in what?
Myocardial ischemia
A client has had a myocardial infarction and has been diagnosed as having damage to the layer of the heart responsible for the pumping action. This client experienced damage to what area of the heart?
Myocardium
The student nurse is preparing a teaching plan for a client being discharged status post MI. What should the nurse include in the teaching plan? Select all that apply.
Need for careful monitoring for cardiac symptoms Need for dietary modifications Need for carefully regulated exercise
A firefighter was trapped in a fire and is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of ARDS and is intubated. What other supportive measures should be initiated in this client?
Nutritional support
A 45-year-old obese man arrives in a clinic reporting daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of what health problem?
Obstructive sleep apnea Explanation: Obstructive sleep apnea occurs in men, especially those who are older and overweight. Symptoms include excessive daytime sleepiness, insomnia, and snoring. Daytime sleepiness and difficulty going to sleep at night are not indications of tonsillitis or adenoiditis. This client's symptoms are not suggestive of laryngeal cancer.
The nurse is explaining the safe and effective administration of nasal spray to a client with seasonal allergies. What information is most important to include in this teaching?
Overuse of nasal spray may cause rebound congestion. Explanation: The use of topical decongestants is controversial because of the potential for a rebound effect. The client should hold his or her head back for maximal distribution of the spray. Only the client should use the bottle.
The nurse is caring for a client with bronchiectasis. Chest auscultation reveals the presence of copious secretions. What intervention should the nurse prioritize in this client's care?
Postural chest drainage
The nurse is performing preoperative teaching with a client who has cancer of the larynx. After explaining the most important information, what is the nurse's best action?
Provide the client with audiovisual materials about the surgery.
A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD?
Respiratory failure
The nurse's assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should consequently identify what nursing diagnosis in the client's plan of care?
Risk for falls related to orthostatic hypotension
A client comes to the ED and is admitted with epistaxis. Pressure has been applied to the client's midline septum for 10 minutes, but the bleeding continues. The nurse should anticipate using what treatment to control the bleeding?
Silver nitrate application
The nurse uses which term for the normal pacemaker of the heart?
Sinoatrial (SA) node
A nurse is developing a teaching plan for an adult client with asthma. Which teaching point should have the highest priority in the plan of care that the nurse is developing?
Take prescribed medications as scheduled.
The nurse is caring for a client with a diagnosis of pleurisy. The client begins reporting right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What is the nurse's best action?
Teach the client to splint the rib cage
An adult client has tested positive for tuberculosis (TB). While providing client teaching, what information should the nurse prioritize?
The importance of adhering closely to the prescribed medication regimen
The nurse is providing client teaching to a young mother who has brought her 3-month-old infant to the clinic for a well-baby checkup. What action should the nurse recommend to the woman to prevent the transmission of organisms to her infant during the cold season? Take preventative antibiotics, as prescribed. Gargle with warm salt water regularly. Dress herself and her infant warmly. Wash her hands frequently.
Wash her hands frequently.
A client with a history of right-sided heart failure lives in a long-term care facility. In the daily assessment, the nurse is required to record the level of this client's peripheral edema. Which would be the main area for examination?
feet and ankles
A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What type of dysrhythmia would the cardiologist likely diagnose?
sinus tachycardia
