medsurg exam 5
A client has been receiving heparin therapy is also started on warfarin sodium (coumadin). The client asks why both medications are being administered. In formulating a response, the nurse incorporates the understanding that warfarin sodium : a. stimulates the breakdown of specific clotting factor by the liver, and it takes 2-3 days for this to exhibit an anticoagulant effect. b .inhibits the synthesis of specific clotting factors in the liver, and it takes 3 to 4 days for this medication to exert an anticoagulation effect c. stimulates production of the body's own thrombolytci substance but it takes 2- 4 days to begin
.inhibits the synthesis of specific clotting factors in the liver, and it takes 3 to 4 days for this medication to exert an anticoagulation effect
A recommended follow-up for a person initially diagnosed with prehypertension is for a blood pressure (BP) recheck within which timeframe? a) Confirm within 2 months b) 2 year c) 1 year d) Evaluate within 1 month
1 year
When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of: a) 2.5 to 3.0 times the baseline control. b) 3.5 times the baseline control. c) 4.5 times the baseline control. d) 1.5 to 2.5 times the baseline control.
1.5 to 2.5 times the baseline control.
The nurse is administering lispro (Humalog) insulin. Based on the onset of action, how soon should the nurse administer the injection prior to breakfast? a) 10 to 15 minutes b) 30 to 40 minutes c) 1 to 2 hours d) 3 hours
10 to 15 minutes
A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is: a) 190 mm Hg/120 mm Hg b) 185 mm Hg/110 mm Hg c) 175 mm Hg/100 mm Hg d) 170 mm Hg/105 mm Hg
190 mm Hg/ 120 mm Hg
The nurse is teaching a patient diagnosed with hypertension about the DASH diet. How many servings of meat, fish, and poultry should a patient consume per day? a) 2 or fewer b) 4 or 5 c) 2 or 3 d) 7 or 8
2 or fewer
When caring for a patient who has started anticoag therapy with warfarin (coumadin) the nurse knows not to expect therapeutic benefits: a. at least 12 hours b. the first 24 hours c. 2-3 days d. 1 week
2-3 days
When the dawn phenomenon occurs, the patient has relatively normal blood glucose until approximate what time of day? a) 9 AM b) 3 AM c) 7 AM d) 5 AM
3 am
Which of the following statements is true regarding gestational diabetes? a) A glucose challenge test should be performed between 24 and 28 weeks. b) There is a low risk for perinatal complications. c) Its onset is usually in the first trimester. d) It occurs in most pregnancies.
A glucose challenge test should be performed between 24 and 28 weeks.
The nurse is assessing the blood pressure for a patient who has hypertension and the nurse does not hear an auscultatory gap. What outcome may be documented in this circumstance? a) A high systolic pressure reading b) A normal reading c) A high diastolic or low systolic reading d) A low diastolic reading
A high diastolic or low systolic reading
A nurse suspects the presence of an abdominal aortic aneurysm. What assessment data would the nurse correlate with a diagnosis of abdominal aortic aneurysm? (Select all that apply.) a) Decreased bowel sounds b) A pulsatile abdominal mass c) Lower abdominal pain d) Diarrhea e) Low back pain
A pulsatile abdominal mass Lower abdominal pain Low back pain
A nurse is caring for a diabetic patient with a diagnosis of nephropathy. What would the nurse expect the urinalysis report to indicate? a) Red blood cells b) Bacteria c) White blood cells d) Albumin
Albumin
Which of the following medications is considered a thrombolytic? a) Lovenox b) Heparin c) Coumadin d) Alteplase
Alteplase
A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following? a) Neither venous nor arterial b) Trauma c) Venous insufficiency d) Arterial insufficiency
Arterial insufficiency
Which of the following conditions contributes to secondary hypertension? a) Hepatic function b) Acid-based imbalance c) Arterial vasoconstriction d) Calcium deficit
Arterial vasoconstriction
A nurse is providing education to a client about monitoring blood pressure readings at home. The nurse will review all the following items except: a) Avoid smoking cigarettes for 1 hour prior to taking blood pressure. b) Avoid talking during the measurement. c) Be sure the forearm is well supported at heart level while taking blood pressure. d) Sit with both feet on the ground during the measurement.
Avoid smoking cigarettes for 1 hour prior to taking blood pressure
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? a) Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute b) Urine output of 150 ml/hour and heart rate of 45 beats/minute c) Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute d) Urine output of 15 ml/hour and 2+ hematuria
Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute
Which of the following is accurate regarding the effects of nicotine and tobacco smoke on the body? Select all that apply. a) Impairs transport and cellular use of oxygen b) Reduces circulation to the extremities c) Increases blood viscosity d) Decreases blood viscosity e) Causes vasospasm
Causes vasospasm Reduces circulation to the extremities Impairs transport and cellular use of oxygen Increases blood viscosity
While making your initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells you the pain is behind their right eye which is red and tearing. What type of headache would you suspect this client of having? a) Tension b) Sinus c) Cluster d) Migraine
Cluster
Choose the statements that correctly match the hypertensive medication with its side effect. Select all that apply. a) Direct vasodilators may cause headache and tachycardia. b) Beta-blockers may cause sedation. c) With adrenergic inhibitors, cough is a common side effect. d) With thiazide diuretics, monitor serum potassium levels. e) With ACE inhibitors, assess for bradycardia.
Direct vasodilators may cause headache and tachycardia. With thiazide diuretics, monitor serum potassium levels.
The nurse is caring for a patient diagnosed with a subarachnoid hemorrhage resulting from a leaking aneurysm. The patient is awaiting surgery. Which of the following nursing interventions would be appropriate for the nurse to implement? Select all that apply. a) Provide a dimly lit environment. b) Ambulate the patient every hour. c) Elevate the head of bed 30 degrees. d) Permit friends to visit often. e) Administer Colace per order.
Elevate the head of bed 30 degrees. Provide a dimly lit environment. Administer Colace per order.
Target organ damage from untreated/undertreated hypertension includes which of the following? Select all that apply. a) Retinal damage b) Hyperlipidemia c) Heart failure d) Stroke e) Diabetes
Heart failure Retinal damage Stroke
Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of: a) Stent dislodgement. b) Thrombosis of the graft. c) Hemorrhage. d) Decreased motor function.
Hemorrhage
A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound? a) Surgical debridement b) Vacuum-assisted closure device c) Hyperbaric oxygen d) Enzymatic debridement
Hyperbaric oxygen
The following statements match nursing interventions with nursing diagnoses. Which statements are true for a patient with a stroke? Select all that apply. a) Self-care deficit: Instruct the patient on use of a walker. b) Impaired physical mobility: Provide wide-grip utensils during meals. c) Impaired verbal communication: Repeat words and instructions. d) Disturbed sensory perception: Stand on the patient's unaffected side. e) Impaired swallowing: Provide a pureed diet.
Impaired swallowing: Provide a pureed diet. Disturbed sensory perception: Stand on the patient's unaffected side. Impaired verbal communication: Repeat words and instructions.
Aging is positively correlated to the incidence of hypertension. This is due to three of the following four structural or functional changes. Which choice is not considered a cause? a) Decreased elasticity of the major blood vessels b) Increased arterial resistance to left ventricular ejection c) Atherosclerosis d) Increased ability to exert diastolic pressure
Increased ability to exert diastolic pressure
Which of the following statements is correct regarding glargine (Lantus) insulin? a) Its peak action occurs in 2 to 3 hours. b) It is given twice daily. c) It is absorbed rapidly. d) It cannot be mixed with any other type of insulin.
It cannot be mixed with any other type of insulin.
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? a) Maintaining the client in a quiet environment b) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess c) Keeping the client in one position to decrease bleeding d) Positioning the client to prevent airway obstruction
Keeping the client in one position to decrease bleeding
Which of the following antiseizure medication has been found to be effective for post-stroke pain? a) Carbamazepine (Tegretol) b) Phenytoin (Dilantin) c) Topiramate (Topamax) d) Lamotrigine (Lamictal)
Lamotrigine (Lamictal)
A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? a) Heparin b) Pregabalin (Lyrica) c) Diphenhydramine (Benadryl) d) Lioresal (Baclofen)
Lioresal (Baclofen)
A nurse is completing an assessment on a patient and discovers an enlarged, red, and tender lymph node. The nurse will describe and document the lymph node using which of the following terms? a) Lymphangitis b) Elephantiasis c) Lymphadenitis d) Lymphedema
Lymphadenitis
Which of the following is the initial diagnostic test for a stroke? a) ECG b) Noncontrast CT scan c) Transcranial Doppler studies d) Carotid Doppler
Noncontrast CT Scan
A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities? a) Use a heating pad to promote warmth. b) Massage the calf muscles if pain occurs. c) Participate in a regular walking program. d) Keep the extremities elevated slightly.
Participate in a regular walking program.
A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs? a) Partial thromboplastin time (PTT) b) Prothrombin time (PT) c) Bleeding time d) Platelet count
Prothrombin time (PT)
A 35-year-old female patient has been diagnosed with hypertension. The patient is a stock broker, smokes daily, and is also a diabetic. During a follow-up appointment, the patient states that she finds it cumbersome and time consuming to visit the doctor regularly just to check her blood pressure (BP). As the nurse, which of the following aspects of patient teaching would you recommend? a) Advising a smoking cessation b) Purchasing a self-monitoring BP cuff c) Administering glycemic control d) Discussing methods for stress reduction
Purchase a self-monitoring BP cuff
A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms? a) Serum glucose level of 52 mg/dl b) Serum calcium level of 10.2 mg/dl c) Serum calcium level of 8.9 mg/dl d) Serum glucose level of 450 mg/dl
Serum glucose of 52 mg/dl
An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons? a) She is taking coumadin. b) She is not within the treatment time window. c) She had surgery 6 weeks ago. d) She is taking digoxin.
She is taking coumadin.
The nursing student knows that all of the following are consequences of hypertension except for: 1. aneurysm 2. stroke 3. shock 4. esophageal varices
Shock
A patient receives a daily injection of glargine (Lantus) insulin at 7:00 AM. When should the nurse monitor this patient for a hypoglycemic reaction? a)This insulin has no peak action and does not cause a hypoglycemic reaction. b) Between 8:00 and 10:00 AM c) Between 7:00 and 9:00 PM d) Between 4:00 and 6:00 PM
This insulin has no peak action and does not cause a hypoglycemic reaction.
A nurse is teaching the Dietary Approaches To Stop Hypertension (DASH) diet to a group of clients who are newly diagnosed with hypertension. The nurse will include all the following points except: a) Two or fewer servings of meat, fish, or poultry per day b) Four to five fruits per day c) Three to four regular dairy foods per day d) Seven to eight whole-grain products per day
Three to four regular dairy foods per day
A client in a clinic setting has just been diagnosed with hypertension. She asks what the end goal is for treatment. The correct reply from the nurse is which of the following? a) To prevent complications/death by achieving and maintaining a blood pressure of 145/95 or less b) To lose weight, achieve a body mass index of 24 or less, and to eat a diet rich in fruits and vegetables c) To stop smoking and increase physical activity to 30 minutes/day most days of the week d) To prevent complications/death by achieving and maintaining a blood pressure of 140/90 or less
To prevent complications/death by achieving and maintaining a blood pressure of 140/90 or less
The nurse is caring for a patient with venous insufficiency. What should the nurse assess the patient's lower extremities for? a) Rudor b) Cellulitis c) Dermatitis d) Ulceration
Ulceration
Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer? a) Applying a heating pad b) Debriding the wound three times per day c) Using sterile technique during the dressing change d) Cleaning the wound with a povidone-iodine solution
Using sterile technique during the dressing change
A nurse providing education to a community group about hypertension is reviewing appropriate lifestyle modifications. Which of the following are among changes that can help prevent and control hypertension? Choose all that apply. a) Increased intake of dietary protein b) Increased intake of dietary sodium c) Increased physical activity d) Weight reduction e) Substitution of low-fat for whole dairy products in diet
Weight reduction Increased physical activity Substitution of low-fat for whole dairy products in diet
The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is a) a contrast phlebography. b) a lymphangiography. c) an air plethysmography. d) a lymphoscintigraphy.
a contrast phlebography.
Mr. L arrived at the emergency department wth a suspected CVA. He is a 45 yo obese male with hypertension, DM Type II and allergies to latex. He was discharged home from the hospital last week after receiving double bypass surgery. Which nursing interventions would his nurse implement? select all that apply. a. administer thrombolytic therapy within three hours as prescribed. b. administer IV heparin as prescribed. c. Elevate head of bed d. place the patient in lithotomy position e. frequent neuro checks
administer IV heparin as prescirbed elevate head of bed frequent neuro checks
Which of the following terms refer to the failure to recognize familiar objects perceived by the senses? a) Agnosia b) Apraxia c) Agraphia d) Perseveration
agnosia
A significant cause of venous thrombosis is a. altered blood coagulation b. stasis of of blood c. vessel wall injury d. all of the above
all of the above
A woman is admitted to the medsurg unit with painful ulcers on legs and feet. You assess the legs. They have no hair, are painful, and pale. She has history of smoking, HTN, and atherosclerosis. Which type of ulcer does she have? a. arterial b. venous
arterial
Which of the following conditions contributes to secondary hypertension? a) Hepatic function b) Arterial vasoconstriction c) Acid-based imbalance d) Calcium deficit
arterial vasoconstriction
Which of the following, if left untreated, can lead to an ischemic stroke? a) Arteriovenous malformation (AVM) b) Ruptured cerebral arteries c) Atrial fibrillation d) Cerebral aneurysm
atrial fibrillation
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless temporary change? a) Coldness of the soles b) Bluish urine c) Redness of the upper part of the feet d) Purplish stools
bluish urine
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? a) Arteriovenous malformation b) Intracerebral hemorrhage c) Cardiogenic emboli d) Cerebral aneurysm
cardiogenic emboli
The treatment goal for those with stage 2 hypertension (hypertension with compelling indications or complications) includes lifestyle modifications and multiple drug therapies. Thiazide diuretics are part of this treatment approach for most complications except for: a) Chronic kidney disease b) Recurrent stroke prevention c) Heart failure d) Diabetes mellitus
chronic kidney disease
Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is: a) Cigarette smoking. b) Obesity. c) Lack of exercise. d) Stress.
cigarette smoking
Which of the following would be inconsistent as a cause of DKA? a) Decreased or missed dose of insulin b) Illness or infection c) Competency in injecting insulin d) Undiagnosed and untreated diabetes
competency in injecting insulin
A health care provider wants a cross-sectional image of the abdomen to evaluate the degree of stenosis in a patient's left common iliac artery. The nurse knows to prepare the patient for which of the following? a) Computed tomography angiography (CTA) b) Magnetic resonance angiography (MRA) c) Angiography d) Doppler ultrasound
computed tomography angiography (CTA)
Which assessment finding is most important in determining nursing care for a client with diabetes mellitus? a) Blood sugar 170 mg/dL b) Respirations of 12 breaths/minute c) Fruity breath d) Cloudy urine
fruity breath
A nurse understands that a major concern with type 2 diabetes is: a) Overactive insulin secretion. b) Insulin resistance. c) Older age (> 60 years). d) Obesity (>20% of IBW).
insulin resistance
A patient is being seen at the clinic on a monthly basis for assessment of blood pressure. The patient has been checking her blood pressure at home as well and has reported a systolic pressure of 158 and a diastolic pressure of 64. What does the nurse suspect this patient is experiencing? a) Hypertensive urgency b) Primary hypertension c) Isolated systolic hypertension d) Secondary hypertension
isolated systolic hypertension
A nurse is teaching the Dietary Approaches To Stop Hypertension (DASH) diet to clients who have been newly diagnosed with hypertension. Which of the following information will the nurse include? a) Three to four regular dairy foods per day b) Four to five servings of meat, fish, or poultry per day c) Seven to eight whole grain products per day d) Seven to eight fruits per day
seven to eight whole grain products per day
A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client? a) Stop smoking. b) Keep your feet elevated above your heart. c) Do not cross your legs for more than 30 minutes at a time. d) Wear antiembolytic stockings daily to assist with blood return to the heart.
stop smoking
Which technique is considered the gold standard for diagnosing DVT? a. ultrasound imaging b. venography c. MRI d. doppler flow study
venography
Underlying pathophysiological changes that occur in a VTE includes: a. venous stasis, dilation, and constriction of capilaries b. hypercoagulability, decreased vascular permeability and dilation of arties c. hypercoaglability, venous stasis, chest pain r/t pulmonary emvolism d. venous stasis, hypercoagulability, damage to endothelial lining
venous stasis, hypercoagulability, damage to endothelial lining
A nurse educator is providing information to a small group of clients about hypertension. A participant asks what her target blood pressure should be. The nurse is aware of the target goals of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7). Which of the following reflects the goal for blood pressure readings for people without co-morbidities? a) 135/85 or lower b) 145/95 or lower c) 135/80 or lower d) 140/90 or lower
140/90 or lower
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? a) 4:00 p.m. b) 3:00 p.m. c) 2:30 p.m. d) 5:30 p.m.
4:00 pm
An emergency department nurse understands that a 110-lb recent stroke victim will receive at least the minimum dose of recombinant tissue plasminogen activator (t-PA). What minimum dose will the patient receive? a) 85 mg b) 60 mg c) 50 mg d) 100 mg
50 mg
A child is brought into the emergency department with vomiting, drowsiness, and blowing respirations. The father reports that the symptoms have been progressing throughout the day. The nurse suspects diabetic ketoacidosis (DKA). Which action should the nurse take first in the management of DKA? a) Begin fluid replacements. b) Administer prescribed dose of insulin. c) Give prescribed antiemetics. d) Administer bicarbonate to correct acidosis.
Begin fluid replacements.
A nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate? a) Serum ketone bodies b) Serum alkalosis c) Below-normal serum potassium level d) Elevated serum acetone level
Below-normal serum potassium level
As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client? a) Demonstrate how to apply and remove elastic support stockings. b) Assess for skin integrity. c) Assess for the sites of bleeding. d) Demonstrate how to self-administer IV infusions.
Demonstrate how to apply and remove elastic support stockings.
An older adult patient is in the hospital being treated for sepsis related to a urinary tract infection. The patient has started to have an altered sense of awareness, profound dehydration, and hypotension. What does the nurse suspect the patient is experiencing? a) Diabetic ketoacidosis b) Multiple-organ dysfunction syndrome c) Systemic inflammatory response syndrome d) Hyperglycemic hyperosmolar syndrome
Hyperglycemic hyperosmolar syndrome
A nursing class is practicing the measurement of blood pressure. The finding in one otherwise healthy man, 36 years old, is 130/88. This man requires follow-up for prehypertension. Which of the following lifestyle factors would the nurse discuss with the client? a) Weight reduction, the DASH diet, and physical activity b) Physical activity, needed medication, and the DASH diet c) Physical activity, dietary sodium, and the DASH diet d) The DASH diet, sexual dysfunction related to required medications, and physical activity
Physical activity, dietary sodium, and the DASH diet
The nurse is completing a cardiac assessment on a patient. The patient has a blood pressure (BP) reading of 126/80. The nurse would identify this blood pressure reading as which of the following? a) Stage 1 hypertension b) Normal c) Prehypertension d) Stage 2 hypertension
Prehypertension
Decreasing hypertension is the main focus of the medical cardiology practice where you practice nursing. Different goals apply to different age groups for managing and reducing blood pressures. Angie Dodd, a 54-year-old nurse, is beginning medical management of her recently diagnosed hypertension. What is considered the most important strategy in her treatment? a) Reducing her systolic pressure below 140 mmHg b) Reducing her diastolic pressure below 80 mmHg c) Reducing her systolic pressure below 130 mmHg d) Reducing her diastolic pressure below 90 mmHg
Reducing her systolic pressure below 140 mmHg
A client is admitted to the unit with diabetic keto acidosis (DKA). Which insulin would the nurse expect to administer intravenously? a) Regular b) NPH c) Glargine d) Lente
Regular
You are the triage nurse in a walk-in clinic when a diabetic client visits the clinic and asks you to take her blood pressure (BP). The measurements are 150/90 mm Hg. Which of the following would the nurse expect as the treatment to normalize the client's BP? a) Daily exercise b) Drug therapy c) Low-fat diet d) Smoking cessation programs
drug therapy
A client with a diagnosis of DKA is being treated in the ER. Which finding would a nurse expect to note as confirming the diagnosis? a. elevated blood glucose level and low plasma bicarbonate b. decreased urine output c. increased respirations and an increase pH d. comatose state
elevated blood glucose level and low plasma bicarb
Which of the following is not a nursing intervention for leg ulcers? a. administer dietary supplements, A and C b. elevate legs c. compression stockings d. encourage high carb diet
encourage high carb diet
IV heparin therapy is ordered for a client. While implementing this order, a nurse ensure that which of the following medications is avalaible on the nursing unit? a. vitamin K b. aminocaproic acid c. potassim chloride d. protamine sulfate
protamine sulfate
A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level? a) Cool, moist skin b) Rapid, thready pulse c) Slow, shallow respirations d) Arm and leg trembling
rapid, thready pulse
When assessing a patient with a suspected CVA, the nurse would first assess a. for any neurological deficits b. lung sounds to determine if fluid overload is the cause c. cadiovascular status d. the airway to determine if the patient has a gag reflex
the airway to determine if the patient has a gag reflex
The nurse is obtaining a healthy history from a client with blood pressure of 146/88 mm Hg. The client states that lifestyle changes have not been effective in lowering the blood pressure. Which medication classification does the nurse anticipate first? a) ACE inhibitors b) Calcium channel blocker c) Beta-blocker d) Thiazide diuretic
thiazide diuretic
The client returns to the recovery room following repair of an abdominal aneurysm, which finding would require further investigation? a. pedal pulses regular b. urinary output less than 20 mL in the past hour c. BP 108/50 d. oxygen saturations 98%
urinary output less than 20 mL in the past hour
A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following? a) Slow heart rate and high blood pressure b) Constant, intense headache and falling blood pressure c) Higher than normal blood pressure and falling hematocrit d) Constant, intense back pain and falling blood pressure
Constant, intense back pain and falling blood pressure
A client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris. After the client's condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of: a) Deficient knowledge (treatment regimen). b) Health-seeking behaviors (diabetes control). c) Defensive coping. d) Impaired adjustment.
Deficient knowledge (treatment regimen).
A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency? a) Elevate the legs periodically for at least an hour. b) Refrain from sexual activity for a week. c) Elevate the legs periodically for at least 15 to 20 minutes. d) Avoid foods with iodine
Elevate the legs periodically for at least 15 to 20 minutes
A standard of nursing practice associated with the care with DVT includes which of the following? a. encourage ambulation to maintain circulation b. elevate the legs, above the level of the heart to promote venous return c. massage the calf to to promote vasodilation and reabsorption of excess fluid d. antiembolic stockings throughout the night to prevent venous stasis
encourage ambulation to maintain circulation
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: a) providing warmth to the extremity. b) encouraging ambulation to prevent pooling of blood. c) forcing blood into the deep venous system. d) elevating the extremity to prevent pooling of blood.
forcing blood into the deep venous system
When the nurse is caring for a patient with type 1 diabetes, what clinical manifestation would be a priority to closely monitor? a) Ketonuria b) Polyphagia c) Hyponatremia d) Hypoglycemia
hypoglycemia
A nurse is providing education about maintaining tissue integrity to a client with peripheral arterial disease. Which of the following statements by the client indicates a need for clarification? a) "It is important to apply sunscreen to the top of my feet when wearing sandals." b) "I should apply powder daily because my feet perspire." c) "I can use lamb's wool between my toes if necessary." d) "Shoes made of synthetic material are best for my feet."
"Shoes made of synthetic material are best for my feet."
A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first? a) Ask the client if he has trouble breathing. b) Ask the client if he has a headache. c) Place antiembolism stockings on the client. d) Take the client's blood pressure.
Ask the client if he has trouble breathing
A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? a) Increased urine output b) Decreased level of consciousness (LOC) c) Elevated blood pressure d) Decreased heart rate
Increased urine output
A nurse has an order to begin adminsitering warfarin sodium (coumadin) to a client. While implementing this order, the nurse ensure that which of the following medications is available on the nursing unit as an antidote to Coumadin? a. vitamin K b. aminocaprioic acid. c. Potassium chloride d. protamine sulfate
vitamin K
The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation? a) "If you feel pain during the walk, keep walking until the end of the hallway is reached." b) "As soon as you feel pain, we will go back and elevate your legs." c) "Walk to the point of pain, rest until the pain subsides, then resume ambulation." d) "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room."
"Walk to the point of pain, rest until the pain subsides, then resume ambulation."
The nurse is preparing to administer IV fluids for a patient with ketoacidosis who has a history of hypertension and congestive heart failure. What order for fluids would the nurse anticipate infusing for this patient? a) 0.9% normal saline b) D5W c) D5 normal saline d) 0.45 normal saline
0.45 normal saline
A health care provider prescribes short-acting insulin for a patient, instructing the patient to take the insulin 20 to 30 minutes before a meal. The nurse explains to the patient that Humulin-R, taken at 6:30 AM will reach peak effectiveness by: a) 10:30 AM. b) 2:30 PM. c) 8:30 AM. d) 12:30 PM.
8:30 AM
Which of the following assessment results is considered a major risk factor for PAD? a) BP of 160/110 mm Hg b) LDL of 100 mg/dL c) Cholesterol of 200 mg/dL d) Triglyceride level of 150 mg/dL
BP of 160/110 mg Hg
Which of the following are indications of a rupturing aortic aneurysm? Select all that apply. a) Constant, intense back pain b) Decreasing blood pressure c) Increasing blood pressure d) Decreasing hematocrit e) Increasing hematocrit
Constant, intense back pain Decreasing blood pressure Decreasing hematocrit
The nurse is volunteering at a community blood pressure screening. A client, never diagnosed with hypertension, presents with a blood pressure of 158/90 mm Hg. Which assessment questions, asked by the nurse, are appropriate? Select all that apply. a) "Are you married and with children?" b) "Do you have a friend accompanying you?" c) "Did you have a beer after work?" d) "Do you smoke?" e) "Have you recently drunk a caffeinated beverage?"
Do you smoke? Have you recently drunk a affeinated beverage
Mr. F is a 63 y old male who is recovering from a CVA. He is struggling with aphasia and you note that he is becoming frustrated and irritable when trying to talk to his wife. The nurse would implement which interventions to improve communication with his family? Select all that Apply. a. consult with speech therapy b. encourage Ms. F to complete his sentence for him to help him decipher how sentences are structured c. maintain a consistent schedule, repetition, and communication board d. encourage Mr. F to attend a support group
consult with speech therapy maintain a consistent schedule, repetition, and communication board encourage Mr. F to attend a support group
Because of a dx of Buergers disease, the nurse collects which of teh follwoing about the client's health history? a. extended period of time smoking cigarettes b. suspectibility to infections c. recent onset of muscle twitching d. increased apprehension
extended period of time smoking cigarettes
Which of the following terms refers to enlarged, red, and tender lymph nodes? a) Elephantiasis b) Lymphangitis c) Lymphedema d) Lymphadenitis
lymphadenitis
The nurse teaches the patient which of the following guidelines regarding lifestyle modifications for hypertension? a) Limit aerobic physical activity to 15 minutes, three times per week b) Stop alcohol intake c) Maintain adequate dietary intake of potassium d) Reduce smoking to no more than four cigarettes per day
maintain adequate dietary intake of potassium
A patient's chart states he has intermittement claudication. Which statement made by the patient would be consistent with this information? a. my fingers when I go outside in the cold b. sometimes I get tired when I climb a lot of staris c. when I stand too long, my feet start to swell up. d. My legs cramp whenever I walk more than a block
my legs cramp whenever I walk more than a block
Aortic dissection may be mistaken for which of the following disease processes? a) Myocardial infarction (MI) b) Angina c) Pneumothorax d) Stroke
myocardial infarcation
A patient diagnosed with a stroke is ordered to receive warfarin (Coumadin). Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is which of the following? a) Clopidogrel (Plavix) b) Dipyridamole (Persantine) c) Ticlodipine (Ticlid) d) Aspirin
aspirin
Pentoxifylline (Trental) is a medication used for which of the following conditions? a) Thromboemboli b) Elevated triglycerides c) Hypertension d) Claudication
claudication
The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin? a) Within the first 24 hours b) Within 12 hours c) In 3 to 5 days d) In 2 days
in 3 to 5 days
In prepartion for discharge of a client with arterial insuffiency and Raynaud's disease, client teaching instructions should include a. walking several times each day as an exerise program b. keeping the heat up so the environment is warm c. wearing TED hose during the day d. using hydrotherapy for increasing oxygenation
keeping the heat up so the environment is warm
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regime, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: a) Dyslipidemia b) Obesity c) Smoking d) Hypertension
Hypertension
A nurse obtains a fingerstick glucose level of 45 mg/dl on a client newly diagnosed with diabetes mellitus. The client is alert and oriented, and the client's skin is warm and dry. How should the nurse intervene? a) Give the client 4 oz of milk and a graham cracker with peanut butter. b) Obtain a repeat fingerstick glucose level. c) Obtain a serum glucose level. d) Notify the physician.
Obtain a repeat fingerstick glucose level.
A type 2 diabetic is ordered metformin (Glucophage) as part of the management regime. Which is the best nursing explanation for the action of this drug in controlling glucose levels? a) Delays digestion of carbohydrates b) Reduces the production of glucose by the liver c) Stimulates insulin release d) Helps tissues use insulin more efficiently
helps tissues use insulin more efficiently
A 55-year-old black male is found to have a blood pressure of 150/90 mm Hg during a work-site health screening. What should the nurse do? a) Recommend he have his blood pressure rechecked within 2 weeks. b) Consider this to be a normal finding for his age and race. c) Recommend he see his physician immediately for further evaluation. d) Recommend he have his blood pressure rechecked in 1 year.
recommend he have his blood pressure rechecked within two weeks
A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client? a) Stop smoking. b) Wear antiembolytic stockings daily to assist with blood return to the heart. c) Keep your feet elevated above your heart. d) Do not cross your legs for more than 30 minutes at a time.
stop smoking
A client comes to the emergency department complaining of visual changes and a severe headache. The nurse measures the client's blood pressure at 210/120 mm Hg. However, the client denies having hypertension or any other disorder. After diagnosing malignant hypertension, a life-threatening disorder, the physician initiates emergency intervention. What is the most common cause of malignant hypertension? a) Pyelonephritis b) Dissecting aortic aneurysm c) Untreated hypertension d) Pheochromocytoma
untreated hypertension
A patient in the ED has a 5-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining a nursing history from the patient, which symptoms will it be most important for the nurse to ask about? a) Changes in bowel and bladder habits b) Back or lumbar pain c) Hoarse voice and difficulty swallowing d) Abdominal swelling and tenderness
hoarse voice and difficulty swallowing
A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findinsg by the nurse is probably unrelated to the aneurysm? a. pulstaile abdominal mass b. hyperactive bowel sounds in that area c. systolic bruit over area of the mass d. subjective sensation of "heart beating" in the abdomen
hyperactive bowel sounds in that area
What should the nurse do to manage the persistent swelling in a patient with severe lymphangitis and lymphadenitis? a) Offer cold applications to promote comfort and to enhance circulation. b) Avoid elevating the area. c) Teach the patient how to apply a graduated compression stocking. d) Inform the physician if the temperature remains low.
teach the patient how to apply a graduated compression stocking
