MOC: exam 2 test bank questions

When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial blood pressure (BP) of 154/82 mm Hg and an ankle pressure of 112/74 mm Hg. The nurse calculates the patient's ankle-brachial index (ABI) as ________ (round up to the nearest hundredth).

.73 to calculate, divide the ankle systolic BP by the brachial systolic BP

The nurse measures a patient's blood pressure as 172/82 mm Hg. What is the patient's mean arterial pressure (MAP)? _________

112 mm Hg

Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 48-yr-old patient with newly diagnosed hypertension?

128/76 mm Hg

A patient with asthma has a personal best peak expiratory flow rate (PEFR) of 400 L/min. When explaining the asthma action plan, the nurse will teach the patient that a change in therapy is needed when the PEFR is less than ___ L/minute.

320

The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient would the nurse assess first?

48-yr-old with a BP of 160/92 mm Hg who reports chest pain

After receiving change-of-shift report, which patient admitted to the emergency department would the nurse assess first?

A 50-yr-old patient who is reporting sudden sharp and severe upper back pain

After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient would the nurse assess first?

A 59-year-old patient with unstable angina who has just returned after apercutaneous coronary intervention (PCI)

After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient would the nurse assess first?

A patient who has new-onset confusion and restlessness.

The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient would the nurse assess first?

A patient with a respiratory rate of 38 breaths/min

The emergency department nurse is evaluating the outcomes for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective?

O2 saturation is >90%.

Which finding on a patient's nursing admission assessment is congruent with the initial medical diagnosis of a 6-cm thoracic aortic aneurysm?

Difficulty swallowing

A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor is on a low-sodium diet. The patient tells the home health nurse about a 5-lb weight gain in the past 3 days. Which action is the nurse's priority?

Assess the patient for manifestations of acute heart failure.

An adult whose employment requires long periods of standing undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions would the nurse provide to the patient before discharge?

Elastic compression stockings should be applied before getting out of bed.

A patient who has chest pain is admitted to the emergency department (ED), and all of the following items are prescribed. Which one would the nurse arrange to be completed first?

Electrocardiogram (ECG)

A patient who has chronic heart failure tells the nurse, ―I was fine when I went to bed, but I woke up feeling like I was suffocating!-- How would the nurse document this finding?

Paroxysmal nocturnal dyspnea

The nurse is caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI). Which information would the nurse anticipate teaching the patient?

Additional diagnostic testing will be required.

A patient seen in the asthma clinic has recorded daily peak flowrates that are 70% of the baseline. Which action will the nurse plan to take next?

Administer a bronchodilator and recheck the spirometry.

The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication would the nurse administer first?

Albuterol (Ventolin HFA) 2.5 mg per nebulizer

Following an acute myocardial infarction, a previously healthy 63-yr-old develops heart failure. Which medication topic would the nurse anticipate including in discharge teaching?

Angiotensin-converting enzyme (ACE) inhibitor

Which topic would the nurse include in teaching for a patient with a venous stasis ulcer on thelower leg?

Application of graduated compression stockings

Which action for a patient at risk for venous thromboembolism could the nurse delegate to assistive personnel (AP)?

Apply sequential compression devices whenever the patient is in bed.

Which action will the nurse take to evaluate the effectiveness of IV nitroglycerin for a patient with a myocardial infarction (MI)?

Ask about chest pain.

A patient with hypertension who was prescribed atenolol (Tenormin) 2 weeks ago returns to the health clinic for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action would the nurse take first?

Ask the patient if the medication is being taken as prescribed.

Which action would the nurse take when giving the first dose of oral labetalol to a patient hospitalized with hypertension?

Ask the patient to request assistance before getting out of bed.

Propranolol (Inderal) is newly prescribed for a patient diagnosed with hypertension. Which information in the patient's history would prompt the nurse to consult with the health care provider before giving this drug?

Asthma

When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action would the nurse perform first?

Attach the heart monitor.

A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action would the nurse take as focused follow-up on this symptom?

Auscultate for a pericardial friction rub.

A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action would the nurse take first?

Auscultate the breath sounds.

The health care provider prescribes heparin infusion and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). Which action would the nurse include in the plan of care?

Avoid giving IM medications to prevent localized bleeding.

Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. Which data would indicate to the nurse that the drug is effective?

Participation in daily activities without chest pain

An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. After the nurse notifies the health care provider, what would the nurse do next?

Keep the patient in bed in the supine position.

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure?

B-type natriuretic peptide

Which topic will the nurse plan to include in discharge teaching for a patient who has heart failure with reduced ejection fraction (HFrEF)?

Benefits and effects of angiotensin-converting enzyme (ACE) inhibitors

After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider?

Bilateral crackles

The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider?

Bilateral crackles in the mid-lower lobes.

An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to reportto the health care provider?

Blood pressure 88/42 mm Hg

Which data indicates to the nurse that the patient with stable angina is experiencing a side effect of metoprolol?

Blood pressure is 90/54 mm Hg.

The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider?

Blood pressure of 148/88 mm Hg

The nurse is caring for a patient who is receiving IV furosemide and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective?

Reduced dyspnea with the head of bed at 30 degrees

While admitting an 82-yr-old patient with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the ―water pill with the ―heart pill. What would the nurse include in the discharge plan?

Referral to a home health care agency

An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which data would indicate to the nurse that the goals of IABP treatment are being met?

Cardiac output (CO) of 5 L/min

A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test is most specific for the nurse to monitor in determining whether the patient has had an AMI?

Cardiac-specific troponin

A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication would the nurse question before giving?

Carvedilol (Coreg) 3.125 mg

The nurse is developing a discharge teaching plan for a patient diagnosed with thromboangiitis obliterans (Buerger's disease). Which expected outcome has the highest priority for this patient?

Cessation of all tobacco use

Which information would the nurse teach the patient who has been prescribed captopril?

Change position slowly to help prevent dizziness and falls.

An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which action would the nurse take first?

Check the patient's blood pressure.

Which action would the nurse take first to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes?

Collect a detailed diet history.

A young adult patient tells the health care provider about having cold, numb fingers. After Raynaud's phenomenon is diagnosed, which condition would the nurse anticipate as a likely comorbidity?

Coronary artery disease

Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider?

Cough productive of bloody, purulent mucus

The nurse is administering a thrombolytic agent to a patient having an acute myocardial infarction. Which patient data indicates that the nurse should stop the drug infusion?

Decreased level of consciousness

Diltiazem is prescribed for a patient newly diagnosed with Prinzmetal's (variant) angina. Which action of diltiazem is accurate for the nurse to include in the teaching plan?

Decreases coronary artery spasms.

To improve the physical activity level for a 68-year-old patient who is mildly obese, which action would the nurse plan to take?

Determine what kind of physical activities the patient usually enjoys.

A 62-yr-old patient who has no history of hypertension has a blood pressure (BP) of 198/110 mm Hg during a routine wellness check. After reconfirming the BP, which information would the nurse provide to the patient?

Diagnosis, treatment, and monitoring will be needed.

The nurse reviews information shown in the accompanying figure from the medical records ofa 43-year-old patient. Which risk factor modification for coronary artery disease would the nurse include in patient teaching?

Dietary changes to improve lipid levels

The nurse is developing a teaching plan for a patient with coronary artery disease (CAD). Which factor would the nurse focus on during the teaching session?

Elevated low-density lipoprotein (LDL) level

Which action by the nurse would support ventilation for a patient with chronic obstructive pulmonary disease (COPD).?

Encourage the patient to sit upright and lean forward.

A patient with a venous thromboembolism (VTE) has new prescriptions for enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate?

Enoxaparin works right away, but warfarin takes several days to prevent clots.

Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider?

Flushing and dizziness

A patient who has recently started taking pravastatin (Pravachol) and niacin reports several new symptoms to the nurse. Which information is most important to communicate to the health care provider?

Generalized muscle aches and pains

A patient in the intensive care unit who has acute decompensated heart failure (ADHF) reports severe dyspnea and is anxious, tachypneic, and tachycardic. Several drugs have been prescribed for the patient. Which action would the nurse take first?

Give PRN IV morphine sulfate 4 mg.

A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which action would the nurse take?

Give the patient's other medications 3 hours after colesevelam.

The nurse is caring for a patient who has just arrived on the telemetry unit after having cardiaccatheterization. Which task could the nurse delegate to a licensed practical/vocational nurse (LPN/VN)?

Give the scheduled aspirin and lipid-lowering medication.

A patient in the clinic with cystic fibrosis (CF) reports increased sweating and weakness during the summer months. Which action would the nurse take?

Have the patient add dietary salt to meals.

Which action would the nurse in the hypertension clinic take to obtain an accurate baseline blood pressure (BP) for a new patient?

Have the patient sit in a chair with the feet flat on the floor.

A patient who has a history of hypertension treated with a diuretic and clonidine (Catapres) arrives in the emergency department. The patient reports a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question would the nurse ask to follow up on these findings?

Have you consistently taken your medications?

When preparing a clinic patient who has chronic obstructive pulmonary disease (COPD) for pulmonary spirometry, which question would the nurse ask?

Have you taken any bronchodilators today?

A patient who has recently had an acute myocardial infarction (AMI) ambulates in the hospital hallway. Which data would indicate to the nurse that the patient should stop and rest?

Heart rate increases from 66 to 98 beats/min.

Which nursing intervention is likely to be most effective when assisting the patient with coronary artery disease to make dietary changes?

Help the patient modify favorite high-fat recipes by using monounsaturated oils.

Which intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously could the nurse delegate to assistive personnel (AP)?

Help the patient to use a pillow to splint while coughing.

Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). How should the nurse explain the purpose of the heparin to the patient?

Heparin prevents the development of new clots in the coronary arteries.

Which risk factor would the nurse focus on when teaching a patient who has a 5-cm abdominal aortic aneurysm?

Hypertension

Which information is important for the nurse to include when teaching a patient newly diagnosed with hypertension?

Hypertension is usually asymptomatic until organ damage occurs.

The nurse has just finished teaching a hypertensive patient about a newly prescribed drug, ramipril (Altace). Which patient statement indicates that more teaching is needed?

I can expect some swelling around my lips and face.

The nurse provides dietary teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effective?

I can have ice cream as a snack every day

Which patient statement is consistent with their experiencing venous insufficiency?

I can't get my shoes on at the end of the day.

The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) after hospitalization for venous thromboembolism (VTE). Which patient statement indicates a need for additional teaching?

I should reduce the amount of green, leafy vegetables that I eat.

Which patient statement indicates that the nurse's teaching about sublingual nitroglycerin (Nitrostat) has been effective?

I will call an ambulance if I have pain 5 minutes after taking nitroglycerin.

A hospitalized patient with chronic heart failure has a new order for captopril 12.5 mg PO. After giving the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective?

I will call for help when I need to get up to use the bathroom.

Which statement by a patient newly diagnosed with heart failure indicates to the nurse that teaching was effective?

I will call the clinic if my weight goes up 3 pounds in a week.

The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action would the nurse take first?

Notify the surgeon and anesthesiologist.

The nurse is evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery. Whichpatient statement indicates that additional teaching is needed?

I will have incisions in my leg where they will remove the vein.

Which statement made by a patient with coronary artery disease indicates that further diet teaching is needed?

I will miss being able to eat peanut butter sandwiches

In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective?

I will sit down before I put the nitroglycerin under my tongue.

The nurse is evaluating the discharge teaching outcomes for a patient with chronic peripheral artery disease (PAD). Which patient statement indicates a need for further instruction?

I will use a heating pad on my feet at night to increase the circulation

A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 mm Hg, and heart rateis 132 beats/min. Based on this information, which patient problem is the priority?

Impaired cardiac function

The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a prescription for enalapril (Vasotec). Which statement by the new nurse to the patient requires the charge nurse's intervention?

Increase your dietary intake of high-potassium foods.

A patient had an open surgical repair of an abdominal aortic aneurysm earlier today. The patient's total urinary output for the past 2 hours was 45 mL. What would the nurse anticipate will be prescribed?

Increased IV fluids

While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. What does this finding indicate?

Increased ventricular filling pressure

Which action would the nurse take when giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE)?

Inject the drug into the abdominal subcutaneous tissue.

A patient is being evaluated for postthrombotic syndrome. Which assessment will the nurse perform?

Inspect for edema and color changes.

Which patient statement indicates that the nurse's teaching about carvedilol (Coreg) for preventing anginal episodes has been effective?

It is important not to suddenly stop taking the carvedilol.

Which instructions would the nurse include in a teaching plan for an older adult patient newly diagnosed with peripheral artery disease (PAD)?

It is very important that you stop smoking cigarettes.

A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment would the nurse complete first?

Listen to the patient's breath sounds.

A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, ―I wish I were dead! I'm just a burden on everybody- Based on this information, which patient problem would the nurse identify?

Low self-esteem

The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How would the nurse determine the appropriate O2 flowrate?

Maintain the pulse oximetry level at 90% or greater.

When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider?

Maroon-colored liquid stool

Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse delegate to experienced assistive personnel (AP)?

Measure O2 saturation using pulse oximetry.

Which action would the nurse include in the plan of care for a patient after endovascular repair of an abdominal aortic aneurysm?

Monitor fluid intake and urine output.

A patient who is receiving dobutamine for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action would be most appropriate for the registered nurse (RN) to delegate to an experiencedlicensed practical/vocational nurse (LPN/VN)?

Monitor the patient's blood pressure and heart rate every hour.

The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action would the nurse include in the plan of care?

Monitor the patient's urinary output every hour.

While waiting for heart transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. Which action would the nurse include in the plan of care for this patient?

Monitoring the incision for signs of infection

Which patient statement supports a history of intermittent claudication?

My legs cramp when I walk more than a block.

Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse?

New onset shortness of breath

Which information about a patient receiving thrombolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider?

No change in the patient's reported level of chest pain

Which information about a patient newly diagnosed with elevated blood pressure is most important for the nurse to address with the patient?

No regular physical exercise

A patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action would the nurse take first?

Notify the health care provider.

Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires immediate action by the nurse?

O2 saturation of 88%

A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on O2 therapy. Which instruction would the nurse include in the discharge teaching?

O2 use can improve the patient's quality of life.

The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action would the nurse perform first?

Obtain vital signs.

A patient with chronic obstructive pulmonary disease (COPD) has been eating very little and has lost weight. Which intervention would be most important for the nurse to include in the plan of care?

Offer high-calorie protein snacks between meals and at bedtime.

The nurse is admitting a patient newly diagnosed with peripheral artery disease who takes clopidogrel. Which admission order would the nurse question?

Omeprazole drug therapy

Which assessment finding in a patient who has had coronary artery bypass grafting using a right radial artery graft is most important for the nurse to communicate to the health care provider?

Pallor and weakness of the right hand

A patient at the clinic says, ―I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though.-- Which focused assessment would the nurse make?

Palpate for the presence of dorsalis pedis and posterior tibial pulses.

The nurse is caring for a 70-yr-old patient who takes hydrochlorothiazide and enalapril (Norvasc). The patient's blood pressure (BP) continues to be high. Which patient information may indicate a need for a change?

Patient uses ibuprofen to treat osteoarthritis.

After receiving change-of-shift report, which patient would the nurse assess first?

Patient who is taking digoxin and has a potassium level of 3.1 mEq/L

The nurse who works in the vascular clinic has several patients with venous insufficiency. Which patient would the nurse assign to an experienced licensed practical/vocational nurse (LPN/VN)?

Patient who needs wound care for a chronic venous stasis ulcer on the lower leg.

Which patient at the cardiovascular clinic requires the most immediate action by the nurse?

Patient with stable angina whose chest pain has recently increased in frequency

A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention would the nurse include in the plan of care?

Perform chest physiotherapy every 4 hours.

Which finding would the nurse expect when assessing a patient with cor pulmonale?

Peripheral edema

The health care provider has prescribed bed rest with the feet elevated for a patient admitted tothe hospital with a venous thromboembolism of the left lower leg. Which action would the nurse take?

Place a pillow under the thighs and 2 pillows under the lower legs.

A patient with diabetes mellitus and chronic stable angina has a new order for captopril. Which information would the nurse teach this patient about the primary purpose of captopril?

Prevents changes in heart muscle.

A patient has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe. Which assessment finding would the nurse expect?

Prolonged capillary refill in all the toes

Which assessment finding is most useful in evaluating the effectiveness of treatment to improve gas exchange?

Pulse oximetry reading of 92%

A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention is appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/VN)?

Reinforcement of teaching about the prescribed medications

A patient with acute coronary syndrome has returned to the coronary care unit after having angioplasty with stent placement. Which assessment data indicate the need for immediate action by the nurse?

Report of chest pain

Which electrocardiographic (ECG) change by a patient with chest pain is most important for the nurse to report rapidly to the health care provider?

ST-segment elevation

A patient newly diagnosed with asthma is being discharged. Which topic would the nurse include in the discharge teaching?

Self-administration of inhaled corticosteroids

The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is important to communicate to the health care provider?

Serum creatinine of 2.8 mg/dL

A patient who has heart failure recently started taking digoxin in addition to furosemide and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider?

Serum potassium level 3.0 mEq/L after 1 week of therapy

A patient is receiving IV furosemide to treat stage 2 hypertension. Which assessment finding is most important to report to the health care provider?

Serum potassium level of 3.0 mEq/L

The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside. Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse (LPN/VN)?

Set up the automatic noninvasive BP machine to take readings every 15 minutes.

A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about safely resuming sexual intercourse. Which response by the nurse provides the most useful information for the patient?

Sexual activity uses about as much energy as climbing two flights of stairs.

A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of daily medications to the nurse. Which medication has the most immediate implications for the patient's care?

Sildenafil (Viagra)

Which group of drugs will the nurse plan to include when teaching a patient who has a new diagnosis of peripheral artery disease (PAD)?

Statins

IV sodium nitroprusside is prescribed for a patient with acute pulmonary edema. Which reassessment finding indicates that the nurse should decrease the rate of nitroprusside infusion?

Systolic BP below 90 mm Hg

A patient with cystic fibrosis has blood glucose levels that are consistently between 180 to 250 mg/dL. Which action will the nurse expect to implement?

Teach the patient about administration of insulin.

An older patient has been diagnosed with possible white coat hypertension. Which planned action by the nurse addresses that suspected cause of the hypertension?

Teach the patient how to self-monitor and record BPs at home.

The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which action would the nurse implement for a patient who has an impairedbreathing pattern due to anxiety?

Teach the patient how to use the pursed-lip technique.

The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reportshaving a baseline peak flow reading of 600 L/min, and the current peak flow is 420 L/min. Which action would the nurse take first?

Teach the patient to use the prescribed albuterol (Ventolin HFA).

A patient who is 2 days post femoral popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/VN) caring for the patient requires the registered nurse (RN) to intervene?

The LPN/VN tells the patient sit in a chair for 2 hours.

Which patient statement would help the nurse confirm the previous diagnosis of chronic stable angina?

The pain goes away with a nitroglycerin tablet.

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain may be from an acute myocardial infarction?

The pain has lasted longer than 30 minutes.

The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most urgent to report to the health care provider?

The patient cannot move the left arm and leg when asked to do so.

After the nurse teaches the patient with stage 1 hypertension about diet modifications, which diet choice indicates that the teaching has been effective?

The patient drinks low-fat milk with each meal.

Which action by the patient with newly diagnosed Raynaud's phenomenon demonstrates that the nurse's teaching about managing the condition has been effective?

The patient exercises indoors during the winter months.

A patient with hypertension received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention?

The patient has developed wheezes throughout the lung fields.

The nurse teaches a patient who has chronic bronchitis about a new prescription for combined fluticasone and salmeterol (Advair Diskus) in a dry powder inhaler. Which patient action indicates to the nurse that teaching about medication administration has been successful?

The patient rapidly inhales the medication.

The home health nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching?

The patient removes the facial mask when the misting stops.

The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is specific in confirming a diagnosis of chronic bronchitis?

The patient reports a productive cough for 3 months of every winter.

The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy?

The patient takes propranolol (Inderal) for hypertension.

The nurse completes an admission assessment on a patient with asthma. Which information indicates a need for discussion with the health care provider about a change in therapy?

The patient used albuterol more often when symptoms were worse in the spring.

The nurse teaches a patient who has asthma about peak flowmeter use. Which action by the patient indicates that teaching was successful?

The patient uses albuterol (Ventolin HFA) for peak flows in the yellow zone.

A 53-yr-old patient with stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is an option. Which response is accurate?

The suitability of a heart transplant depends on many factors.

Which information will the nurse include in the teaching plan for a patient newly diagnosed with asthma?

Tremors are an expected side effect of rapidly acting bronchodilators.

Which action will be included in the plan of care for a patient who is receiving intravenous nicardipine to treat a hypertensive emergency?

Use an automated noninvasive blood pressure machine to obtain frequent measurements.

Which assessment finding for a patient with a history of asthma indicates that the nurse wouldtake immediate action?

Use of accessory muscles in breathing

Which instruction would the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)?

Use the bronchodilator before you start to exercise.

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions wouldbe appropriate for the nurse to include in the plan of care?

Walk 15 to 20 minutes a day at least 3 times/wk.

After having a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, ―It was just a little chest pain. As soon as I get out of here, I'm going for my vacation as planned.‖ Which reply would be most appropriate for the nurse to make?

What do you think caused your chest pain?

A patient is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question would the nurse ask to determine whether the patient is a candidate for thrombolytic therapy?

What time did your pain begin?

The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Which information would the nurse plan to provide today?

When cardiac rehabilitation will begin

Which action would the nurse take to prepare a patient for spirometry?

Withhold bronchodilators for 6 to 12 hours before the examination.

A young adult female patient with cystic fibrosis (CF) tells the nurse that she is considering trying to become pregnant. Which initial response would the nurse provide?

Would like more information to help you with that decision?

Which foods would the nurse recommend limiting for a patient on a 2000-mg sodium diet?

Yogurt and milk products

The nurse in the emergency department receives arterial blood gas results for 4 recently admitted patients with obstructive pulmonary disease. The results for which patient willrequire the most rapid action by the nurse?

pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg

A 30-year-old patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which topic would the nurseplan to teach the patient?

α1-Antitrypsin testing