NURS 320 Final Exam
A nurse developing a plan of care for a client who has active TB. which of the following isolation precautions should the nurse include in the plan? A. Airborne B. Neutropenic C. Contact D. Droplet
A. Airborne
A nurse in an ED is caring for a client who's experiencing a pulmonary embolism. Which of the following actions should the nurse take first? A. Apply supplemental oxygen. B. Increase the rate of IV fluids. C. Administer pain medication. D. Initiate cardiac monitoring.
A. Apply supplemental oxygen.
A nurse is assessing a client who has lung cancer. which of the following manifestations should the nurse expect? A. Blood-tinged sputum B. Decreased tactile fremitus C. Resonance with percussion D. Peripheral edema
A. Blood-tinged sputum Rationale: The nurse should expect blood-tinged sputum secondary to bleeding from the tumor.
A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. the nurse should identify that which of the following assessments if the priority? A. presence of gag reflex B. pain level rating using 0 to 10 scale C. hydration status D. appearance of the IV insertion site
A. presence of gag reflex Rationale: The greatest risk to the client is aspiration due to a depressed gag reflex.
A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on 4 clients. For which of the following clients should the nurse clarify the provider's prescription? A. pt w/ epistaxis B. pt w/ amyotrophic lateral sclerosis C. pt w/ pneumonia D. pt w/ emphysema
A. pt w/ epistaxis
A charge nurse is reviewing the care of a client who has a chest tube connected to a water seal drainage system in a place following thoracic surgery w/ newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of when to notify the provider? A. "I will notify the provider if there is a fluctuation of drainage in the tubing with inspiration." B. "I will notify the provider if there is continuous bubbling in the water seal chamber." C. "I will notify the provider if there is drainage of 60 milliliters in the first hour after surgery." D. "I will notify the provider if there are several small, dark-red blood clots in the tubing."
B. "I will notify the provider if there is continuous bubbling in the water seal chamber." Rationale: Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider.
A nurse is assessing a client who's 4 hr postoperative following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider? A. Bleeding at the surgical site B. Decreased oxygen saturation C. Urinary retention D. Increased pain level
B. Decreased oxygen saturation
A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? A. Rhonchi on inspiration B. Elevated temperature C. Barrel-shaped chest D. Diminished breath sounds
B. Elevated temperature
A nurse is caring for a newly admitted client who has emphysema. the nurse should place the client in which of the following positions to promote effective breathing? A. Lateral position with a pillow at the back and over the chest to support the arm B. High-Fowler's position with the arms supported on the overbed table C. Semi-Fowler's position with pillows supporting both arms D. Supine position with the head of the bed elevated to 15°
B. High-Fowler's position with the arms supported on the overbed table
A nurse is caring for a client who's in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client w/ highest level of oxygen? A. Nasal cannula B. Nonrebreather mask C. Simple face mask D. Partial rebreather mask
B. Nonrebreather mask
A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? A. Increased anterior-posterior chest diameter B. Productive cough with green sputum C. Clubbing of the fingers D. Pursed-lip breathing with exertion
B. Productive cough with green sputum Rationale: Productive cough with green sputum is indicative of an infection. The other answer choices are expected findings in a client with COPD.
A nurse is providing discharge teaching to a client who has pulmonary TB and a new prescription for rifampin. Which of the following instructions should the nurse include? A. "Ringing in the ears is an adverse effect of this medication." B. "Have your skin test repeated in 4 months to show a positive result." C. "Expect your urine and other secretions to be orange while taking this medication." D. "Remember to take this medication with a sip of water just before your first bite of each meal."
C. "Expect your urine and other secretions to be orange while taking this medication." Rationale: Hepatotoxicity is associated w/ Rifampin
A nurse is caring for 4 clients. which of the following clients is at greatest risk for a pulmonary embolism? A. A client who is 48 hr postoperative following a total hip arthroplasty B. A client who is 8 hr postoperative following an open surgical appendectomy C. A client who is 2 hr postoperative following an open reduction external fixation of the right radius D. A client who is 4 hr postoperative following a laparoscopic cholecystectomy
C. A client who is 48 hr postoperative following a total hip arthroplasty Rationale: The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery.
A nurse is caring for a client who's in acute respiratory failure and is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen? A. BP B. Cap refill C. ABGs D. HR
C. ABGs
A nurse is caring for a client who's receiving mechanical ventilation when the low-pressure alarm sounds. which of the following situations should the nurse recognize as a possible cause of the alarm? A. Excess secretions B. Kinks in the tubing C. Artificial airway cuff leak D. Biting on the endotracheal tube
C. Artificial airway cuff leak Rationale: An artificial airway cuff leak interferes with oxygenation and causes the low-pressure alarm to sound.
A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client? A. Extra drainage system B. Suture removal kit C. Container of sterile water D. Non adherent pads
C. Container of sterile water Rationale: The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected to prevent a pneumothorax.
A nurse is caring for a client who's 1 hr postoperative following a thoracentesis. Which of the following is the priority assessment finding? A. Pallor B. Insertion site pain C. Persistent cough D. Temperature 37.3° C (99.1° F)
C. Persistent cough Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is a persistent cough because this can indicate a tension pneumothorax, which is a medical emergency.
A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include? A. Schedule respiratory treatments following meals. B. Have the client sit up in a chair for 2-hr periods three times per day. C. Provide a diet that is high in calories and protein. D. Combine activities to allow for longer rest periods between activities.
C. Provide a diet that is high in calories and protein.
A nurse is caring for a client who has asthma and is receiving albuterol. for which of the following adverse effects should the nurse monitor the client? A. Hyperkalemia B. Dyspnea C. Tachycardia D. Candidiasis
C. Tachycardia
A nurse is assessing a client who has bacterial pneumonia. Which of the following manifestations should the nurse expect? A. decreased fremitus B. SaO2 95% on room air C. temperature 38.8° C (101.8° F) D. bradypnea
C. temperature 38.8° C (101.8° F)
A nurse is providing teaching to a client who has chronic asthma and a new prescription for montelukast. Which of the following client statements indicates an understanding of the teaching? A. "I will monitor my heart rate every day while taking this medication." B. "I will make sure I have this medication with me at all times." C. "I will need to carefully rinse my mouth after I take this medication." D. "I will take this medication every night even if I don't have symptoms."
D. "I will take this medication every night even if I don't have symptoms."
A nurse is caring for a client who has pulmonary embolism. Which of the following interventions is the nurse's priority? A. Provide a quiet environment B. Encourage use of incentive spirometer every 1-2 hrs C. Obtain blood sample for electrolyte study D. Administer heparin via continuous IV infusion
D. Administer heparin via continuous IV infusion
A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider? A. Decreased bowel sounds B. Oxygen saturation 92% C. CO2 24 mEq/L D. Intercostal retractions
D. Intercostal retractions
A nurse in an ED is caring for a client who's experiencing acute respiratory failure. Which of the following lab findings should the nurse expect? A. Arterial pH 7.50 B. PaCO2 25 mm Hg C. SaO2 92% D. PaO2 58 mm Hg
D. PaO2 58 mm Hg
A nurse working in an ED is caring for a client following an acute chest trauma. which of the following findings should indicate to the nurse that the client is possibly experiencing a tension pneumothorax? A. Collapsed neck veins on the affected side B. Collapsed neck veins on the unaffected side C. Tracheal deviation to the affected side D. Tracheal deviation to the unaffected side
D. Tracheal deviation to the unaffected side Rationale: The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator that the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.
A nurse is planning care for a client who has asthma. Which of the following meds should the nurse plan to administer during an acute asthma attack? A. cromolyn sodium B. prednisone C. fluticasone/salmeterol D. albuterol
D. albuterol
A nurse is caring for a client who's postoperative and has an RR of 9/min secondary to general anesthesia effects. Which of the following ABG values indicates the client is experiencing respiratory acidosis? A. pH 7.50, PO2 95 mm Hg, PaCO2 25 mm Hg, HCO3- 22 mEq/L B. pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3- 30 mEq/L C. pH 7.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3- 20 mEq/L D. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L
D. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L
A home health nurse is teaching a client who has active TB and is following a four-drug medication regimen. Which of the following statements indicates understanding? Select all that apply. a. "I will wash my hands each time I cough" b. "I will wear a mask when I am in a public area" c. "I am glad I don't have to have any more sputum specimens" d. " I don't need to worry where I go once I start taking my medications"
a and b
Which patients may require a CT scan? Select all that apply a. Patient with suspected abdominal bleeding b. Patient with suspected pulmonary embolism c. Patient with fever and a bladder infection d. A pregnant female with a fracture femur
a and b
Which are the clinical manifestations of right-sided heart failure? Select all that apply. a. Ascites b. Dyspnea c. Hepatomegaly d. Generalized edema e. Weak pulses
a, c, and d
A nurse in the emergency department is caring for a client who is experiencing an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? Select all that apply. a. SaO2 95% b. wheezing c. retraction of sternal muscles d. pink mucous membranes e. tachycardia
b, c, and e
Besides monitoring Carlos for decreased perfusion to the heart, which test would best confirm if heart failure is present? a electrocardiogram b. echocardiogram c. serum troponin d. holter monitor
b. echocardiogram
A nurse is assessing a client with a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? a. sex b. environmental allergies c. alcohol use d. history of diabetes
b. environmental allergies
A nurse is caring for a client who has pneumonia. Assessment findings include temperature 100 degrees F, respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions. a. administer antibiotics b. obtain sputum culture c. administer oxygen d. instruct the client to obtain a yearly influenza vaccine
c -> b -> a -> d
Which discharge teaching should the nurse include in the teaching plan for a client who was treated for tuberculosis? Select all that apply. a. "Family members should have chest x-rays done." b. "Stop medication when coughing subsides." c. "Persons living with you should have skin testing." d. "Use your best judgment in terms of your daily medications." e. "Maintain adequate nutrition."
c and e
Carlos is admitted to the ER. Which question will be most appropriate for the nurse to ask in order to determine if Carlos is experiencing angina or myocardial infarction? a. "Why did the pain start?" b. "How did you get to the hospital?" c. "Do you have any other symptoms?" d. "Did you follow your diet and exercise?"
c. "Do you have any other symptoms?"
The nurse is asking family health history information of a young adult. The patient's father has obstructive sleep apnea (OSA). Which statement by the client requires additional education? a. "If I maintain a healthy weight, there is less chance I will get sleep apnea." b. "I'll never be a cigarette smoker like my dad; that's disgusting." c. "I enjoy drinking with my friends; we usually have a few beers each evening." d. "I'm at a higher risk of OSA because I'm a man."
c. "I enjoy drinking with my friends; we usually have a few beers each evening."
Which medication is most likely to be prescribed to treat pulmonary edema in a patient with heart failure? a. Digoxin b. Nesiritide c. Furosemide d. Nitroglycerin
c. Furosemide
It appears Carlos may be having an myocardial infarction. Which test would best confirm the this diagnosis? a. Homocysteine b. CK-BB c. Troponin d. LDL
c. Troponin
Which instruction should the nurse provide to a patient who is scheduled to have an exercise electrocardiography test? a. Have nothing to drink or eat after midnight b. Avoid smoking or drinking for at least 2 weeks before the test c. Wear comfortable, loose clothing and supportive rubber soled shoes d. Someone must drive you home because of the medication side effects.
c. Wear comfortable, loose clothing and supportive rubber soled shoes
The nurse is teaching a patient about the interventions to prevent the development of deep-vein thrombosis (DVT). Which statement made by the patient indicates the need for further teaching? a. "I should take adequate fluids." b. "I should use compression stockings." c. "I should elevate my legs 10° to 20° while at rest." d. "I should limit my physical activity and spend more time sitting."
d. "I should limit my physical activity and spend more time sitting."
A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? a. "I will place the adapter on my finger to read my blood oxygen saturation level." b "I will lie on my back with my knees bent" c. "I will rest my hand over my abdomen to create resistance" d. "I will take in a deep breath and hold it before exhaling"
d. "I will take in a deep breath and hold it before exhaling"
Carlos is instructed to report to the cardiology center the next day for a stress echo test. Which instruction should the nurse provide to Carlos? a. The dye that is inserted may cause a warm flushing sensation. b. It is important to keep a record of activities while you are wearing the monitor c. You will need to be NPO after midnight d. It is important to return to the table immediately following exercising.
d. It is important to return to the table immediately following exercising.
Carols is found to have mild heart failure and is treated with low dose Digoxin and Lasix. To prevent possible complications of this drug combination, the nurse should take which action? a. Keep an accurate measure of intake and output b. Teach the patient about dietary restriction of sodium c. Take the apical pulse and withhold the heart medication if the heart rate is irregular d. Monitor the serum potassium levels
d. Monitor the serum potassium levels
Which condition requires the nurse to educate the patient on steps to prevent vasoconstriction? a. Fluid Volume Deficit b. Beurger's Disease c. Hypernatremia d. Raynaud's Disease
d. Raynaud's Disease
A charge nurse is providing an in-service to a group of staff nurses about endotracheal suctioning. Which of the following statements by a staff nurse indicates an understanding of the teaching? A. "I will use clean technique when suctioning a client's endotracheal tube." B. "I will use a rotating motion when removing the suction catheter." C. "I will suction the oropharyngeal cavity prior to suctioning the endotracheal tube." D. "I will suction a client's endotracheal tube every 2 hours."
B. "I will use a rotating motion when removing the suction catheter."
Which medication is prescribed to enhance contractility of the heart muscle in patients suffering from heart failure? a. Beta blockers b. Angiotensin receptor blockers (ARB) c. Cardiac glycosides d. Venous vasodilators
c. Cardiac glycosides
The nurse is evaluating the effectiveness of a small volume nebulizer bronchodilator treatment for a patient with emphysema. Which assessment change indicates an effective outcome of the therapy? Select all that apply. a. Pulse oximetry reading goes from 92% to 94%. b. Audible wheezes are diminished. c. Heart rate increases from 98 to 110 beats per minute. d. The client states "my breathing is the same." e. Facial complexion is a ruddier color.
a and b
The CT Scan may involve which types of contrast material. Select all that apply. a. oral solution b. injectable material c. barium enema d. suppository medication
a, b, and c
Which tests can the nurse anticipate will be ordered for the patient admitted with chest pain and dyspnea? Select all that apply. a. Troponin b. D-Dimer c. Electrolytes d. Albumin
a, b, and c
The patient is scheduled for a cardiac catheterization. Which interventions are appropriate by the nurse? Select all that apply a. Instruction the patient that a warm sensation may be felt during the procedure b. Inform patient to report pain while the catheter is being inserted c. Instruct the patient that medications will be given to induce sleep d. Check the patient for allergies to shellfish
a, b, and d
Which assessment findings are considered modifiable risk factors for cardiac disease? Select all that apply. a. obesity b. smoking c. parent dies of heart attack at 55 years of age d. diabetes mellitus e. female 60 years of age
a, b, and d
A nurse is assisting a provider who's performing a thoracentesis at the beside of a client. Which of the following actions should the nurse take? (Select all that apply) a. Wear goggles and a mask during the procedure. b. Cleanse the procedure area with an antiseptic solution. c. Instruct the client to take deep breaths during the procedure. d. Position the client laterally on the affected side before the procedure. e. Apply pressure to the site after the procedure.
a, b, and e
The nurse is caring for a client admitted with COPD who is having difficulty breathing. Which actions can the nurse take to provide support? Select all that apply. a. Place client in semi-Fowler's position b. Provide bronchodilators, if ordered c. Offer small, frequent meals d. Encourage smoking cessation e. Wean from oxygen
a, b, c, and d
The nurse is taking a history and vital signs on the patient with fatigue. The nurse notes a regular apical pulse of 110 beat/min. Which contributing factor does the nurse assess as a possible rationale for the patient's condition? (Select all that apply) a. Anxiety b. Stress c. Hypovolemia d. Anemia e. hypothyroidism
a, b, c, and d
A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? Select all that apply. a. client who has dysphagia b. client who has AIDs c. client who was vaccinated for pneumococcus and influenza 6 months ago d. client who is post-op and received local anesthesia e. client who has a closed head injury and is receiving mechanical ventilation f. client who has myasthenia graves
a, b, e, and f Rationale: The client with dysphagia is at risk for pneumonia due to aspiration. The client with AIDs is immunocompromised. The client with the head injury is at risk for ventilator-associated pneumonia. The client with myasthenia graves has generalized weakness and may have difficulty clearing secretions, which can lead to pneumonia.
A patient admitted with a deep vein thrombosis (DVT) asks the nurse what can decrease the risk of getting one in the future. How should the nurse respond? Select all that apply. a. "Be sure to take the anticoagulant medication that you are prescribed upon discharge." b. "Each morning when you get up, perform a daily calf massage." c. "Do not sit in one place for more than an hour or two; get up and walk around." d. "Wear compression stockings during the day, especially when standing for long periods of time." e. "Perform deep breathing exercises every few hours."
a, c, and d
A patient is a female age 35, who smokes a pack of cigarettes a day, has a total cholesterol of 99 and is obese. Her living father had a heart attack at the age of 52 years. This female patient has how many modifiable risk factors? a. One b. Two c. Three d. Four
b. Two
A nurse is caring for a group of clients. Which of the following are at risk for pulmonary embolism? Select all that apply. a. A client who has a BMI of 30 b. A female client who is postmenopausal c. A client who has a fractured femur d. A client who is a marathon runner e. A client who has chronic atrial fibrillation
a, c, and e
A nurse is preparing to administer an initial dose of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects? Select all that apply. a. hypokalemia b. tachycardia c. fluid retention d. nausea e. black, tarry stools
a, c, and e
The nurse is caring for a client with a diagnosis of active tuberculosis. Which symptoms does the nurse expect this client to exhibit? Select all that apply. a. Fever b. Abdominal rigidity c. Abnormal breathing sounds d. Hypothermia e. Decreased oxygen saturation
a, c, and e
Which medications are prescribed for patients with chronic obstructive pulmonary disorder (COPD) because of relaxation of the smooth muscles of the respiratory tract? Select all that apply. a. Anticholinergics b. Glucocorticoids c. Short acting beta2-agonists d. Antibiotics e. Long acting beta2-agonists
a, c, and e
A nurse is providing information about TB to a group of clients at a community center. Which of the following manifestations should the nurse include? Select all that apply. a. Persistent cough b. Weight gain c. Fatigue d. Night sweats e. Purulent sputum
a, c, d, and e
Which instruction should the nurse provide to a client who has just received a PPD (purified protein derivative)? a. Return to the clinic in 48-72 hours to have the test read. b. Take antiviral medication as prescribed. c. Massage the subcutaneous injection site. d. There may be a very small amount of bleeding on the forearm.
a. Return to the clinic in 48-72 hours to have the test read.
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. The nurse should plan to monitor for and report which of the following findings to the provider immediately? a. Slurred speech b. Irregular pulse c. Dependent edema d. Persistent fatigue
a. Slurred speech
Which is the main cause of blood tinged, rust-colored sputum in a patient suffering from tuberculosis (TB)? a. The destruction of lung parenchyma tissue b. The inflammatory process of the lungs c. Decreased pH and increased carbon dioxide (CO2) d. Tachypnea and tachycardia
a. The destruction of lung parenchyma tissue
Which nursing actions are appropriate when caring for a client diagnosed with tuberculosis? Select all that apply. a. Place on droplet precautions. b. Humidify oxygen when administered. c. Request dietary consult. d. Offer family members N95 masks. e. Medication teaching.
b, c, and e
A nurse is assessing a client who has a PE. Which of the following manifestations should the nurse expect? Select all that apply. a. Bradypnea b. Pleural friction rub c. Hypertension d. Petechiae e. Tachycardia
b, d, and e
Carlos is placed on an ACE inhibitor for his hypertension. Which statement by Carlos requires intervention by the nurse? a. "I will remember to take this medication every day in the morning before I leave for work" b. "I am going to limit the fatty snacks and eat more fruits such as cantaloupes and bananas." c. "This medication may make me urinate more since it works with the kidney." d. "I may develop a cough with this medication and will notify the doctor if one develops".
b. "I am going to limit the fatty snacks and eat more fruits such as cantaloupes and bananas."
A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following statements indicates understanding? a. "This medication can decrease my immune response" b. "I take this medication to prevent asthma attacks" c. "I need to take this medication with food" d. "This medication has a slow onset to treat my symptoms"
b. "I take this medication to prevent asthma attacks"
A nurse is monitoring a client's ECG monitor and notes the client's rhythm has changed from normal sinus rhythm to supraventricular tachycardia. The nurse should prepare to assist with which of the following interventions? a. Initiate chest compressions b. Vagal stimulation c. Administration of atropine IV d. Defibrillation
b. Vagal stimulation
The nurse is consulting with a nutritionist about the dietary therapy for a patient with chronic venous stasis ulcers. What are the dietary recommendations would be most important to recommend to this patient? a. Low sodium foods b. Vitamin A, & C and zinc c. Low fat foods d. High calcium foods
b. Vitamin A, & C and zinc
A nurse is assessing a client who has left-sided heart failure. Which of the following manifestations should the nurse expect to find? a. Increased abdominal girth b. Weak peripheral pulses c. Jugular venous neck distention d. Dependent edema
b. Weak peripheral pulses
A nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hrs. Which of the following client statements indicates a need for further clarification by the nurse? a. "My arthritis is really bothering me because I haven't taken my aspirin in a week" b. "My blood pressure shouldn't be high because I took my blood pressure medication this morning" c. "I took my warfarin last night according to my usual schedule" d. "I will check my blood sugar because I took a reduced dose of insulin this morning"
c. "I took my warfarin last night according to my usual schedule"
A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following statements indicates understanding? a. "I will decrease my fluid intake while taking this medication" b. "I will expect to have black, tarry stools" c. "I will take my medication with meals" d. "I will monitor for weight loss while on this medication"
c. "I will take my medication with meals"
A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following statements should the nurse include? a. "Take quick breaths upon inhalation" b. "Place your hand over your stomach' c. "Take a deep breath int through your nose" d. "Puff your cheeks upon exhalation"
c. "Take a deep breath int through your nose"
Which patient is at greatest risk for developing venous insufficiency? a. 37-year-old mail carrier b. 19-year-old retail store cashier c. 40-year-old operating room scrub nurse d. 25-year-old pregnant woman in the first trimester
c. 40-year-old operating room scrub nurse Rationale: They are standing for a long period of time
Carlos has the following lipid levels... HDL: 32 mg/dLLDL: 190 mg/dLTotal Cholesterol: 250mg/dL Carlos inquires about these levels. Which statement is most appropriate by the nurse? a. Total cholesterol below 300mg/dL is normal b. As long as the LDL is below 200 mg/dL no medications are needed c. A HDL level below 40 mg/dL is a risk factor for heart disease d. These levels are borderline and given your risk factors, diet and activity changes need to be made.
c. A HDL level below 40 mg/dL is a risk factor for heart disease
A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states, "I am anxious and unable to get enough air." Vital signs are HR 117/min, RR 38/min, temp 101.2 degrees F, and BP 100/54. Which of the following actions if the priority? a. Notify the provider b. Administer heparin via IV c. Administer oxygen therapy d. Obtain a CT scan
c. Administer oxygen therapy
Which is true regarding influenza? a. Decreased activity tolerance is related to impaired alveolar-capillary interface. b. Altered nutrition status is related to insensible losses from fever and tachypnea. c. Alteration in decreased gas exchange is related to impaired alveolar-capillary interface. d. An ineffective breathing pattern is related to hypoxia resulting in decreased tissue perfusion.
c. Alteration in decreased gas exchange is related to impaired alveolar-capillary interface.
Which assessment is essential for the nurse to complete immediately following a transesophageal echocardiogram (TEE)? a. Check pedal pulses b. Monitor urine output c. Check gag reflex d. Complete a neuro assessment
c. Check gag reflex
A nurse is reviewing the lab results of several male clients who have peripheral arterial disease. the nurse should plan to provide dietary teaching for the client who has which of the following lab values? a. Cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90 mg/dL b. Cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dL c. Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL d. Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL
c. Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL
A patient with a severe cough and decreased appetite arrives at the hospital. On assessment, the nurse finds the anterior-posterior diameter as 2:2. After reviewing the assessment findings, what action should the nurse take first? a. Apply 100% nonrebreather mask. b. Request a bronchodilator small volume nebulizer (SVN) treatment. c. Encourage pursed-lip breathing. d. Draw arterial blood gasses.
c. Encourage pursed-lip breathing.
A patient with a lower extremity thrombosis is found to have tenderness and pain in the distal thigh and popliteal regions. There is swelling that has extended to the knee. Which is the most likely cause? a. Iliofemoral thrombosis b. Calf thrombosis c. Femoral thrombosis d. Upper extremity thrombosis
c. Femoral thrombosis
Carlos just finished arguing with Eleanor (mother-in-law) regarding taking over the TV and smoking in the house. (Carlos is trying to quit smoking again). Shortly after he approaches Debbie and states that his head and chest hurts. He reported taking one Nitro tab 5 minutes ago. Which actions should Debbie take first? a. Take Carlos's blood pressure, tell him to avoid Eleanor and sit down b. Inquire if Carlos administered his nitroglycerin patch and take a 2nd sublingual tab c. Given him an Aspirin and another sublingual Nitro tab and call 911 d. Discuss the possibility of Eleanor living somewhere else and tell Carlos to ignore her.
c. Given him an Aspirin and another sublingual Nitro tab and call 911
The nurse is teaching about spironolactone as a treatment for patients with heart failure. Which dietary instruction indicates a need for further teaching? a. "Avoid alcohol intake." b. "Limit salt in your diet." c. "Decrease the intake of foods that are high in fat." d. "Increase the intake of potassium-containing foods."
d. "Increase the intake of potassium-containing foods."
A nurse is providing teaching for a client who is 2 days postoperative following a heart transplant. which of the following statements should the nurse include in the teaching? a. "Your level of activity intolerance will not change" b. "You will be able to stop taking immunosuppressant's after 12 months c. "After 6 months you will no longer need to restrict your sodium intake" d. "You might no longer be able to feel chest pain"
d. "You might no longer be able to feel chest pain"
Which patient with asthma requires immediate treatment? a. A patient with a pulse rate of 65 beats/min b. A patient with oxygen saturation of 90% c. A patient with blood pressure 120/90 mm Hg d. A patient with respiratory rate 12 breaths/min
d. A patient with respiratory rate 12 breaths/min
A nurse in an emergency department is caring for a client who had an anterior myocardial infarction. The client's history reveals she is 1 week post-op following an open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated? a. Administering IV morphine sulfate b. Administering oxygen at 2 L/min via nasal cannula c. Helping the client to the bedside commode d. Assisting with thrombolytic therapy
d. Assisting with thrombolytic therapy
The patient is experiencing a decreased pulse oximetry reading with obvious respiratory distress. Auscultation reveals wheezing, especially on expiration. The peak flow reading is lower than normal. Which medication should the nurse administer? a. Mucolytics b. Antibiotics c. Corticosteroids d. Bronchodilators
d. Bronchodilators
The patient has a peripheral arterial bypass with graft placement. The nurse notes erythema, tenderness and drainage at the site. What should the nurse do next? a. Notify the physician b. Auscultate the patient's lungs and check the pulse oximeter c. Assess the patient for signs of bleeding and reviews the PT results d. Checks the patient's temperature and looks at the white blood cell count.
d. Checks the patient's temperature and looks at the white blood cell count.
A woman who is undergoing chemotherapy for breast cancer develops a warm, reddened area in her left calf. The nurse gives a Situation, Background, Assessment, Recommendation (SBAR) report to the provider. Which test should the nurse request? a. Radiography imaging b. D-dimer test c. Treadmill test d. Plethysmography
b. D-dimer test
For a patient with a thoracentesis, which assessment would be of concern? a. Decrease in accessory muscles b. Decreased breath sounds c. Pain at the puncture site d. Increased appetite
b. Decreased breath sounds
The patient is admitted to the emergency room with suspected heart failure. Which action should the nurse take first? a. Ask the patient about his symptoms b. Assess the heart rate and lungs sounds c. Check for peripheral edema d. Check troponin and electrolyte levels
b. Assess the heart rate and lungs sounds
The nurse is explaining to the nursing student the concept of Virchow's triad, the three mechanisms that can create a venous thrombosis. The nurse explains that which of the following is not a mechanism included in Virchow's triad? a. Increased tendency of the blood to clot b. Decreased number of platelets c. Decreased blood flow rate d. Damage to the blood vessel wall
b. Decreased number of platelets
A patient reporting chest tightness arrives at the hospital. On assessment, the nurse notes wheezing, cough, elevated blood pressure, and pulse rate. The primary healthcare provider prescribes corticosteroids. Which is the most likely outcome of the prescribed therapy? a. Increases the hydration of airway b. Decreases the inflammation of the airway c. Aids in bronchial smooth muscle relaxation d. Aids in muscle relaxation around the alveoli
b. Decreases the inflammation of the airway
A nurse in an emergency department s caring for a client who has a blood pressure of 254/139 mm hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first. a. Tell the client to report vision changes b. Elevate the head of the clients bed c. Start a peripheral IV d. Initiate Seizure precautions
b. Elevate the head of the clients bed
The nurse is teaching a client about a thoracentesis. How would the nurse best describe this procedure? a. You will be asleep when they make the incision b. Fluid will be drawn off the area around your lung c. It involves lying very still in a large noisy machine d. Your doctor will be able to see inside the lung
b. Fluid will be drawn off the area around your lung
The nurse is caring for a patient with COPD who is on ventilator therapy. Which test is most beneficial to evaluate the patient's response to ventilator therapy? a. Spirometry b. Pulse oximetry c. Arterial blood gases (ABG) d. Forced expiratory volume (FEV1)
c. Arterial blood gases (ABG)
Which is true regarding emphysema? a. It is caused by inflammation of bronchioles. b. It is associated with blood-tinged sputum. c. It is associated with chronic respiratory acidosis. d. It is associated with chronic dilation of bronchioles.
c. It is associated with chronic respiratory acidosis.
The nurse is caring for a patient who is receiving intravenous therapy for a pulmonary embolism. The activated partial thromboplastin time (aPTT) returns at 100 seconds. What action should the nurse anticipate? a. Leave the heparin infusion at the current rate and reevaluate the aPPT in 4 hours. b. Stop the heparin infusion and discontinue the medication. c. Lower the dose of heparin and reevaluate the aPTT in 4 to 6 hours. d. Increase the dose of heparin and reevaluate the aPTT in 6 hours.
c. Lower the dose of heparin and reevaluate the aPTT in 4 to 6 hours. Rationale: If the aPTT is above therapeutic (40-90 seconds), the rate of the infusion will be reduced.
Which course of action should a nurse take when caring for a patient with influenza to prevent secondary bacterial pneumonia? a. Administer humidified supplemental oxygen to the patient. b. Administer antipyretics to the patient per order. c. Place the patient's head of the bed in a semi- to high-Fowler's position. d. Ensure that adequate fluid is provided to the patient.
c. Place the patient's head of the bed in a semi- to high-Fowler's position.
The nurse is assessing a patient who has developed orthopnea and rales. On further investigation, the nurse finds that the patient often coughs up rust-colored sputum. The patient also has night sweats and weight loss. Which kind of tuberculosis (TB) does the nurse expect the patient to be diagnosed with in this situation? a. Latent TB infection (LTBI) b. Multidrug-resistant TB (MDR TB) c. Primary progressive TB infection (PPTBI) d. Primary TB infection (PTBI)
c. Primary progressive TB infection (PPTBI)
The Troponin level was slightly elevated and it appears that Carlos has experienced a minor MI. The nurse administered Morphine IV to Carlos after still reporting a pain rating of 9 (0-10 scale). When evaluating the response 5 minutes after giving the medication, which data would indicate a need for immediate further action? a. The blood pressure decreases from 114/65 to 106/58 b. The respiratory rate drops from 18 to 14 breaths/minute c. Carlos complains of feeling dizzy and lightheaded d. Carlos complains has chest pain at a level of 3 (0-10 level)
d. Carlos complains has chest pain at a level of 3 (0-10 level)
Which finding indicates to the nurse that treatment plan for Carlos's heart failure is effective? a. Peripheral pulse has changed from +3 to +4 b. Lungs are clear to auscultation c. Minimal jugular vein distention d. Carlos reports completing ADL without dyspnea
d. Carlos reports completing ADL without dyspnea
A patient has a positive D-dimer and has just returned from a positive spiral CT scan. What vital sign changes should the nurse anticipate? Select all that apply. a. Tachycardia b. Hypotension c. Hyperthermia d. Hypoventilation e. Hypoxia
a, b, c, and e
Carols is being discharged and will be participating in outpatient cardiac rehab. Which statements by Carlos warrants further teaching by the nurse? (Mark all that apply) a. "I will use my push lawn mower early in the day when it is not so hot" b. "I can change my diet to decrease my intake of fatty foods." c. "I am looking forward to resuming my skiing activity in a few weeks since it reduces my stress." d. "I need to take my medication every day to keep my blood pressure under control." e. "I can't wait to start my weight lifting again next week at the gym."
a, c, and d
The nurse is evaluating the effectiveness of therapy in a patient with asthma. Which statement made by the patient indicates an effective outcome of the therapy? Select all that apply. a. "I stopped smoking 3 months ago." b. "I keep my pets in a separate room." c. "I can speak in complete sentences without shortness of breath." d. "I can breathe easier through pursed-lip breathing." e. "I monitor my peak flow reading every other day."
a, c, and d
A nurse is planning a presentation for a group of clients who have hypertension. Which of the following lifestyle modifications should the nurse include? Select all that apply. a. Tobacco cessation b. Decreased magnesium intake c. Reduced potassium intake d. Regular exercise program e. Limited alcohol intake
a, d, and e
The nurse is teaching about the pathophysiology of tuberculosis (TB). Which statement made is correct? a. "Destruction of the lung tissue occurs in the patient during granuloma formation." b. "Pleuritic chest pain is the result of the sputum present." c. "The unexplained weight loss is due to the destruction of lung tissue." d. "Micro bleeds are the result of the collection of white blood cells in an attempt to wall off the infection."
a. "Destruction of the lung tissue occurs in the patient during granuloma formation."
A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure? a. "I can't get rid of these hiccups" b. "I feel dizzy when I stand" c. "My incision site stings" d. "I have a headache"
a. "I can't get rid of these hiccups" Rationale: Hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can occur as a result of a lead wire perforation.
The nurse is evaluating a patient's knowledge about cholesterol maintenance. Which statement by the patient requires correction? a. "I need to keep my LDL cholesterol higher than 100 mg/dL." b. "My HDL cholesterol is good and should be as high as possible." c. "It is good if my total cholesterol is below 200 mg/dL." d. "My triglyceride levels should be less than 150 mg/dL."
a. "I need to keep my LDL cholesterol higher than 100 mg/dL."
A nurse si discharging a client who has COPD. The client is concerned about not being able to leave the house due to the need for staying on continuous oxygen. Which of the following responses should the nurse make? a. "There are portable oxygen delivery systems that you can take with you" b."When you go out, you can remove the oxygen and then reapply it when you get home" c. "You probably will not be able to go out as much as you used to" d. "Home health services will come to you so you will not need to get out"
a. "There are portable oxygen delivery systems that you can take with you"
A nurse is assessing a client who has pulmonary edema related to heart failure. Which of the following findings indicates effective treatment of the client's condition? a. Absence of adventitious breath sounds b. Presence of a nonproductive cough c. Decrease in respiratory rate at rest d. SaO2 86% on room air
a. Absence of adventitious breath sounds
The nurse is assessing a patient with tuberculosis (TB). Which best describes the gas exchange in the patient? a. Alteration in gas exchange related to necrosis of lung tissue b. Alteration in comfort: pain related to pleurisy c. Risk for fluid volume deficit related to insensible losses from fever and tachypnea d. Alteration in gas exchange: decreased related to impaired alveolar-capillary interface
a. Alteration in gas exchange related to necrosis of lung tissue
The nurse is assessing a patient who is suspected to have left-sided heart failure. Which assessment provides specific information regarding the left-sided heart function? a. Auscultating lung sounds b. Monitoring for hepatomegaly c. Palpating for peripheral edema d. Assessing for jugular vein distension
a. Auscultating lung sounds
The nurse on the 3-11 shift received report and is caring for three patents in addition to Carlos. Which patient should the nurse see first? a. Carlos scheduled for discharge tomorrow, reported vomiting a few minutes ago and is complaining of muscle weakness b. Mike newly diagnosed with hypertension, is awaiting medication teaching and needs an echocardiogram c. Rocco 3 days post MI is constipated, anxious and demanding that the doctor be notified. d. Ann admitted with acute coronary syndrome received her first dose of propranolol (Inderal) and aspirin this morning.
a. Carlos scheduled for discharge tomorrow, reported vomiting a few minutes ago and is complaining of muscle weakness Rationale: Possible Digoxin toxicity
Carlos 's stress test reflects angina and he is ordered Nitroglycerin SL prn for pain and nitroglycerin transdermal patch apply in am and remove at bedtime. Which instruction should the nurse provide regarding these medications? a. Change position slowly b. Chew the nitroglycerin tab to enhance absorption c. Store the Nitroglycerin patches in the refrigerator d. You cannot take both the patch and tablets at the same time.
a. Change position slowly Rationale: Nitro puts at risk for orthostatic HTN
Which diagnostic test can the nurse expect the health care provider will order first for the patient with a heart murmur? a. Echocardiogram b. Holter monitor c. Cardiac catheterization d. Stress test
a. Echocardiogram
A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? a. Hip arthroplasty 2 weeks ago b. Elevated sedimentation rate c. Incident of exercise-induced asthma 1 week ago d. Elevated platelet count
a. Hip arthroplasty 2 weeks ago Rationale: A patient who has had a major surgery within the last few weeks should not receive thrombolytic therapy because of the risk of hemorrhage from the surgical site.
A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? a. I smoked a cigarette this morning to calm my nerves about having this procedure b. I didn't take my heart pills this morning because my doctor told me not to c. I have had chest pain a couple of times since I saw my doctor in the office last week d. Im still hungry after the bowl of cereal I ate at 7 am
a. I smoked a cigarette this morning to calm my nerves about having this procedure
The instructor is monitoring a student who is caring for a patient returning to the unit from a cardiac catheterization(femoral vein used). Which student action requires the nursing instructor to intervene? The student... a. Instructs the patient to remain in bed for 24 hours b. Assesses the pedal pulses and skin for temperature and color c. Monitors the intake and output d. Checks the patient's groin pressure dressing
a. Instructs the patient to remain in bed for 24 hours
Which is true regarding primary progressive TB infection (PPTBI)? a. It may develop in individuals who are exposed to bacterium. b. It may mean that the first-line medications used for the treatment of TB will be ineffective. c. It is often asymptomatic and is only confirmed by positive sputum cultures and a positive skin test. d. It is only when the immune system becomes compromised that the disease can become reactivated.
a. It may develop in individuals who are exposed to bacterium.
A patient with end-stage chronic obstructive pulmonary disorder (COPD) develops sudden dyspnea and chest pain. A spontaneous pneumothorax is suspected. What is the nurse's priority action? a. Maintain oxygenation. b. Place chest tube. c. Intubate. d. Provide pain medicine.
a. Maintain oxygenation.
Which classification of tuberculosis (TB) infection can be caused by primary or secondary spread? a. Multidrug-resistant TB b. Latent TB infection c. Primary TB infection d. Primary progressive TB infection
a. Multidrug-resistant TB
A nurse is teaching a client who is starting to take an ace inhibitor to treat hypertension. The nurse should instruct the client to notify his provider if he experiences which of the following adverse effects of this medication? a. Persistent Cough b. Frequent Urination c. Constipation d. Tendon Pain
a. Persistent Cough
A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching? a. Place the patch on an area of skin away from skin folds and joints b. Apply the new patch to the same site as the previous patch c. Replace the patch at the onset of angina d. Keep the patch on 24 hr per day
a. Place the patch on an area of skin away from skin folds and joints
The nurse is teamed with an LPN in caring for a group of patients on a cardiac floor. Which action by the LPN indicates the need for the RN to intervene immediately? a. Reminds the patient of his NPO status after returning from a cardiac catheterization b. Checks a patient's blood pressure before administering Nitroglycerin SL c. Returns a patient back to bed after the patient's heart rate increases 72 to 96 while ambulating in the hall d. Brings breakfast to a patient scheduled for an echocardiogram later in the morning
a. Reminds the patient of his NPO status after returning from a cardiac catheterization Rationale: Patient is not NPO following cardiac Cath. The patient needs to drink fluids to flush out dye.
A nurse is caring for a client who, upon awakening, was disoriented to person, place and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority? a. obtain baseline vital signs and oxygen saturation b. obtain a sputum culture c. obtain a complete history from the client d. provide a pneumococcal vaccine
a. obtain baseline vital signs and oxygen saturation
A nurse is caring for a postoperative client 1 hr following an aortic aneurysm repair. which of the following findings can indicate shock and should be reported to the provider? a. urine output of 20ml/hr b. Severe pain with coughing c. Serosanguineous drainage on dressing d. increase in temperature from 98.2 to 99.5
a. urine output of 20ml/hr
The student nurse is reviewing care of patients post bronchoscopy. Which statement by the student warrants action by the instructor? a. "I will check the pulse ox frequently." b. "I will encourage fluids to flush out the dye." c. "I will check the sputum for blood." d. "I will monitor for any stridor or wheezing."
b. "I will encourage fluids to flush out the dye."
A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include? a. "You will need to continue to take the multi medication regimen for 4 months" b. "You will need to provide monthly sputum samples to monitor the effectiveness of the medication" c. "You will need to remain hospitalized for treatment" d. "You will need to wear a mask at all times"
b. "You will need to provide monthly sputum samples to monitor the effectiveness of the medication"
Which patient scheduled for a MRI with contrast requires immediate action by the nurse? a. 18 year old who has a suspected muscle tear in the right thigh muscle and in severe pain is scheduled for MRI of leg b. 30 year old with chronic renal failure and lower back pain is scheduled for MRI of the spine c. 40 year old with a history of migraines that are getting worse is scheduled for MRI of the head d. 75 year old with right side and leg pain and has difficulty walking is scheduled for MRI of the hip
b. 30 year old with chronic renal failure and lower back pain is scheduled for MRI of the spine
A nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral arterial disease? a. A client who has hypothyroidism b. A client who has diabetes mellitus c. A client whose daily caloric intake consists of 25% fat d. A client who consumes two 12-oz beers a day
b. A client who has diabetes mellitus
A patient with a cardiac disease presents with an elevated homocysteine level. Which diet instruction should the nurse recommend to the patient? a. A diet with total fat that is less than 30% of total calories. b. A diet that includes green vegetables c. Increasing fiber in the diet d. Avoiding canned food and processed meats
b. A diet that includes green vegetables
Which assessment finding would cause the nurse the greatest concern in a patient with hypertension? a. A patient has BP readings ranging from 120/70 to 150/85. b. A urine sample shows positive albumin c. A patient has a BP of 130/80 in the right arm and 135/85 in the left arm. d. A dietary history demonstrated that the patient is consuming processed and instant foods.
b. A urine sample shows positive albumin Rationale: Target organ damage is a concern
The client with emphysema comes to the emergency department with difficulty breathing. What assessment finding should the nurse anticipate? a. Excess mucous production b. Barrel shaped chest c. Hypoventilation d. Blueish skin tones
b. Barrel shaped chest
A nurse is caring for a client who is 8 hr postoperative following a coronary artery bypass graft (CABG). Which of the following client findings should the nurse report? a. Mediastinal drainage 100 mL/hr b. Blood pressure 160/80 mmHg c. Temperature 37.1 C d. Potassium 4.0 mEq/L
b. Blood pressure 160/80 mmHg
Which assessment is essential for the nurse to make following a bronchoscopy? a. Check level of consciousness b. Check gag reflex c. Check neuromuscular function d. Check pedal pulses
b. Check gag reflex Rationale: Remember reflex was numbed to allow passage of scope. Need to verify reflex has returned prior any fluids given to prevent aspiration
The patient is returning to the floor after a cardiac catheterization. Two hours later, the patient complains of numbness and pain in the right foot. Which action should the nurse take next? a. Call physician b. Check the pedal pulse c. Take the blood pressure d. Inform the patient this is expected e. Continue to monitor
b. Check the pedal pulse
A nurse in an emergency room is assessing a client who has bradydysrhythmia. Which of the following findings should the nurse monitor for? a. Friction Rub b. Confusion c. Dry Skin d. Hypertension
b. Confusion
The nurse is reviewing the report from the test in the image of a patient being ruled out for a pulmonary embolism (PE). What finding would suggest a clot is present in the lungs? a. High-ventilation with high-perfusion b. High-ventilation with low-perfusion c. Low-ventilation with high-perfusion d. Low-ventilation with low-perfusion
b. High-ventilation with low-perfusion
It is determined that Carlos now needs to undergo a cardiac catheterization with possible percutaneous transluminal coronary angioplasty. Which action is most appropriate by the nurse when Carlos returns back to the floor? a. Obtain lung sounds and apical pulse every 15 minutes b. Instruct Carlos to stay in bed and keep leg immobilized c. Limit one visitor per hour and monitor Carlos 's temperature d. Check the gag reflex before starting fluids
b. Instruct Carlos to stay in bed and keep leg immobilized
Which nursing intervention should be considered a priority when caring for a patient with tuberculosis (TB) infection? a. Conducting a Mantoux Tuberculin skin test as prescribed b. Isolating the patient in a private room with negative airflow c. Conducting a chest x-ray per order of the provider d. Administering first-line antitubercular medications as prescribed
b. Isolating the patient in a private room with negative airflow
A nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following adverse effects of the medication? a. SOB b. Lightheadedness c. Dry cough d. Metallic taste
b. Lightheadedness
A patient comes to the clinic with a 7-day history of purulent nasal drainage, facial pressure, and pain. He has been using oral and nasal decongestants, and over-the-counter pain and sleep medicine. He says, "I am miserable!" What is the nurse's priority assessment? a. Auscultation of the lung sounds. b. Obtain a temperature. c. Observation of the color of nasal drainage. d. Obtain an allergy history.
b. Obtain a temperature.
The nurse is reviewing the factors of deep-vein thrombosis. What provides the greatest risk? a. Diabetes b. Pregnancy c. Dyslipidemia d. Limb ischemia
b. Pregnancy
A patient with chronic obstructive pulmonary disorder (COPD) is reporting shortness of breath. On assessment, the nurse finds a pulse rate of 115 beats/min, a blood pressure of 152/94 mm Hg, a temperature of 101°F, and a respiratory rate of 28. Which respiratory test is priority? a. Perform incentive spirometry b. Pulse oximetry c. Obtain a forced expiratory volume d. Peak expiratory flow readings
b. Pulse oximetry
The nurse is caring for a patient with asthma. Which assessment finding noted by the nurse indicates poor oxygenation? a. Temperature of 101°F b. Pulse rate of 110 beats/min c. Blood pressure of 120/80 mm Hg d. Respiratory rate of 35 breaths/min
b. Pulse rate of 110 beats/min
A nurse is caring for client who is receiving heparin therapy and develops hematuria. which of the following actions should the nurse take if the clients aPTT is 96 seconds? a. Request a Prothrombin time (PT) b. Stop the heparin infusion c. Continue to monitor the heparin infusion as prescribed d. Increase the heparin infusion flow rate by 2ml/hr
b. Stop the heparin infusion
Which statement by the nursing student warrants intervention by the instructor? Central Perfusion.... a. begins when the heart is stimulated by an electrical impulse b. involves the body's ability to maintain cardiac output c. involves blood flowing through arteries and capillaries to the target organs d. is impacted by preload and afterload
c. involves blood flowing through arteries and capillaries to the target organs
A nurse is providing discharge teaching for a client who has a heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider? a. increase of 10 mm/hg in systolic blood pressure b. dizziness when rising quickly c. weight gain of 0.9KG (2lb) in 24 hr d. dyspnea with exertion
c. weight gain of 0.9KG (2lb) in 24 hr
Which assessment is essential for the nurse to ask the patient prior to a MRI procedure? a. Do you take any sedative medications? b. Do you have a history of headaches? c. Do you have any hearing issues? d. Do you have any metal or implants in your body?
d. Do you have any metal or implants in your body?
The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. Which assessment can the nurse expect to find in this patient? a. Bounding pulse b. Night blindness c. Pupil dilate d. Elevated blood pressure
d. Elevated blood pressure
A nurse is assessing a client who has a history of DVT and is receiving warfarin. Which of the following findings should indicate to the nurse that the medication is effective? a. Hemoglobin 14 g/dL b. Minimal bruising of extremities c. Decreased BP d. INR 2.0
d. INR 2.0
The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order? a. Furosemide (Lasix) 20 mg po now b. Oxygen via face mask at 2 L c. KCl 20 mEq PO two times per day d. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
d. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
A patient with asthma is reporting shortness of breath. On assessment, the nurse finds a pulse rate of 110 beats/min, a blood pressure of 130/90 mm Hg, and a temperature of 101°F (37.8°C). Which diagnostic test is most beneficial in determining the treatment plan? a. Spirometry b. Pulse oximetry c. Forced expiratory volume d. Peak expiratory flow readings
d. Peak expiratory flow readings
A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure? a. Hemoglobin 14.4 g/dL b. History of PAD c. Urine output 200 mL/4 hrs d. Previous allergic reaction to shellfish
d. Previous allergic reaction to shellfish
A nurse is caring for a client who was admitted for a treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. the client is experiencing weakness and an irregular hear rate. which of the following actions should the nurse take first? a. Obtain clients current weight b. Determine the time of the last digoxin dose c. Check the clients urine output d. Review serum electrolyte Values
d. Review serum electrolyte Values
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complications? a. Ventricular depolarization b. Guillain-Barre syndrome c. Myelodysplastic syndrome d. Valvular disease
d. Valvular disease
A nurse is caring for a client that has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to administer? a. antibiotic b. beta-blocker c. antiviral d. beta-2 agonist
d. beta-2 agonist
A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer? a. ask if the client has had a recent infection b. Explore the clients family history of peripheral vascular disease c. Note the presence of absence of pain at the ulcer site d. inquire about the presence or absence of claudication
d. inquire about the presence or absence of claudication
A nurse is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? a. percussion of posterior lobes of lungs b. auscultation of the trachea c. inspection of the conjunctive d. palpation of the orbital areas
d. palpation of the orbital areas
