Realize It 4-6
The nurse is preparing an educational session for student nurses on the differences between diverticulitis and diverticulosis. The nurse should ensure that the students understand that diverticulosis often has which of the following? Localized cramping Often has no symptoms Frequently develops peritonitis Rectal bleeding
Diverticulosis is the presence of multiple non-inflamed diverticula. Diverticulitis is inflammation of one or more diverticula, resulting in perforation into the peritoneum.
The nurse is assessing a patient with chronic heart failure. The nurse would expect to identify which of these clinical manifestations? Expiratory wheezing Inspiratory crackles Asymmetrical chest expansion Subcutaneous crepitus
When the heart's pumping ability is impaired it can cause respiratory problems. There are no valves to protect the pulmonary system from increased pressure in the left atrium. When there is decreased pumping ability of the heart fluid backs up into the pulmonary system. Inspiratory crackles are caused when air collides with fluid in the lungs.
The nurse is caring for a patient who has been diagnosed with heart failure. Which statement, if made by the patient, supports the diagnosis of heart failure? "I get out of breath when I go up a flight of stairs." "I get hot and break out in a sweat during the night." "I often feel pain in my lower legs when I take my walk." "I sometimes feel pain in the middle of my chest during exercise."
"I get out of breath when I go up a flight of stairs." Each of these statements are associated with common alterations in health. Think about how decreased pumping ability of the heart can cause problems during the patient's daily activities. Decreased pumping ability of the heart results in decreased cardiac output and pulmonary congestion, causing shortness of breath.
The nurse is educating a patient about the care related to a new diagnosis of mitral valve prolapse. What statement made by the client demonstrates understanding? "I will avoid caffeine, alcohol, and smoking." "I shouldn't get a tattoo but I can get my tongue pierced." "I will take antibiotics before getting my teeth cleaned." "This disorder will progress and I will need a heart transplant."
"I will avoid caffeine, alcohol, and smoking."
The nurse is caring for a patient who has been diagnosed with heart failure and has been prescribed digoxin (Lanoxin). Which of the following will the nurse include when teaching the patient about this medication? Select all that apply "Report any visual changes to the doctor's office immediately." "Call the doctor's office if you experience nausea or lack of appetite." "Increase dietary sodium to maintain your fluid balance." "If you miss a dose, you should double the dose next time." "If your pulse is less than 60 beats per minute, do not take the medication." "You should keep a record of your daily weights."
"Report any visual changes to the doctor's office immediately." "Call the doctor's office if you experience nausea or lack of appetite." "If your pulse is less than 60 beats per minute, do not take the medication." "You should keep a record of your daily weights." The nurse will teach the patient about how the medication helps treat problems caused by heart failure. The patient should be taught how to self-administer the medication safely. The patient needs to know how to recognize signs and symptoms of digoxin toxicity. Doubling the dose of digoxin is not safe because it has a narrow therapeutic index. Increased dietary sodium adds to the circulatory volume and can increase the workload on the heart.
Which of the following laboratory tests indicates a diagnosis of pancreatitis? (1) Lipase 230 IU/L (2) Calcium 6.0 mEq/L (3) Blood glucose 65 mg/dL (4) WBC count 5,000/mm3
(1) Lipase 230 IU/L\ For pancreatits, the liapse, amylase, glucose and WBC are all elevated. The calcium is low for 7-10 days and is a sign of severe pancreatitis.
For a patient with advanced cirrhosis, which assessment finding best indicates deterioration of liver function.\ ? (1) fatigue and muscle weakness (2) Difficulty in arousal (3) Nausea and anorexia (4) Weight gain
(2) Difficulty in arousal
Which of the follwing clients is more likely to develop pancreatitis? (1) 59 y/o male w/ a hx of occasional ETOH use (2) Pt. w/ renal problems and hypocalcemia (3) Pt. recovering from MI with hypercholesterolemia (4) A client with a stone lodged in the pancreatic duct
(4) A client with a stone lodged in the pancreatic duct
The client with pancreatitis may exhibit Cullen's sign on physical examination. Which of the following data best describes Cullen's sign? (1) Jaundiced sclera (2) Pain that occurs with movement (3) Bluish discoloration of the left flank area (4) Bluish discoloration of the periumbilical area
(4) Bluish discoloration of the periumbilical area
What is the duration of a normal PR-interval? 0.04 - 0.12 seconds (1-3 small squares) 0.12-0.2 seconds (3-5 small squares) 0.8-0.12 (2-3 small square) 0.04-0.08 seconds (1-2 small squares
0.12-0.2 seconds (3-5 small squares)
For the client with ascites receiving diuretic therapy, careful intake and output measurement is essential for safe diuretic therapy. Diuretics lead to fluid losses, which if not monitored closely and documented, could place the client at risk for serious fluid and electrolyte imbalances. After administration of a diuretic a key nursing action is strict monitoring of intake and output. The nurse would want to check the client's weight on a daily basis and would monitor for hypokalemia versus hyperkalemia. Similarly, the pertinent risk for this patient would be hypovolemia post-diuretic administration as opposed to hypervolemia.
Hepatic encephalopathy results from an increased ammonia level due to the liver's inability to covert ammonia to urea, which leads to neurologic dysfunction and possible brain damage.
The nurse is completing discharge planning for a client with hepatitis A. Which of the following information should be included for the family to reduce the risk of spread? Using good sanitation with dishes and shared bathrooms Forbidding the sharing of needles or syringes Avoiding contact with blood-soiled clothing or dressing Keeping the client in complete isolation
Hepatitis A is transmitted through the fecal oral route or from contaminated water or food. Measures to protect the family include good handwashing, personal hygiene and sanitation, and use of standard precautions. Complete isolation is not required.
A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of: 1. water and sodium retention secondary to a severe decrease in the glomerular filtration rate. 2. a decreased serum phosphate level secondary to kidney failure. 3. an increased serum calcium level secondary to kidney failure. 4. metabolic alkalosis secondary to retention of hydrogen ions.
1. water and sodium retention secondary to a severe decrease in the glomerular filtration rate.
The nurse is assessing a client diagnosed with Irritable Bowel Syndrome (IBS). The nurse understand that a diagnosis is achieved by which of the following? CT Scan Symptoms Blood tests X-ray
IBS is diagnosed solely on symptoms. Diagnosing IBS requires the presence of abdominal pain and/or discomfort at least 3 months that is associated with two or more of the following: improvement with defecation, change in stool frequency at onset, or change in the stool appearance at onset
If a rhythm is described as sinus, what does this indicate? QRS-complexes are present P-waves are present A QRS-complex precedes each T-wave A P-wave precedes each QRS-complex
If a rhythm is describes as sinus it indicates that a P-wave precedes each QRS-complex.
The nurse is caring for a patient who has physiological changes common in geriatric patients. The nurse understands that which of these factors may increase the risk of heart failure in older patients? Increased myocardial contractility Increased stroke volume Impaired diastolic filling Decreased sympathetic activity
Impaired diastolic filling As a person ages, the myocardium becomes less compliant. Decreased myocardial compliance results in impaired filling of the cardiac chambers during diastole. Impaired filling during diastole may result in diastolic heart failure.
Septal involvement occurs in which type of cardiomyopathy? Dilated Hypertrophic Congestive Restrictive
In hypertrophic cardiomyopathy, hypertrophy of the ventricular septum—not the ventricle chambers—is apparent. This abnormality isn't seen in other types of cardiomyopathy.
What is the normal duration of a QRS complex? 0.08 seconds (2 small squares) 0.16 seconds (4 small squares) 0.04 seconds (1 small square) 0.12 seconds (3 small squares)
In most healthy individuals you would expect QRS complexes to be around 0.12 second or slightly less. If the QRS lasts longer it is described as a "wide QRS" and can be a sign of inefficient conduction of the ventricle's such as bundle branch block
A patient is being assessed for possible heart failure. Which of these laboratory results will provide support this diagnosis? Increased creatinine kinase Decreased serum sodium Decreased C-reactive protein Increased brain natriuretic peptide (BNP)
Increased brain natriuretic peptide (BNP) Think about how heart failure affects the circulation of blood through the heart. Heart failure is associated with increased cardiac filling pressures and stretch of the myocardium. The actions of the renin-angiotensin system is increased in heart failure. Increased fluid volume causes an increased stretch of the myocardium, causing the cells to release BNP. BNP is a peptide that opposes the actions of the renin-angiotensin system.
Which of the following nursing actions can be performed and delegated to the licensed practical nurse/licensed vocational nurse? Select all that apply. Teach the patient about home gastric tube care Administer medications to the patient while receiving enteral feedings Assess a patient's condition with continuous feeding for complications Remove an NG tube Position the patient while the enteral feeding is continuously infusing Insert NG tube for a stable patient
Insert NG tube for a stable patient Remove an NG tube
A patient can have heart failure without being aware of it? True False
It's common for people to be in the early stages of heart failure and not be aware of it. Early on, there may be no symptoms because the body and heart can often compensate for any deficits.
Mitral regurgitation involves blood flowing back from the _________________ into the ________________ during systole. Right ventricle, right atrium Pulmonary artery, right ventricle Left ventricle, left atrium Aorta, left ventricle
Left ventricle, left atrium MR allows blood to flow backward from the left ventricle to the left atrium because of incomplete valve closure during systole. Both the left ventricle and left atrium must work harder to preserve an adequate CO.
The nurse is preparing to educate a client who has chronic pancreatitis abut pancreatic function. The nurse should include information on pancreatic lipase as it performs which of the following functions? Transports fatty acids into the brush border Breaks down protein into dipeptides and amino acids Triggers cholecystokinin to contract the gallbladder Breaks down fat into fatty acids and glycerol
Lipase breaks down fat into fatty acids and glycerol.
Which of the following clinical findings would the nurse look for in a client with chronic renal failure? 1. Hypotension 2. Uremia 3. Metabolic alkalosis 4. Polycythemia
2. Uremia
Which of the following is a function of antidiuretic hormone (ADH)? 1. Sodium absorption and potassium excretion 2. Water reabsorption and urine concentration 3. Water reabsorption and urine dilution 4. Sodium reabsorption and potassium retention
2. Water reabsorption and urine concentration
A client is admitted with a diagnosis of acute renal failure. The nurse should monitor closely for: 1. enuresis. 2. drug toxicity. 3. lethargy. 4. insomnia
2. drug toxicity.
A client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, the nurse knows that the client is most likely to experience: 1. hematuria. 2. weight loss. 3. increased urine output. 4. increased blood pressure.
2. weight loss.
Buerger"s disease is characterized by all the following except: Lipid deposits in the arteries Redness or cyanosis in the limb when it is dependent Venous inflammation and occlusion Arterial thrombosis formation and occlusion
Lipid deposits in the arteries Thromboangiitis obliterans (Buerger's disease) is a nonatherosclerotic, segmental, recurrent inflammatory disorder of the small and medium arteries and veins of the upper and lower extremities. The disease occurs mostly in young men (younger than 45 years of age) with a long history of tobacco and/or marijuana use and chronic periodontal infection but without other CVD risk factors (e.g., hypertension, hyperlipidemia, diabetes).
The nurse is educating a client who has been diagnosed with cholecystitis. The nurse should include education on which of the following diets in the education session? 4-6 small meals of low-carbohydrate foods daily High-fat, low protein meals Low-fat, high-carbohydrate meals High-fat, high-carbohydrate meals
Low-fat, high-carbohydrate meals For the client with cholecystitis, fat intake should be reduced. The calories from fat should be substituted with carbohydrates.
The nurse had attended a conference on the topic of Malabsorption. The nurse understand that malabsorption results from impaired absorption of which of the following? Select all that apply. Fats Water Carbohydrates Minerals Proteins Vitamins
Malabsorption is the condition where there is impaired absorption of fats, carbohydrates, proteins, minerals, and vitamins. The stomach, small intestine, liver, and pancreas regulate normal digestion and absorption, which is where digestive enzymes ordinarily break down nutrients so that absorption can take place. Malabsorption occurs if there is a breakdown in the process.
What is an indication for parental nutrition that is not an appropriate indication for enteral tube feeding? Head and neck cancer Protein-calorie malnutrition Hypermetabolic states Malabsorption syndrome
Malabsorption syndrome in malabsorption syndromes, foods that are ingested into the intestinal tract cannot be digested or absorbed and tube feedings infused into the intestinal tract would not be absorbed. All of the other conditions can be treated with enteral or parenteral nutrition, depending on the patient's needs.
The nurse has attended an education session on aging and cardiac problems. The nurse understands which of the following are most likely to be early signs of cardiac problems in older persons? Select all that apply. Mental status changes Sudden changes in GI function Frequent Falls Agitation
Many cardiovascular functions are complicated in that they involve many other systems. Mental status changes, agitation, and falls can be early signs of cardiac problems in the older person. Changes in function in the GI system are not typical signs of a cardiac problem
The nurse is assessing a client admitted with acute cholecystitis. Which of the following signs and symptom would the nurse assess for? Jaundice, dark urine, and steatorrhea Acute right lower quadrant (RLQ) pain, diarrhea, and dehydration Nausea, vomiting, and anorexia Ecchymosis petechiae, and coffee-ground emesis
Nausea, vomiting, and anorexia
A client who has been treated for chronic renal failure (CRF) is ready for discharge. The nurse should reinforce which dietary instruction? 1. "Be sure to eat meat at every meal." 2. "Monitor your fruit intake, and eat plenty of bananas." 3. "Make sure to include carbohydrates in your diet." 4. "Drink plenty of fluids, and use a salt substitute."
3. "Make sure to include carbohydrates in your diet."
The nurse had attended a seminar on gallbladder associated diseases. The nurse understands that primary cancer of the gallbladder is common. True False
Primary cancer of the gallbladder is uncommon. The majority of gallbladder carcinomas are adenocarcinomas.
Which of the following is of the greatest VTE risk to an individual? Oral Contraception (The Pill) Long haul flight Dehydration History of VTE Immobility
Prior VTE— Patients with a previous episode of VTE have a high chance of recurrence.
With aortic stenosis, the patient should receive _____________ antibiotics to prevent endocarditis. Inductive Prophylactic Palliative Operative
Prophylactic A patient with progressive valvular heart disease may need outpatient care or hospitalization for management of HF, endocarditis, embolic disease, or dysrhythmias.
Which of the following aneurysms is the most likely to dissect? Abdominal Aortic They are all equally likely Peripheral Thoracic
The thoracic region of the aorta often has the highest pressure and force due to being closest to the heart.
What are the signs & symptoms of DVT? Select all that apply. Swelling Heat Bruising Redness Pain
7 early warning signs and symptoms of DVT Pain. Swelling. Warmth. Redness. Leg cramps, often starting in the calf. Leg pain that worsens when bending the foot. Bluish or whitish skin discoloration.
The red blood cell (RBC) production in a client with chronic renal failure (CRF) has decreased. The nurse should monitor this client for: 1. nausea and vomiting. 2. diarrhea and hypokalemia. 3. fatigue and weakness. 4. thrush and circumoral pallor.
3. fatigue and weakness.
The nurse is caring for a client admitted with acute pancreatitis. The nurse understands that which of the following should be included in the plan of care? Select all that apply. Monitoring for infection, particularly respiratory tract infection. Giving insulin based on a sliding scale. Providing a diet low in carbohydrates. Observing stools for signs of steatorrhea. Checking for signs of hypocalcemia.
??? Insulin is secreted by the pancreas and this can be interrupted during an episode of acute pancreatitis, also the pancreatic enzymes that protect the lining of the gastric and respiratory systems is depleted and therefore respiratory infections are a risk.
Which of the following aneurysms is composed of a collection of blood leaking completely out of an artery or vein but confined to the vessel by the surrounding tissue? False Dissecting Saccular Fusiform
A false aneurysm, or pseudoaneurysm, is a collection of blood leaking completely out of an artery or vein, but confined next to the vessel by the surrounding tissue.
The nurse is teaching a group of senior citizens about risk factors for heart failure. Which of these factors will the nurse include in the teaching? Select all that apply Obesity Hypertension Sleep apnea History of Pre-eclampsia Increased high density lipoproteins (HDL) High Sodium Intake
A sustained increase in cardiac workload can cause heart failure. Untreated hypertension increases peripheral vascular resistance and cardiac workload. Women who were diagnosed with preeclampsia during pregnancy are at increased risk for developing hypertension later in life. High sodium intake increases circulating volume and preload. Sleep apnea is associated with diastolic dysfunction. Obesity increases cardiac workload.
For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is most important? 1. Encouraging coughing and deep breathing 2. Promoting carbohydrate intake 3. Limiting fluid intake 4. Providing pain-relief measures
3. Limiting fluid intake
Venous Thromboembolism is a term for what type of condition? Deep Vein Thrombosis and Pulmonary Embolism Ventricular Tachycardia Vancomycin Resistant Enterococcus Pulmonary Hypertension and Post Thrombotic Syndrome
A venous thrombus is a blood clot (thrombus) that forms within a vein. Thrombosis is a term for a blood clot occurring inside a blood vessel. A common type of venous thrombosis is a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg.
Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy? A. Passage of two or three soft stools daily B. Evidence of watery diarrhea C. Daily deterioration in the client's handwriting D. Appearance of frothy, foul-smelling stool
A. Passage of two or three soft stools daily
The nurse has attended a seminar about the clinical manifestations of acute pancreatitis. The nurse understands that this would include which of the following symptoms? hypertension Abdominal pain Dyspnea Nausea
Abdominal pain is the predominant manifestation of acute pancreatitis. The pain is due to distention of the pancreas, peritoneal irritation, and obstruction of the biliary tract. The pain is usually located in the left upper quadrant, but it may be mid-epigastric.
A client requires hemodialysis. Which of the following drugs should be withheld before this procedure? 1. Phosphate binders 2. Insulin 3. Acetaminophen 4. Cardiac glycosides
4. Cardiac glycosides
Which of the following heart muscle diseases is unrelated to other cardiovascular disease? Coronary heart disease Myocardial Infarction Cardiomyopathy Pericardial effusion
Cardiomyopathy isn't usually related to an underlying heart disease such as atherosclerosis. The etiology in most cases is unknown. CAD and MI are directly related to atherosclerosis. Pericardial effusion is the escape of fluid into the pericardial sac, a condition associated with Pericarditis and advanced heart failure.
In the patient with a dysrhythmia, which assessment indicates decreased cardiac output (CO)? Bounding pulses and a ventricular heave Chest pain and decreased mentation Abdominal distention and hepatomegaly Hypertension and bradycardia
Chest pain and decreased mentation
The nurse is educating a client on dietary therapy prior to discharge for a diagnosis of heart failure. Which of the following should the nurse include in her teaching plan? Select all that apply Weigh yourself at the same time every day Avoid using salt when preparing foods Examine labels to determine sodium content Eat large, spaced out meals
Weigh yourself at the same time every day Avoid using salt when preparing foods Examine labels to determine sodium content A client with heart failure should eat small, spaced meals.
The nurse is caring for a client with peripheral arterial disease (PAD). For which of symptoms does the nurse assess? Pulse oximetry reading of 90% Reproducible leg pain with exercise Unilateral swelling of affected leg Decreased pain when legs are elevate
Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances. Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin; PAD results from atherosclerotic occlusion of peripheral arteries.
The nurse is caring for a patient who has been diagnosed with patient is diagnosed with heart failure and is prescribed digoxin (Lanoxin) and furosemide (Lasix). Before administering the furosemide to the patient, which laboratory result should the healthcare provider to review? Blood urea nitrogen (BUN) Serum Potassium Serum Troponin Serum Sodium
Digoxin is a high risk medication with a narrow therapeutic index. Think about possible drug-drug interactions between digoxin and furosemide. Furosemide may cause hypokalemia, which increases the risk of digoxin toxicity.
The nurse is caring for a patient who has been diagnosed with a recent diagnosis of heart failure has been prescribed furosemide (Lasix) in an effort to physiologically do what for the patient? Reduce preload Decrease afterload Increase contractility Promote vasodilation
Diuretics such as furosemide are used in the treatment of heart failure to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone.
A client with decreased urine output refractory to fluid challenges is evaluated for renal failure. Which condition may cause the intrinsic (intrarenal) form of acute renal failure? 1. Poor perfusion to the kidneys 2. Damage to cells in the adrenal cortex 3. Obstruction of the urinary collecting system 4. Nephrotoxic injury secondary to use of contrast media
4. Nephrotoxic injury secondary to use of contrast media
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive the highest priority at this time? Altered peripheral tissue perfusion related to venous congestion Impaired gas exchange related to increased blood flow Risk for injury related to edema Fluid volume excess related to peripheral vascular disease
Altered peripheral tissue perfusion related to venous congestion Venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive the highest priority at this time? Fluid volume excess related to peripheral vascular disease Impaired gas exchange related to increased blood flow Altered peripheral tissue perfusion related to venous congestion Risk for injury related to edema
Altered peripheral tissue perfusion related to venous congestion Venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis
The nurse has attended a conference on the subject of Anal Fistula. The nurse understands that an anal fistula is the abnormal tunnel leading from the Anus or rectum Bladder or rectum Anus or vagina Vagina or rectum
An anal fistula is an abnormal tunnel leading from the anus or rectum. It may extend to the outside of the skin, vagina, or buttocks and often precedes an abscess. Correct
What is the definitive test used to diagnose an abdominal aortic aneurysm? Ultrasound Arteriogram Abdominal X-ray CT Scan
An arteriogram accurately and directly depicts the vasculature; therefore, it clearly delineates the vessels and any abnormalities. Option A: An abdominal aneurysm would only be visible on an X-ray if it were calcified. Options C and D: CT scan and ultrasound don't give a direct view of the vessels and don't yield as accurate a diagnosis as the arteriogram.
Which nursing intervention is most important during the oliguric phase of acute renal failure (ARF)? (1) Encourage coughing and deep breathing (2) Promoteing carb intake (3) Limiting fluid intake (4) Controlling pain
Answer: (3) Limit fluid intake in the oliguric phase of acute renal failure, urine output is dimishes and can lead to fluid overload.
Which is a priority nursing intervention for a patient during the acute phase of rheumatic fever? Performance of frequent active range-of-motion exercises Management of pain with opioid analgesics Encouragement of fluid intake for hydration Administration of antibiotics as ordered
Antibiotic therapy does not change the course of the acute disease or the development of carditis. It does eliminate residual group A streptococci remaining in the tonsils and pharynx and prevents the spread of organisms to close contacts.
When teaching a patient about risk factors for AAA, which of the following, if stated by the patient indicates correct understanding? Being female Genetic disorder Taking ACE inhibitors or ARBS Straining while pooping
Aortic Aneurysm can be caused by being male, smoking, family history or congenital weakness, and hypertension
The nurse is assessing a patient and feels a pulse with quick, sharp strokes that suddenly collapse. The nurse knows that this type of pulse is diagnostic for which disorder? Mitral Insufficiency Tricuspid insufficiency Tricuspid stenosis Aortic regurgitation
Aortic regurgitation Patients with chronic, severe AR develop a water-hammer pulse (strong, quick beat that collapses immediately). Heart sounds may include a soft or absent S1, S3, or S4 and a soft, high-pitched diastolic murmur.
Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy? Heart Failure Myocardial Infarction (MI) Diabetes Pericardial Effusion
Because the structure and function of the heart muscle is affected, heart failure most commonly occurs in clients with cardiomyopathy. MI results from prolonged myocardial ischemia due to reduced blood flow through one of the coronary arteries. Pericardial effusion is most predominant in clients with pericarditis.
A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for: A. Malaise B. Stomatitis C. Hand tremors D. Weight loss
C. Hand tremors
The telemetry nurse is unable to read the telemetry monitor at the nurse's station. Which intervention should the telemetry nurse implement first? Request the nursing assistant to take the crash cart to the client's room. Instruct the primary nurse to assess the client Contact the client on the client call system Go to the client's room to check the client.
Contact the client on the client call system If the client answers the call light and is not experiencing chest pain, then there is probably a monitor artifact, which is not a life-threatening emergency. After talking with the client, send a nurse to the room to check the monitor. The telemetry nurse should not leave the monitors unattended at any time. The telemetry nurse must have someone go assess the client, but this is not the first intervention. The crash cart should be taken to a room when the client is experiencing a code. If the client answers the call light and is not experiencing chest pain, then there is probably a monitor artifact, which is not a life-threatening emergency. After talking with the client, send a nurse to the room to check the monitor.
The nurse is caring for a client diagnosed with chronic pancreatitis. Which of the following interventions would be appropriate to reduce acute exacerbations of the pancreatitis. Counselling to stop alcohol consumption Encouraging daily exercise Modifying dietary protein Allowing liberalized fluid intake
Counselling to stop alcohol consumption Chronic pancreatitis typically results from repeated episodes of acute pancreatitis. More than half of chronic pancreatitis cases are associated with alcoholism. Counselling to stop alcohol consumption would be the most helpful for the client.
The nurse is caring for a client with left sided heart failure. The nurse understands that which of the following symptoms is most commonly associated with left-sided heart failure? Hepatic Engorgementterm-0 Crackles Hypotension Arrhythmias
Crackles in the lungs are a classic sign of left-sided heart failure. These sounds are caused by fluid backing up into the pulmonary system. Arrhythmias can be associated with both left and right sided heart failure. Left-sided heart failure causes hypertension secondary to an increased workload on the system.
A patient has had a successful heart transplant for end-stage heart disease. What immunosuppressant will be necessary for this patient to take to prevent rejection? Cycloporine Procardia Vancocin Calan
Cycloporine
A nurse is providing teaching to a client who has CKD and is about to start hemodialysis. Which of the following information should the nurse include in the teaching? A. hemodialysis restores renal function B. Hemodialysis replaces hormonal function the the renal system C. hemodialysis allows an unrestricted diet D. hemodialysis returns a balance of serum electrolytes
D. hemodialysis returns a balance of serum electrolytes
The nurse is caring for a patient with chronic constrictive pericarditis. Which assessment finding reflects a more serious complication of this condition? Fatigue Jugular venous distention Thickened pericardium on echocardiography Peripheral edema
Decreased CO accounts for many of the clinical manifestations. These include dyspnea on exertion, peripheral edema, ascites, fatigue, anorexia, and weight loss. The most prominent finding on physical examination is jugular venous distention (JVD).
The nurse is administering an angiotensin converting enzyme (ACE) inhibitor to a patient diagnosed with heart failure. Which of the following describe the ways in which the ACE inhibitor is therapeutic for the patient who has heart failure? Select all that apply Decreases cardiac preload Decreases cardiac output Increases myocardial contractility Decreases myocardial remodelling Increases peripheral vascular resistance Decreases cardiac workload
Decreased pumping ability of the heart causes decreased renal perfusion. Decreased renal perfusion causes sympathetic nervous system (SNS) activation and initiation of the renin-angiotensin-aldosterone system (RAAS). RAAS and SNS activation cause increased peripheral vascular resistance, increased preload, and increased afterload.
The nurse is caring for a patient who has been diagnosed with heart failure. The patient complains of sudden vision changes that include seeing yellowish-green halos around the lights. Which of the following medications should the nurse suspect is causing this issue? Lasix Digoxin Lisinopril Losartan
Digoxin Yellowish-green halos/vision changes are classic signs of Digoxin toxicity
The nurse is teaching a class about diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis? Select all that apply Increase fluid intake. Take an antacid every two (2) hours. Eat a high-fibre diet. Walk 30 minutes a day. Elevate the HOB after eating.
Eat a high-fibre diet. A high-fibre diet will help to prevent constipation, which is the primary reason for diverticulitis. Increase fluid intake. Increased fluids will help keep the stool soft and prevent constipation. Walk 30 minutes a day. Exercise will help prevent constipation. This will not do anything to help prevent diverticulitis No medications are prescribed to prevent an acute exacerbation of diverticulitis. Antacids are used to neutralize hydrochloric acid in the stomach
Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)? "Elevate your legs above heart level to prevent swelling" "Walk to the point of leg pain, resuming when the pain stops" "Inspect your legs daily for brownish discoloration around the ankles" "Apply a heating pad to the legs if they feel cold"
Exercise may improve arterial blood flow by building collateral circulation; instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther.
The nurse is caring for a client diagnosed with Anal Rectal Fissure. Which of the following symptoms will the nurse expect to find? Watery diarrhea Rectal itching Perianal pus Severe anal pain
Extremely painful defecation, burning, and bleeding characterize fissures.
The nurse is education a group of student nurses on cardiac disease. A student asks if Congestive Heart Failure and Heart Failure are the same. What should the nurse say? False True
False. Heart failure and congestive heart failure are often used interchangeably, but they are not the same. Congestive heart failure (CHF) refers to a specific type of heart failure where fluid "congestion" collects in the lungs and other body tissues. When the heart is not able to pump efficiently, the kidneys don't receive as much blood so they work less efficiently and less fluid is filtered out of the body as urine. This fluid backs up throughout the body, especially the lungs, legs and ankles, and the abdomen.
Priority nursing management for a patient with myocarditis includes interventions related to which of the following? Tight glycemic control Antibiotic prophylaxis Oxygenation and ventilation Meticulous skin care
Focus your interventions on managing the signs and symptoms of HF. Select nursing measures to decrease cardiac workload
The nurse is assessing a client who has a diagnosis of ascites and now presents to the clinic with increased abdominal girth. The physician prescribes a diuretic and following administration which of the following is a priority action for the nurse? Assessing the client for hypervolemia Documenting precise intake and output Measuring the client's weight weekly Measuring serum potassium for hyperkalemia
For the client with ascites receiving diuretic therapy, careful intake and output measurement is essential for safe diuretic therapy. Diuretics lead to fluid losses, which if not monitored closely and documented, could place the client at risk for serious fluid and electrolyte imbalances. After administration of a diuretic a key nursing action is strict monitoring of intake and output. The nurse would want to check the client's weight on a daily basis and would monitor for hypokalemia versus hyperkalemia. Similarly, the pertinent risk for this patient would be hypovolemia post-diuretic administration as opposed to hypervolemia.
The nurse is caring for a patient receiving 1000ml of parenteral nutrition solution over 24 hours. When it is time to change the solution, 150ml remain in the bottle. What is the most appropriate action by the nurse? Open the IV line and rapidly infuse the remaining solution Wait to change the solution until the remaining solution infuses at the prescribed rate Hang the new solution and discard the unused solution Notify the health care provider for instructions regarding the infusion rate
Hang the new solution and discard the unused solution remaining solution should be discarded. Bacterial growth occurs at room temperature in nutritional solutions. Therefore, solutions must not be infused for longer than 24 hours. Speeding up the solution may cause hyperglycemia and should not be done. The HCP does not need to be notified as the rate is determined to meet the patient's nutritional needs.
The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's recommendations for the early detection of colon cancer? A flexible sigmoidoscopy should be done yearly after age 40 Beginning at age 60, a digital rectal examination should be done yearly. After reaching middle age, a yearly fecal occult blood test should be done. Have a colonoscopy at age 50 and then once every five (5) to 10 years.
Have a colonoscopy at age 50 and then once every five (5) to 10 years. The American Cancer Society recommends a colonoscopy at age 50 and every five (5) to 10 years thereafter, and a flexible sigmoidoscopy and a barium enema every five (5) years.
The nurse has attended a conference on heart failure. The nurse understands that heart failure is which of the following? A heart attack A condition in which the heart cannot pump enough blood to meet the bodies needs A condition in which the heart stops beating A condition in which the patient experiences chest pain
Heart failure does not necessarily mean the heart has stopped working. It simply describes a condition in which the heart fails to work as it should, and it cannot pump blood to sufficiently meet the body's needs.
The nurse is education a group of clients on the subject of Hemorrhoid's. The nurse should ensure the group understands that hemorrhoid's are caused by which of the following changes to hemorrhoidal veins? ruptured constricted Displaced Dilated
Hemorrhoids are dilated hemorrhoidal veins. They may be internal (occurring above the internal sphincter) or external (occurring outside the external sphincter)
A client with cirrhosis begins with a flapping of the hands whenever the arms are extended. Her orientation is decreased, she is having trouble concentrating, and appears anxious. The client is probably developing what?
Hepatic encephalopathy Rationale: Hepatic encepalopathy is a complication of cirrhosis and is manifested by changes in consciousnes and motor fx. Asterixis is the flapping tremor of the hands when extending the arms.
Before administering a bolus of intermittent tube feeding to a patient with a percutaneous endoscopic gastrostomy (PEG), the nurse aspirates 220 ml of gastric contents. What should the nurse do next? Discard the aspirate to prevent over-distending the stomach when the new feedings is given Return the aspirate to the stomach and continue with the tube feeding as planned Notify the HCP that the feedings have been schedule too frequently to allow for stomach emptying Return the aspirate to the stomach and recheck the volume of aspirate in an hour
Return the aspirate to the stomach and continue with the tube feeding as planned with intermittent feedings, less than 250 ml residual does not require further action. With continuous feeding and a residual of 250ml or more after a second residual check, a promotility agent should be considered. The aspirate will not be discarded as this could alter the patient's fluid, electrolyte, and pH balance.
When teaching a patient about the long-term consequences of rheumatic fever, the nurse should discuss the possibility of? Superior Vena Cava Syndrome Pulmonary hypertension Valvular heart disease Hypertrophy of the right ventricle
Rheumatic endocarditis is found mainly in the valves, with swelling and erosion of the valve leaflets.
The nurse is caring for clients in the nursing home setting who are bedridden. In which of the following disorders would the nurse expect to assess sacral edema in a bedridden client? Right-sided Heart failure Renal failure Pulmonary embolism Diabetes
Right-sided Heart failure The most accurate area on the body to assess dependent edema in a bed-ridden client is the sacral area. Sacral or dependent edema is secondary to right-sided heart failure.
The nurse has attended a conference about short bowel syndrome (SBS). The nurse understands that SBS likely to develop in patients with a loss of Two thirds of the small intestine Two thirds of the large intestine One third of the small intestine All of the small intestine
SBS is likely to develop in patients with a loss of two-thirds length of the small intestine. The length and area of the remaining small intestine and the presence of the colon affect the patient's outcome.
The nurse is educating a client with Irritable Bowel Disease (IBD) about the medication sulfasalazine (Asulfidine). Which of the following indicated the rationale for the use of sulfasalazine (Asulfidine) in clients with IBD? Slows gastrointestinal motility and reduces diarrhea. Kills the bacteria causing the exacerbation. It is a rectal medication that helps decrease colon inflammation. Acts topically on the colon mucosa to decrease inflammation.
Sulfasalzine (Asulfidine) is not well absorbed from the gastrointestinal tract and acts topically on the colonic mucosa to inhibit the inflammatory process.
The nurse is assessing a client who has been diagnosed with Celiac disease. Which of the following are symptoms of celiac disease? Select all that apply. Diarrhea Weight gain Joint pain Excessive gas Weight loss
Symptoms of celiac disease include weight loss, diarrhea, excessive gas, behavior changes, delayed growth (in children), failure to thrive (in infants), bone or joint pain, seizures, tingling numbness in the legs, tooth discoloration, and infertility. Symptoms differ from person to person; some have only abdominal symptoms, others have no symptoms. People without symptoms still have undamaged parts of their small intestine that are able to absorb enough nutrients. These people are still at risk for complications.
The nurse is caring of a client who has symptoms of lactose intolerance. The nurse understands that which of the following symptoms should be included when assessing for lactose intolerance? Select all that apply. Flatulence Cramping abdominal pain Bloating Nausea Diarrhea
Symptoms of lactose intolerance include bloating, flatulence, cramping abdominal pain, and diarrhea. Diarrhea results from the excess, undigested lactose in the small intestine attracting water molecules, which prevents them from being properly absorbed.
The nurse is planning an education session about pancreatic cancer. As part of the "risks" section the nurse should include which of the following? Select all that apply. Cigarette smoking Diabetes mellitus Chronic pancreatitis Low fat diet Family history of pancreatic ca
The cause of pancreatic cancer remains unknown. Risk factors for pancreatic cancer include chronic pancreatitis, diabetes mellitus, age, cigarette smoking, and family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as Benzedrine.
The nurse is caring for a client diagnosed with hyperbilirubinemia who is experiencing pruritus. Which of the following should be included in the client's plan of care? Decreasing the client's dietary protein intake Keeping the client's fingernails short and smooth Administering vitamin K subcutaneously Applying pressure when giving I.M. injections
The client with pruritus experiences itching, which may lead to skin breakdown and possibly infection from scratching. Keeping his fingernails short and smooth helps prevent skin breakdown and infection from scratching.
The nurse is assessing a client who has been diagnosed with ulcerative colitis. Which of the following signs and/or symptoms should the nurse expect to find during her assessment? Oral temperature of 102˚F. Urinary stress incontinence. Hard, rigid abdomen. Twenty bloody stools a day.
When the colon is ulcerated it is unable to absorb water and this results in diarrhea, which is bloody due to the erosion of the walls of the colon.
In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include: Keeping the heat up so that the environment is warm Walk several times each day as an exercise program Using hydrotherapy for increasing oxygen Wearing TED hose during the day
The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful when preventing vasoconstriction, but TED hose would not be therapeutic. Walking would most likely increase pain
The nurse is caring for a client who has been admitted with a diagnosis of cholelithiasis (gall stones). The nurse understands that the most common site for the gallstones to lodge is which of the following? Tubule of gallbladder Neck of gallbladder Base of gallbladder Body of gallbladder
The gallstones may get lodged in the neck of the gallbladder or in the cystic duct. Cholecystitis (inflammation of the gallbladder wall) is usually associated with cholelithiasis and usually occurs together, but a person can have cholelithiasis without cholecystitis.
The nurse is caring for a client diagnosed with Anal Cancer. Which of the following symptoms will the nurse expect to find? Severe anal pain Rectal bleeding Perianal pus Watery diarrhea
The most frequent initial symptom is rectal bleeding. Other symptoms include rectal pain and sensation of a rectal mass. Some patients have no symptoms, which leads to delayed diagnosis and treatment.
If medical treatments fail, which of the following invasive procedures is necessary for treating cardiomyopathy? Intra-aortic balloon pump (IABP) Heart transplant Coronary artery bypass graph (CABG) Cardiac catheterization
The only definitive treatment for cardiomyopathy that can't be controlled medically is a heart transplant because the damage to the heart muscle is irreversible.
Which of the following are signs of a rupturing AAA? Select all that apply Intermittent abdominal pain Decreased BP Low Back Pain Increased BP Decreased Hct
The patient is losing blood pressure and dropping hematocrit due to bleeding. Pain is a key sign of a rupturing (or close to rupturing) Aortic Abdominal Aneurysm. Usually, when rupturing, the pain becomes constant rather than intermittent.
The nurse is assessing a client who has been admitted to the cardiac unit with a diagnosis of right ventricular failure. Which of the following assessment findings would the nurse expect to observe? Dyspnea and pulmonary crackles Fatigue and hemoptysis Bradycardia and circumoral cyanosis Peripheral edema and jugular vein distension
The right ventricle receives blood from the right atrium. If right ventricular pumping is impaired, blood will back up through the right atrium and into the venous system. his causes movement of fluid into the tissues and organs (e.g., peripheral edema, abdominal ascites, hepatomegaly, jugular venous distention).
When considering tube feeding for a patient with severe protein-calorie malnutrition, what is an advantage of a gastrostomy tube versus a nasogastric (NG) tube: Aspiration resulting from reflux of formula into the esophagus is less common Routine checking for placement is not required because gastrostomy tubes do not become displaced The patient experiences the sights and smells associated with eating There is less irritation to the nasal and esophageal mucosa
There is less irritation to the nasal and esophageal mucosa standard nasogastric tubes are only used for tube feeding for short-term feeding problems because prolonged therapy can result in irritation and erosion of the mucosa of the upper GI tract. Gastric reflux and the potential for aspiration can occur with both NG and gastrostomy feeding tubes. Both tubes deprive the patient of the sensations associated with eating and can become displace.
The nurse is caring for a client admitted with heart failure. The nurse is filling out the care plan and understand that which of the following are appropriate nursing diagnosis for clients with heart failure? Select all that apply Activity intolerance related to a balance between O2 supply and demand secondary to cardiac sufficiency and pulmonary congestion Decreased cardiac output related to altered contractility, altered preload and/or altered stroke volume. Excess fluid volume related to increased venous pressure and decreased renal perfusion secondary to heart failure Impaired gas exchange related to increased preload and alveolar-capillary membrane changes
There is no activity intolerance if there is a balance between O2 demand secondary to cardiac sufficiency and pulmonary congestion. This does not make sense.
The nurse has attended an education session on types of heart failure. The nurse understands which of the following is not one of the types of heart failure? Congestive heart failure Left-sided heart failure Right-sided heart failure Myocardial heart failure
There is no such thing as myocardial heart failure. There are three types of heart failure: - Left-sided heart failure: The heart cannot effectively pump blood out to the body. - Right-sided heart failure: Usually occurs as a result of left-sided heart failure. The right side of the heart becomes damaged, and blood starts backing up in the body. - Congestive heart failure: Fluid collects mainly in the lungs and other body tissues.
Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions? Pericarditis Heart Failure Hypertension Myocardial Infarction (MI)
These are the classic signs of heart failure. Pericarditis is exhibited by a feeling of fullness in the chest and auscultation of a pericardial friction rub. Hypertension is usually exhibited by headaches, visual disturbances, and a flushed face. MI causes heart failure but isn't related to these symptoms.
The nurse is educating a client with celiac disease on diet and nutrition. Which of the following should the nurse include as items the client can still eat? Select all that apply Pasta Potatoes Dried Beans Rice Soy Beans
These foods do not contain wheat gluten and so are safe to eat. In addition, flours made from these foods and corn grains are available for baking and cooking. Gluten-free products are also available. Other foods that are safe to eat include plain meat, fish, fruits, and vegetables.
A patient is admitted with myocarditis. While performing the initial assessment, the nurse may find which clinical signs and symptoms. Select all that apply. Splinter hemorrhages Presence of Osler's nodes Myocarditis Pleuritic chest pain Pericardial friction rub
These include pleuritic chest pain with a pericardial friction rub and effusion because pericarditis often accompanies myocarditis. The clinical features of myocarditis are variable, ranging from a benign course without any overt symptoms to severe heart involvement or sudden cardiac death (SCD). Fever, fatigue, malaise, myalgias, pharyngitis, dyspnea, lymphadenopathy, and nausea and vomiting are early manifestations of the viral illness.
If there were 3 large squares in an R-R interval what would the heart rate be? 80 bpm 90 bpm 100 bpm 70 bpm
To calculate heart rate from an ECG you count the number of large squares in an R-R interval then divide 300 by this number. Therefore 300/3 = 100 bpm
When a patient has a confirmed acute DVT what should they wear on their legs? ace bandage compression stockings Intermittent pneumatic compression devise Nothing
To help prevent swelling associated with deep vein thrombosis, these are worn on the legs from the feet to about the level of the knees.
The nurse is admitting a client with a diagnosis of viral hepatitis. Which of the following will the nurse include in the care plan? Adequate bed rest Increase fluid intake to 3000 ml per day Bland Diet Administer antibiotics as ordered
Treatment of hepatitis consists of bed rest during the acute phase to reduce metabolic demands on the liver, thus increasing blood supply and cell regeneration.
Virchow's triad has the following components. Select all that apply Stasis of blood flow Epithelial Injury Hypercoagulability Nerve injury Hypocoagulability
Virchow's triad or the triad of Virchow describes the three broad categories of factors that are thought to contribute to thrombosis. Hypercoagulability. Hemodynamic changes (stasis, turbulence)
The nurse is caring for a client admitted with acute pancreatitis. Which of the following should be included in the clients plan of care? Preparation for a paracentesis and administration of diuretics Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent suction Dietary plan of a low-fat diet and increased fluid intake to 2,000 ml/day Administration of vasopressin and insertion of a balloon tamponade
With acute pancreatitis, the client is kept on nothing-by-mouth status to inhibit pancreatic stimulation and secretion of pancreatic enzymes. NG intubation with low intermittent suction is used to relieve nausea and vomiting, decrease painful abdominal distention, and remove hydrochloric acid.x
what all should be included in hemodialysis postprocedure care?(select all that apply) a. check BUN and creatinine b. administer medications held prior to dialysis c. observe for signs of hypovolemia d. assess the access site for bleeding e. evaluate BP on side of AV access
a. check BUN and creatinine b. administer medications held prior to dialysis c. observe for signs of hypovolemia d. assess the access site for bleeding
a nurse is planning care for a client who had postrenal acute kidney injury due to metastatic cancer. The client has a creatinine of 5mg/gL. which of the following are appropriate actions by the nurse? (select all the apply) a. provide a high protein diet b. assess for urine in the blood c. monitor for intermittent anuria d. administer diuretic medications e. provide NSAIDs for pain
a. provide a high protein diet b. assess for urine in the blood c. monitor for intermittent anuria
a nurse is caring for a client who is receiving hemodialysis and develops disequilibrium syndrome. Which of the following is an appropriate action by the nurse? a. administer opioid medication b. monitor for HTN c. assess LOC d. increase the diaylsis exchange rate
c. assess LOC