Test #1 - Fall 2014

Adults age ____ and older should have a fasting lipid profile performed at least once every 5 years.

20.

The nurse is carign for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?

Assessing the extremity for neurovascular integrity.

The telemetry unit nurse is caring for a client who was just transferred from the coronary care unit (CCU). The client is anxious because he fears he won't be monitored as closely as he was in the CCU. How can the nurse allay his fears?

Assign the same nurse to the client when possible.

A client is recovering from coronary artery bypass graft (CABG) surgery. The nurse knows that for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and family to expect which common symptom that typically resolves spontaneously?

Depression.

During _____, the heart chambers fill with blood in preparation for ejection.

Diastole

The nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, the nurse can anticipate using:

Diuretics.

The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first:

Establish unresponsiveness.

After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24-48 hours after the accident, the nurse must monitor the client closesly for which potential complication of a fractured pelvis?

Fat embolism.

A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in teh postoperative care plan?

Keeping a pillow between the client's legs at all times.

Higher HDL levels are associated with ______ risk for coronary artery disease.

Lower

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

Positioning the client on the side with knees flexed.

Which symptom is a warning sign of colon cancer?

Rectal bleeding.

A client is prescribed hydralazine for blood pressure management. The nurse is teaching the client about hydralazine therapy. When should the client take his hydralazine?

With food.

What nursing action is most appropriate for a client hospitalized with acute pancreatitis?

Withholding all oral intake, as ordered, to decrease pancreatic secretions.

A client is diagnosed with osteoporosis. What statements should the nurse include when teaching the client about the disease?

1. It's common in females after menopause. 2. It's a degenerative disease characterized by a decrease in bone density. 3. It can cause pain and injury.

To avoid a falsely elevated serum digoxin level, the nurse should wait how long after administering oral digoxin (Lanoxin) to draw a blood sample?

At least 8 hours.

True or false: The sympathetic and vagus nerves control the heart rate of a transplanted donor heart.

False

A client is admitted with severe pain in the knees. Which form of arthritis is characterized by urate deposits and joint pain, usually in teh feet and legs, and occurs primarily in men over age 30?

Gouty arthritis.

The nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching?

Hanging the irrigation bag 24"-36" above the stoma. (Should be 18"-24")

A client is admitted to undergo lumbar laminectomy for treatment of a herniated disc. Which action should the nurse take first to promote comfort preoperatively?

Help the client assume a more comfortable position.

Which is the most appropriate nursing diagnosis for a client with a strained ankle?

Impaired physical mobility.

After a person experiences a closure of the epiphyses, which of the following is true?

No further increase in bone length occurs.

The nurse is giving instructions to a client who's going home with a cast on his leg. Which point is most critical?

Reporting any signs of impaired circulation.

The nurse should monitor the client with a pelvic fracture receiving an opium derivative, such as morphine, for what common adverse reaction?

Respiratory depression.

A client is hospitalized for open reduction of a fractured femur. During postoperative assessment, the nurse monitors for signs and symptoms of fat embolism, which include:

Restlessness and petachiae.

A ______ provides structural support to a coronary artery following angioplasty to minimize risk of stenosis.

Stent.

A client, age 50, visits the physician for a routine checkup. The history reveals that the client was diagnosed with a spinal curvature at age 45. The nurse knows that life-threatening complications can occur if the progressive spinal curvature exceeds 65 degrees. To assess the client's risk for such a complication, the nurse should evaluate the severity of the curvature in which region of the spine?

Thoracic

A patient scheduled for a cardiac stress test should be advised to avoid stimulants including ________ and caffeine prior to the examination.

Tobacco

A client undergoes a total hip replacement. Which statement made by the client would indicate to the nurse that the client requires further teaching?

"I don't know if I'll be able to get off that low toilet seat at home by myself."

A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in his cast care?

"Keep your right leg elevated to heart level."

X-rays reveal a leg fracture in a client who was brought to the emergency department after falling on ice. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs?

"Place the unaffected leg on the first step, followed by the crutches and injured leg, which should move together."

The nurse is peforming an admission assessment on a client admitted with a pelvic fracture. Which statement by the client requires the nurse to seek more information from a legal standpoint?

"Sometimes my husband gets so angry with me."

A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of the disease. How should the nurse respond?

"You may experience progressive deterioration in all voluntary muscles."

At a health fair, a woman, age 43, with a family history of osteoporosis asks the nurse how much calcium she should consume. The nurse tells her that the recommended daily calcium intake for premenopausal women is:

1,000-1,200mg per day.

A client has a heart rate of 170 beats/minute. The physician diagnoses ventricular tachycardia and orders lidocaine hydrochloride (xylocaine), an initial I.V. bolue of 50mg followed in 5 minutes by a second 50-mg bolus, then continuous I.V. infusion at 2 mg/minute. The nurse can expect the client to begin experiencing an antiarrhythmic effect within:

1-2 minutes after I.V. bolus administration.

A client with a suscpected diagnosis of acute myocardial infarction is admitted to the coronary care unit. To help confirm the diagnosis, the physician orders serial enzyme tests. Increased serum levels of the isoenzyme creatinine kinase of myocardial muscle (CK-MB), found only in cardiac muscle, can be detected how soon after the onset of chest pain?

4-6 Hours.

The point of maximum impulse (PMI) is normally palpable in the left midclavicular line at the _______ intercostal space.

5th

Individuals with a blood pressure greater than 120/__ are considered prehypertensive and at risk for heart disease.

80.

When assessing a client during a routine checkup the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as:

A canker sore of the oral soft tissues.

The most common site of aneurysm formation is in the:

Abdominal aorta, just below the renal arteries.

A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of:

Acute pulmonary edema.

A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning the client's care, the nurse should anticipate which measure?

Administering large doses of I.V. antibiotics as prescribed.

The nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include:

Administration of nonsteroidal anti-inflammatory drugs (NSAIDS) and initiation of an exercise program.

The nurse is assessing a client with possible osteoarthritis. The most significant risk factor for osteoarthritis is:

Age.

When assessing a client with left-sided heart failure, the nurse expects to note:

Air hunger.

Following a boating accident, a 30-year-old client with multiple fractures is admitted to a semiprivate room in a progressive care unit. The client, who was driving the boat, is unaware that his girlfriend's 9-year-old son was killed in the accident. The client's parents instruct the nurse to prohibit phoen calls and to withhold information about the accident. During an assessment of the client, the nurse notices that the telveision is on and the news is starting. It would be most appropriate for the nurse to:

Allow the client to view the television and deal with any questions as they come.

The patient with valvular disease requires prophylaxis with _______ prior to undergoing invasive or dental procedures to decrease risk of endocarditis.

Antibiotics

In addition to sublingual nitroglycerin, a patient experiencing chest pain due to angina will receive 160-325 mg of _______ to reduce risk of MI.

Aspirin.

After total hip replacement, a client is receiving epidural analgesia to relieve pain. Which of the following is a nursing priority for this client?

Assessing for sensation in the legs.

A client has a Fiberglas cast on the right arm. What action should the nurse indicate in the care plan?

Assessing movement and sensation in the fingers of the right hand.

Which task can the nurse delegate to a nursing assistant?

Assisting a client who had surgery three days ago walk down the hallway.

The nurse monitors a client receiving enoxaparin (Lovenox) 30mg S.C. b.i.d. after hip replacement surgery. Which adverse reaction is the client most likely to experience?

Bleeding.

In caring for a client with vasovagal syncope, the nurse should know that the associated temporary loss of consciousness is often related to:

Bradyrhythmia

A client is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder?

Calcium and phosphorous.

A client with substernal chest pain that radiates to the jaw is admitted to the coronary care unit. The client subsequently develops hypotension and suffers cardiac arrest. Which calcium preparation is injected into the ventricle during cardiac arrest?

Calcium chloride.

A client recently had a right total hip replacement. As a result of intraoperative blood loss, postoperative serum hemoglobin levels and hematocrit are low. The physician prescribes two units of packed red blood cells. During the infusion of the first unit of blood, the client develops a transfusion reaction and experiences urticaria, itching, and bronchospasm. The nurse discontinues the transfusion and notifies the physician. Which antihistamine would the physician most likely prescribe to treat this time of hypersensitivity reaction?

Chlorpheniramine Maleate (Chlor-Trimenton)

The physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should:

Collect the specimen in a sterile container.

An x-ray of the left femur shows a fracture that extends through the midshaft of the bone and multiple splintering fragments. What is this type of fracture called?

Comminuted fracture.

Most septal heart defects are _____ and repaired during infancy or early childhood.

Congenital

To help prevent osteoporosis, what should the nurse advise a young woman to do?

Consume at least 1,000mg of calcium daily.

A client is prescribed lisinopril (Zestril) for treatment of hypertension. He asks the nurse about possible adverse effects. The nurse should teach him about which common adverse effects fo angiotensin-converting enzyme (ACE) inhibitors?

Dizziness, headache, and hypotension.

A client seeks medical attention for a ganglion. Which statement about this musculoskeleton mass is true?

Dorsiflexion exacerbates signs and symptoms of a ganglion.

The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:

Drink liquids only between meals.

The initial symptom of mitral stenosis is typically ______ caused by pulmonary venous hypertension.

Dyspnea

True or false: Creatine kinase (CK) levels are measured to determine whether a patient is in heart failure.

False

True or false: Firm palpation is essential when assessing the dorsalis pedis pulse.

False

True or false: Mitral valve prolapse is caused by stenosis of the valve's leaflets.

False

True or false: The characteristic symptom of pericarditis is chest pain which is relieved when the patient lies down.

False

True or false: A desirable LDL level for patients with a diagnosis of coronary artery disease is 160mg/dl.

False - less than 100mg/dl would be a more appropriate goal.

The nurse is caring for a client with a cast on the left arm after sustaining a fracture. Which assessment finding is most significant for thsi client?

Fingers on the left hand are swollen and cool.

A client is diagnosed with gout. Which foods should the nurse instruct the client to avoid?

Foods high in purines - such as liver, cod, and sardines. Also avoid anchovies, kidneys, sweetbreads, lentils and alcoholic beverages - especially beer and wine.

Which of the following structures is seldom dislocated?

Foot.

A client is treated in the emergency room for a Colles' fracture sustained during a fall. What is a Colles' fracture?

Fracture of the distal radius.

During a scoliosis screening in a college health center, a student asks the public health nurse about the consequences of untreated scoliosis. The nurse would be accurate by identifying one of the direct complications as:

Impingement on pulmonary function.

When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?

Irritability and drowsiness.

Angina pectoris is chest pain resulting from myocardial ________?

Ischemia.

A client takes 30ml of magnesium hydroxide and aluminum hydroxide with simethicone (Maalox TC) P.O. 1 hour and 3 hours after each meal and at bedtime for treatment of a duodenal ulcer. Why does the client take this antacid so frequently?

It has a short duration of action.

A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan?

Keeping a pillow between the client's legs at all times.

The nurse is caring for a client who recently underwent a total hip replacement. The nurse should:

Limit client hip flexion when sitting.

A client is in Buck's skin traction after fracturing the right hip. The nurse should indicate which action in the care plan?

Maintaining correct body alignment.

The S1 heart sound results from close of the ____ and tricuspid valves.

Mitral

A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition?

Monitoring the client's weight every day.

The nurse is educating a client who's at risk for coronary artery disease (CAD). The nurse tells the client that CAD has many risk factors. Risk factors that can be controlled or modified include:

Obesity, inactivity, diet and smoking.

A client with severe abdominal pain is being evaluated for appendicitis. What is the most common cause of appendicitis?

Obstruction of the appendix.

After suffering a fall at home, a client is brought to the emergency department by ambulance. An x-ray confirms the diagnosis of a displaced fracture of the next of the left femur. Which intervention best immobilizes the client's femur and prevents complication?

Preparing the client for surgical intervention.

When a heart valve fails to close completely, blood flows backward through the valve in a process called _____.

Regurgitation

Which nursing diagnosis takes highest priority for a client with a compound fracture?

Risk for infection related to effects of trauma.

Which nursing diagnosis is a priority for the client with a traumatically amputated lower extremity?

Risk for injury related to injury and amputation.

The nurse is developing a teaching plan for a client who must undergo an above-the-knee amputation of the left leg. After a leg amputation, exercise of the remaining limb:

Should begin the day after surgery.

The nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the team, she correctly identifies which ECG changes associated with an evolving MI?

T-wave inversion, prolonged PR-interval, and ST-segment elevation.

A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan?

Teach the client how to prevent problems caused by immobility.

The nurse just received shift repotr for a group of clients on the telemetry unit. Which client should the nurse assess first?

The client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block.

The nurse is evaluating a client who had a myocardial infarction (MI) 7 days ago. Which outcome indicates that the client is responding favorably to therapy?

The client demonstrates the ability to tolerate increasing activity without chest pain.

What would be a primary reason for a hemovac to not collect drainage post abdominal surgery?

The hemovac drawin is not compressed; instead, it's fully expanded.

A client is in the emergency department with a suspected fracture of the right hip. Which assessment findings would the nurse expect?

The right leg is shorter than the left leg. The right leg is adducted. The right leg is externally rotated.

True or false: Blood vessels commonly used to bypass occluded coronary arteries include the saphenous veins in the leg.

True

True or false: Elderly patients are less likely to experience chest pain associated with angina and acute coronary syndrome than are younger patients.

True

True or false: Myocardial dysfunction occurs when irreversibly damaged heart muscle is replaced by adipose tissue.

True

True or false: The AV node relays electrical impulses from the atria to the ventricles.

True

True or false: The pathophysiology of artherosclerosis involves an inflammatory response to arterial wall injury.

True

True or false: The pathophysiology of cardiomyopathy results in impaired cardiac output.

True

True or false: Type 2 diabetics are prone to metabolic syndrome which increases their risk for heart disease.

True

True or false: When aortic stenosis is present, a loud murmur can be heard over the aortic area.

True

True or false: A pulmonary artery catheter is used for hemodynamic monitoring of cardiac output.

True.

A client is on bed rest after sustaining injuries in a car accident. Which nursing action would help the client avoid complications of immobility?

Turning the client every 2 hours and providing a low-air-loss mattress.

A client is admitted to the hospital with an exacerbation of his chronic gastritis. When assessing his nutritional status, the nurse should expect a deficiency in:

Vitamin B12

A client with acute diarrhea is prescribed paregoric, 5 ml by mouth, up to four times daily, until acute diarrhea subsides. The client asks the nurse how soon the medication will start to work after the first dose is taken. How should the nurse respond?

Within 1 hour.

When a defective heart valve is replaced with a porcine or bovine valve, the procedure is called a ______.

Xenograft

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing thsi client, the nurse expects to note:

Yellow sclerae.