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3 rev Flashcards

1
Q

The nurse suspects that her client is in cardiac arrest. According to the American Heart Association, the nurse should perform the actions listed below. Order these actions in the sequence that the nurse should perform them.

I. Activate the emergency medical system.
II. Assess responsiveness.
III. Call for a defibrillator.
IV. Provide two slow breaths.
V. Assess pulse.
VI. Assess breathing.

A. 2.1.3.6.4.5
B. 132456
C. 1,2,3,6,5,4
D. 2,3.1,5,6,4

A

A. 2.1.3.6.4.5

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2
Q

A client comes to the ER complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior wall myocardial infarction (MI). Which ECG characteristics indicates myocardial ischemia?
A. Prolonged PR interval
B. Absent Q wave
C. Elevated ST segment
D. Widened QRS complex

A

C. Elevated ST segment

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3
Q

Nyosh admits himself on the ER following an intense chest pain and the doctor orders an ECG. The result below will be interpreted as
A. AV bundle block
B. Sinus rhythm
C. Atrial flutter
D. Sinus arrhythmia

A

B. Sinus rhythm

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4
Q

The electrocardiogram (ECG) tracing shown below, excluding the seventh beat, has a normal QRS complex, one premature atrial contraction (PAC), and what other attributes?
A. P wave is identifiable, PR is 0.16 second, and sinus rhythm is at 95 beats/minute.
B. P wave and PR interval are unidentifiable and sinus arrhythmia is at 95 beats/minute.
C. P wave is identifiable, PR interval is 0.16 second, and sinus rhythm is at 95 beats/minute.
D. P wave is identifiable, PR interval is
0.16 second, and sinus arrhythmia is at
95 beats/minute.

A

D. P wave is identifiable, PR interval is
0.16 second, and sinus arrhythmia is at
95 beats/minute.

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5
Q

A client who is awake and diaphoretic has a palpable pulse. The nurse runs an electrocardiogram (ECG) strip, which reveals the following pattern for the lead I. What does the pattern indicate?

A. Normal sinus rhythm
B. Atrial fibrillation
C. Ventricular standstill
D. Ventricular tachycardia

A

A. Normal sinus rhythm

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6
Q

Mrs. Chua a 78-year-old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to client’s lungs indicative of chronic heart failure would be:
A. Stridor
B. Crackles
C. Wheezes
D. Friction rubs

A

B. Crackles

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7
Q

Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that morphine
A. Decrease anxiety and restlessness
B. Prevents shock and relieves pain
C. Dilates coronary blood vessels
D. Helps prevent fibrillation of the heart

A

B. Prevents shock and relieves pain

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8
Q

Which of the following should the nurse teach the client about the signs of digitalis toxicity?
A. Increased appetite
B. Elevated blood pressure
C. Skin rash over the chest and back
D. Visual disturbances such as seeing yellow spots

A

D. Visual disturbances such as seeing yellow spots

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9
Q

Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help…
A. Retard rapid drug absorption
B. Excrete excessive fluids accumulated at night
C. Prevents sleep disturbances during night
D. Prevention of electrolyte imbalance

A

C. Prevents sleep disturbances during night

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10
Q

What would be the primary goal of therapy for a client with pulmonary edema and heart failure?
A. Enhance comfort
B. Increase cardiac output
C. Improve respiratory status
D. Peripheral edema decreased

A

B. Increase cardiac output

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11
Q

Nurse Linda is caring for a client with head injury and monitoring the client with decerebrate posturing. Which of the following is a characteristic of this type of posturing?
A. Upper extremity flexion with lower extremity flexion
B. Upper extremity flexion with lower extremity extension
C. Extension of the extremities after a stimulus
D. Flexion of the extremities after stimulus

A

C. Extension of the extremities after a stimulus

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12
Q

A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following maybe experienced as side effects of this medication:
A. GI bleeding
B. Peptic ulcer disease
C. Abdominal cramps
D. Partial bowel obstruction

A

C. Abdominal cramps

Cascara sagrada is an OTC laxative
Plant ni sya or sumsht

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13
Q

Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Which of the following is the most essential nursing action?
A. Monitoring urine output frequently
B. Monitoring blood pressure every 4 hours
C. Obtaining serum potassium levels daily
D. Obtaining infusion pump for the medication

A

D. Obtaining infusion pump for the medication

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14
Q

During the second day of hospitalization of the client after a Myocardial Infarction. Which of the following is an expected outcome?
A. Able to perform self-care activities without pain
B. Severe chest pain
C. Can recognize the risk factors of Myocardial Infarction
D. Can Participate in cardiac rehabilitation walking program

A

A. Able to perform self-care activities without pain

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15
Q

A 68-year-old client is diagnosed with a right-sided brain attack and is admitted to the hospital. In caring for this client, the nurse should plan to:
A. Application of elastic stockings to prevent flaccid by muscle
B. Use hand roll and extend the left upper extremity on a pillow to prevent contractions
C. Use a bed cradle to prevent dorsiflexion if feet
D. Do passive range of motion exercis

A

B. Use hand roll and extend the left upper extremity on a pillow to prevent contractions

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16
Q

Nurse Liza is assigned to care for a client who has returned to the nursing unit after left nephrectomy. Nurse Liza’s highest priority would be…
A. Hourly urine output
B. Temperature
C. Able to turn side to side
D. Able to sips clear liquid

A

A. Hourly urine output

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17
Q

A 64-year-old male client with a long history of cardiovascular problem including hypertension and angina is to be scheduled for cardiac catheterization. During pre cardiac catheterization teaching, Nurse Cherry should inform the client that the primary purpose of the procedure is…
A. To determine the existence of CHD
B. To visualize the disease process in the coronary arteries
C. To obtain the heart chambers pressure
D. To measure oxygen content of different heart chambers

A

B. To visualize the disease process in the coronary arteries

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18
Q

During the first several hours after a cardiac catheterization, it would be most essential for nurse Cherry to…
A. Elevate client’s bed at 45°
B. Instruct the client to cough and deep breathe every 2 hours
C. Frequently monitor client’s apical pulse and blood pressure
D. Monitor client’s temperature every hour

A

C. Frequently monitor client’s apical pulse and blood pressure

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19
Q

Kate who has undergone mitral valve replacement suddenly experiences continuous bleeding from the surgical incision during postoperative period. Which of the following pharmaceutical agents should Nurse Aiza prepare to administer to Kate?
A. Protamine Sulfate
B. Quinidine Sulfate
C. Vitamin C
D. Coumadin

A

A. Protamine Sulfate

Protamine sulfate is a medication that is used to reverse the effects of heparin

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20
Q

In reducing the risk of endocarditis, good dental care is an important measure. To promote good dental care in client with mitral stenosis in teaching plan should include proper use of…
A. Dental floss
B. Electric toothbrush
C. Manual toothbrush
D. Irrigation device

A

C. Manual toothbrush

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21
Q

Among the following signs and symptoms, which would most likely be present in a client with mitral regurgitation?
A. Altered level of consciousness
B. Exceptional Dyspnea
C. Increase creatine phospholinase concentration
D. Chest pain

A

B. Exceptional Dyspnea

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22
Q
  1. Kris with a history of chronic infection of the urinary system complains of urinary frequency and burning sensation. To figure out whether the current problem is in renal origin, the nurse should assess whether the client has discomfort or pain in the…
    A. Urinary meatus
    B. Pain in the Labium
    C. Suprapubic area
    D. Right or left costovertebral angle
A

D. Right or left costovertebral angle

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23
Q

Nurse Perry is evaluating the renal function of a male client. After documenting urine volume and characteristics, Nurse Perry assesses which signs as the best indicator of renal function.
A. Blood pressure
B. Consciousness
C. Distension of the bladder
D. Pulse rate

A

A. Blood pressure

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24
Q

John suddenly experiences a seizure, and Nurse Gina notice that John exhibits uncontrollable jerking movements. Nurse Gina documents that John experienced which type of seizure?
A. Tonic seizure
B. Absence seizure
C. Myoclonic seizure
D. Clonic seizure

A

C. Myoclonic seizure

Myo” means muscle and “clonus” (KLOH-nus) means rapidly alternating contraction and relaxation—jerking or twitching—of a muscle.

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25
Q

Smoking cessation is critical strategy for the client with Burgher’s disease, Nurse Jasmin anticipates that the male client will go home with a prescription for which medication?
A. Paracetamol
B. Ibuprofen
C. Nitroglycerin
D. Nicotine (Nicotrol)

A

D. Nicotine (Nicotrol)

Buerger’s disease (also known as thromboangiitis obliterans)affects blood vessels in the body, most commonly in the arms and legs. Blood vessels swell, which can prevent blood flow, causing clots to form.

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26
Q

Which of the following lab studies should be done periodically if the client is taking warfarin sodium (Coumadin)?
A. Stool specimen for occult blood
B. White blood cell count
C. Blood glucose
D. Erythrocyte count

A

A. Stool specimen for occult blood

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27
Q

A client is admitted with a diagnosis of polycythemia vera. The nurse should closely monitor the client for:
A. Increased blood pressure
B. Decreased respirations
C. Increased urinary output
D. Decreased oxygen saturation

A

A. Increased blood pressure

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28
Q

The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are highest in vitamin B12?
A. Meat, eggs, dairy products
B. Peanut butter, raisins
C. Broccoli, cauliflower, cabbage
D. Shrimp, legumes, bran cereals

A

A. Meat, eggs, dairy products

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29
Q

Which of the following arteries primarily feeds the anterior wall of the heart?
A. Circumflex artery
B. Internal mammary artery
C. Left anterior descending artery
D. Right coronary artery

A

C. Left anterior descending artery

It supplies blood to the front (anterior wall) and part of the side (anterolateral wall) of the left ventricle, to the top of the left ventricle, and to most of the wall between the ventricles (interventricular septum).

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30
Q

When do coronary arteries primarily receive blood flow?
A. During inspiration
B. During diastole
C. During expiration
D. During systole

A

B. During diastole

because this is when the heart is relaxed, and they received the least blood flow during systole because this is when the myocardium contracts are decreasing the blood flow through the coronary arteries.

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31
Q

Which of the following illnesses is the leading cause of death in the US?
A. Cancer
B. Coronary artery disease
C. Liver failure
D. Renal failure

A

B. Coronary artery disease

Heart disease is the leading cause of death for both men and women. This is the case in the U.S. and worldwide.

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32
Q

Which of the following conditions most commonly results in CAD?
A. Atherosclerosis
B. DM
C. MI
D. Renal failure

A

A. Atherosclerosis

thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery.

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33
Q

Atherosclerosis impedes coronary blood flow by which of the following mechanisms?
A. Plaques obstruct the vein
B. Plaques obstruct the artery
C. Blood clots form outside the vessel wall
D. Hardened vessels dilate to allow the blood

A

B. Plaques obstruct the artery

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34
Q

Which of the following risk factors for coronary artery disease cannot be corrected?
A. Cigarette smoking
B. DM
C. Heredity
D. HPN

A

C. Heredity

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35
Q

Exceeding which of the following serum cholesterol levels significantly increases the risk of coronary artery disease?
A. 100 mg/dl
B. 150 mg/dl
C. 175 mg/dl
D. 200 mg/dl

A

D. 200 mg/dl

The following levels are considered to be “good” in healthy people: Total cholesterol: Levels below 200 mg/dL (5.2 mmol/L)

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36
Q
  1. Which of the following actions is the first priority care for a client exhibiting signs and symptoms of coronary artery disease?
    A. Decrease anxiety
    B. Enhance myocardial oxygenation
    C. Administer sublingual nitroglycerin
    D. Educate the client about his symptoms
A

B. Enhance myocardial oxygenation

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37
Q

Medical treatment of coronary artery disease includes which of the following procedures?
A. Cardiac catheterization
B. Coronary artery bypass surgery
C. Oral medication administration
D. Percutaneous transluminal coronary angioplasty are invasive, surgical treatments.

A

C. Oral medication administration

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38
Q

Prolonged occlusion of the right coronary artery produces an infarction in which of the following areas of the heart?
A. Anterior
B. Apical
C. Inferior
D. Lateral

A

C. Inferior

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39
Q

After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs?
A. Left-sided heart failure
B. Pulmonic valve malfunction
C. Right-sided heart failure
D. Tricuspid valve malfunction

A

A. Left-sided heart failure

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40
Q

Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage?
A. Cardiac catheterization
B. Cardiac enzymes
C. Echocardiogram
D. Electrocardiogram

A

C. Echocardiogram

Echocardiogram. Sound waves directed at your heart from a wand-like device held to your chest produce video images of your heart. An echocardiogram can help identify whether an area of your heart has been damaged and isn’t pumping normally. Stress echocardiogram.

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41
Q

What is the first intervention for a client experiencing myocardial infarction?
A. Administer morphine
B. Administer oxygen
C. Administer sublingual nitroglycerin
D. Obtain an electrocardiogram

A

B. Administer oxygen

Administering supplemental oxygen to the client is the first priority of care. The myocardium is deprived of oxygen during an infarction, so additional oxygen is administered to assist in oxygenation and prevent further damage.

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42
Q

What is the most appropriate nursing response to a myocardial infarction client who is fearful of dying?
A. “Tell me about your feeling right now.”
B. “When the doctor arrives, everything will be fine.”
C. “This is a bad situation, but you’ll feel better soon.”
D. “Please be assured we’re doing everything we can to make you feel better.”

A

A. “Tell me about your feeling right now.”

43
Q

Which of the following classes of medications protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation?
A. Beta-adrenergic blockers
B. Calcium channel blockers
C. Narcotics
D. Nitrates

A

A. Beta-adrenergic blockers

Lower bp vasodilator

44
Q

What is the most common complication of a myocardial infarction?
A. Cardiogenic shock
B. Heart failure
C. Arrhythmias
D. Pericarditis

A

C. Arrhythmias

About 90% of patients who have an acute myocardial infarction (AMI) develop some form of cardiac arrhythmia during or immediately after the event.

45
Q

With which of the following disorders is jugular vein distention most prominent?
A. Abdominal aortic aneurysm
B. Heart failure
C. Myocardial infarction
D. Pneumothorax

A

B. Heart failure

The most common underlying cause of JVD is heart failure.

46
Q

What position should the nurse place the head of the bed in to obtain the most accurate reading of jugular vein distention?
A. High-Fowler’s
B. Raised 10 degrees
C. Raised 30 degrees
D. Supine position

A

C. Raised 30 degrees

47
Q

Which of the following parameters should be checked before administering digoxin?
A. Apical pulse
B. Blood pressure
C. Radial pulse
D. Respiratory rate

A

A. Apical pulse

Electrolytes, mainly potassium levels, must be assessed and normalized before digoxin administration.

48
Q

Toxicity from which of the following medications may cause a client to see a green halo around lights?
A. Digoxin
B. Furosemide
C. Metoprolol
D. Enalapril

A

A. Digoxin

49
Q

Which of the following symptoms is most commonly associated with left-sided heart failure?
A. Crackles
B. Arrhythmias
C. Hepatic engorgement
D. Hypotension

A

A. Crackles

50
Q

In which of the following disorders would the nurse expect to assess sacral edema in bedridden client?
A. DM
B. Pulmonary emboli
C. Renal failure
D. Right-sided heart failure

A

D. 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.

51
Q

Which of the following symptoms might a client with right-sided heart failure exhibit?
A. Adequate urine output
B. Polyuria
C. Oliguria
D. Polydipsia

A

C. Oliguria

52
Q

Which of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility?
A. Beta-adrenergic blockers
B. Calcium channel blockers
C. Diuretics
D. Inotropic agents

A

D. Inotropic agents

53
Q

Stimulation of the sympathetic nervous system produces which of the following responses?
A. Bradycardia
B. Tachycardia
C. Hypotension
D. Decreased myocardial contractility

A

B. Tachycardia

54
Q

A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
A. Taking hourly blood pressures with mechanical cuff
B. Encouraging fluid intake of at least 200mL per hour
C. Position in high fowlers with knee gatch raised
D. Administering Tylenol as ordered

A

B. Encouraging fluid intake of at least 200mL per hour

55
Q

A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention:
A. Adjust the room temperature
B. Give a bolus of IV fluids
C. Start Oxygen
D Administer meperidine (Demerol) 75mg IV push

A

C. Start Oxygen

56
Q

A male client who takes theophylline for chronic obstructive pulmonary disease is seen in the urgent care center for respiratory distress. Once the client is stabilized, the nurse begins discharge teaching. The nurse would be especially vigilant to include information about complying with medication therapy If the client’s baseline theophylline level was.
A. 10 mcg/ml
B. 12 mcg/ml
C. 15 mcg/ml
D. 18 mcg/ml

A

A. 10 mcg/ml

to achieve modest bronchodilatation through phosphodiesterase inhibition, blood concentrations (10-20 mg/L) are required that are associated with adverse effects

57
Q

Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate?
A. Do nothing, because this is an expected finding.
B. Immediately clamp the chest tube and notify the physician
C. Check for an air leak because the bubbling should be intermittent
D. Increase the suction pressure so that bubbling becomes vigorous

A

A. Do nothing, because this is an expected finding.

58
Q

A nurse has assisted a physician with the insertion of a chest tube. The nurse monitors the adult client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on the assessment, which action would be appropriate?
A. Inform the physician
B. Continue to monitor the client
C. Reinforce the occlusice dressing.
D. Encourage the client to deep-breathe

A

B. Continue to monitor the client

59
Q

The nurse is caring for a male client with a chest tube, turns the client to the side and the chest tube accidentally disconnects. The initial nursing action is to:
A. Call the physician
B. Place the tube in a bottle of sterile water
C. Immediately replace the chest tube system
D. Place the sterile dressing ove the disconnection site.

A

B. Place the tube in a bottle of sterile water

60
Q

Nurse Paul is assisting a physician with the removal of a chest tube. The nurse should instruct the client to:
A. Exhale slowly
B. Stay very still
C. Inhale and exhale quickly
D. Perform the Valsalva maneuver

A

D. Perform the Valsalva maneuver

The Valsalva maneuver is forced expiration against a closed glottis. It mimics many normal and, in some cases, routine activities, such as straining during defecation, blowing up a balloon, or playing the saxophone

61
Q

While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing acting is to:
A. Call the physician to reinsert the tube
B. Grasp the retention sutures to spread the opening
C. Call the respiratory therapy department to reinsert the tracheostomy
D. Cover the tracheostomy wite with sterile dressing to prevent infection.

A

B. Grasp the retention sutures to spread the opening

62
Q

A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?
A. Stridor
B. Occasional, pink-tinged sputum
C. A few basilar lung crackles on the right
D. Respiratory rate of 24 breaths/min

A

A. Stridor

The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea.

63
Q

An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?
A. A low respiratory
B. Diminished breathe sounds
C. The presence of a barrel chest
D. A sucking sound at the site of injury

A

B. Diminished breathe sounds

64
Q

A nurse is caring for a male client hospitalized with acute exacerbation of chronic obstructive pulmonary disease Which of the following would the nurse expect to note on assessment of this client?
A. Hypocapnia
B. A hyperinflated chest noted on the chest ray
C. Increase oxygen saturation With exercise
D. A widened diaphragm noted on the chest xray

A

B. A hyperinflated chest noted on the chest ray

65
Q

A community health nurse is conducting an educational session With community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is:
A. Dyspnea
B. Chest pain
C. A bloody, productive cough
D. A cough with the expectoration Of mucoid sputum

A

D. A cough with the expectoration Of mucoid sputum

66
Q

A nurse performs an admission assessment on a female client With a diagnosis of tuberculosis. The nurse reviews the results of which diagnostic test that Will confirm this diagnosis?
A Bronchoscopy
B Sputum culture
C Chest x-ray
D Tuberculin skin test

A

B Sputum culture

A sputum culture is a test that checks for bacteria or another type of organism that may be causing an infection in your lungs or the airways leading to the lungs.

67
Q

62 The nursing instructor asks a nursing student to describe the route of transmission of tuberculosis. The instructor concludes that the student understands this Information if the student states that the tuberculosis is transmitted by:
A. Hand and mouth
B. The airborne route
C. The fecal-oral route
D. Blood and body fluids

A

B. The airborne route

68
Q

A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that It does not exceed.
A. 1 L/min
B 2 L/min
C 6 Limin
D 10 L/min

A

B 2 L/min

correct answer is Oxygen at 1-2 L/min is given to maintain hypoxic stimulus for breathing.

69
Q

A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of purSed-lip breathing is to:
A Promote oxygen intake.
B Strengthen the diaphragm.
C Strengthen the intercostal muscles.
D. Promote carbon dioxide elimination.

A

D. Promote carbon dioxide elimination.

70
Q

Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen?
A. Limiting fluids
B. Having the clients take three deep breaths
C. Asking the client to split into the collection container
D. Asking the client to obtain the specimen after eating

A

B. Having the clients take three deep breaths

71
Q

A nurse is caring for a female client after a bronchoscopy and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physicians?
A. Dry cough
B Hematuria
C Bronchospasm
D Blood-streaked sputum

A

C Bronchospasm

72
Q

A nurse is suctioning fluids from a male client via a tracheostomy tube When suctioning, the nurse must limit the suctioning time to a maximum of:
A. 1 minute
B. 5 seconds
C. 10 seconds
D. 30 seconds

A

C. 10 seconds

Tracheostomy suctioning is done for 10 to 15 seconds. Suctioning for a longer time period stimulates the vagus nerve. Stimulation of the vagus nerve results in bradycardia and hypoxia. The time should not exceed 15 seconds.

73
Q

A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention?
A Continue to suction.
B. Notify the physician immediately.
C. stop the procedure and reoxygenate the client.
D. Ensure that the suction is limited to 15 seconds

A

C. stop the procedure and reoxygenate the client.

74
Q

An unconscious male client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of:
A. Metabolic acidosis
B. Respiratory acidosis
C. Overcompensated respiratory acidosis
D. Combined respiratory and metabolic acidosis

A

A. Metabolic acidosis

75
Q

A female client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation Of pulmonary embolism?
A. Dyspnea
B Bradypnea
C Bradycardia
D Decreased respiratory

A

A. Dyspnea

76
Q

A nurse teaches a male client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching?
A. Inhales the mist and quickly exhales
B. Removes the cap and shakes the inhaler well before use
C. Presses the canister down with the finer as he breathes in
D. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed

A

A. Inhales the mist and quickly exhales

77
Q

A female client has just returned to a nursing unit following bronchoscopy. A nurse would implement which Of the following nursing interventions for this client?
A. Administering atropine intravenously
B. Administering small doses of midazolam (Versed)
C. Encouraging additional fluids for the next 24 hours
D. Ensuring the return of the gag reflex before offering food or fluids

A

D. Ensuring the return of the gag reflex before offering food or fluids

78
Q

A nurse is assessing the respiratory status of a male client who has suffered a fractured rib. The nurse would expect to note which of the following?
A. Slow deep respirations
B. Rapid deep respirations
C. Paradoxical respirations
D. Pain, especially With inspiration

A

D. Pain, especially With inspiration

79
Q

A female client with chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of flail chest
A. Cyanosis
B. Hypotension
C. Paradoxical chest movement
D. Dyspnea, especially on exhalation

A

C. Paradoxical chest movement
Paradoxical movement is an obvious sign that the portion of the chest wall is not assisting with the breathing function. Other symptoms of flail chest can include: Bruises, grazes, and/or discoloration in the chest area. Telltale markings from a seat belt.

80
Q

A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has an absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of:
A Right pneumothorax
B Pulmonary embolism
C Displaced endotracheal tube
D Acute respiratory distress syndrome

A

A. Right pneumothorax

81
Q

A client has just been diagnosed with type 1 diabetes mellitus. Which comment by the client correlates best with this disorder?
A. “I was thirsty all the time. I just couldn’t get enough to drink.”
B. “It seemed like I had no appetite. I had to make myself eat.”
C. “I had a cough and cold that just didn’t seem to go away.’
D. “I noticed I had pain when I went to the bathroom.

A

A. “I was thirsty all the time. I just couldn’t get enough to drink.”

82
Q

Which outcome would indicate successful treatment of diabetes insipidus?
A. Fluid intake of less than 2,500 ml in 24 hours
B. Urine output of more than 200 ml/hr.
C. Blood pressure of 90/50
D. pulse rate of 126 beats/minute

A

A. Fluid intake of less than 2,500 ml in 24 hours

83
Q

A nurse administered NPH insulin to a client with Diabetes mellitus at 7 am. At what time would the nurse expect the client to be at greatest risk for a hypoglycemic reaction?
A. 10 am
B Noon
C. 4 pm
D. 10 pm

A

C. 4 pm

NPH intermediate-acting insulin peak is at 8-12 hours

84
Q

Which instruction should be included in the teaching plan for a client requiring insulin?
A. Administer insulin
B. Administer insulin at a 45 degree angle into a deltoid muscle
C. Shake the vial of insulin vigorously before withdrawing the medication
D. Draw up clear insulin first when mixing two types of insulin in one syringe

A

D. Draw up clear insulin first when mixing two types of insulin in one syringe

85
Q
  1. A client with a serum glucose level of 618 mg/dl is admitted to the facility. He’s awake and oriented; has hot, dry skin; and has the following vital signs: temperature 38.1 degrees Celsius, heart rate of 116 beats/min and blood pressure of 108/70 mmHg. Based on these assessment findings, which nursing diagnosis takes highest priority?
    A. Deficient fluid volume related to osmotic diuresis
    B. Decreased cardiac output related to osmotic diuresis
    C. Imbalanced Nutrition: less than body requirements related to insulin deficiency
    D. Ineffective thermoregulation related to dehydration
A

A. Deficient fluid volume related to osmotic diuresis

86
Q

For the first 72 hours after thyroidectomy surgery, a nurse would assess a client for Chvostek’s and Trousseau’s signs because
they indicate:
A. Hypocalcemia
B. Hypercalcemia
C. Hypokalemia
D. Hyperkalemia

A

A. Hypocalcemia

87
Q

On a medical-surgical floor, the nurse is caring for a cluster of clients who have been diagnosed with diabetes mellitus. Which client should the nurse assess first?
A. An 80-year-old client with a blood glucose level of 350 mg/dl
B. A 20-year-old client with a blood glucose level of 70 mg/dl
C. A 60-year-old client experiencing nausea and vomiting
D. A 55-year-old client complaining of chest pressure

A

D. A 55-year-old client complaining of chest pressure

88
Q

The nurse is assigned to a 40-yr old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory results, anticipating a laboratory report that indicates a serum amylase level of:
A. 45 units/L
B. 100 units/L
C. 300 units/L
D. 500 units/L

A

C. 300 units/L

89
Q

What laboratory finding is the primary diagnostic indicator for pancreatitis?
A. Elevated blood urea nitrogen (BUN)
B. Elevated serum lipase
C. Elevated aspartate aminotransferase (AST)
D. Increased lactate dehydrogenase (LD)

A

B. Elevated serum lipase

The diagnosis of acute pancreatitis is made when a serum lipase activity is at least three times greater than the upper limit of normal. A serum amylase test is also performed in the diagnostics of AP, but it has a lower clinical value

Lipase. The best test for acute pancreatitis is the serum lipase test. If the lipase concentration is >3x the upper limit of normal, a diagnosis of acute pancreatitis is highly likely.

90
Q

A nurse is caring for client with pheochromocytoma. The client asks for a snack and something warm to drink. The most appropriate choice for this client to meet nutritional needs would be which of the following?
A. Crackers with cheese and tea
B. Graham crackers and warm milk
C. Toast with peanut butter and cocoa
D. Vanilla wafers and coffee with cream and Sugar

A

B. Graham crackers and warm milk

91
Q

A nurse is performing an assessment on a client with pheochromocytoma. Which of the following assessment data would indicate a potential complication associated with this disorder?
A. A coagulation time of 5 minutes
B. A blood urea nitrogen level of 20 mg/dl
C. A urinary output of 50 ml per hour
D. A heart rate that is 90 beats/min and
irregular

A

D. A heart rate that is 90 beats/min and
irregular

92
Q

A nurse is preparing to provide instructions to a client with Addison’s disease regarding diet therapy. The nurse knows that which of the following diets most likely would be prescribed for this client?
A. High fat intake
B. Low protein intake
C. Normal sodium intake
D. Low carbohydrate intake

A

C. Normal sodium intake

93
Q

A nurse is interviewing a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the treatment for this disorder?
A. “I take oral insulin instead of shots”
B. “By taking these medications, I am able to eat more.”
C. “When I become ill, I need to increase the number of pills I take.”
D. “The medications I’m taking help release the insulin I already make.

A

D. “The medications I’m taking help release the insulin I already make.

94
Q

A nurse is providing discharge instructions to a client who has Cushing’s syndrome. Which client statement indicates that instructions related to dietary management are understood?
A. “I can eat foods that have a lot of potassium in them.”
B. “I will need to limit the amount of protein in my diet.”
C. “I am fortunate that I can eat all the salty foods I enjoy.”
D. “I am fortunate that I do not need to follow any special diet.”

A

A. “I can eat foods that have a lot of potassium in them.”

95
Q

A client is taking NPH insulin daily every morning. The nurse instructs the client that the most likely time for a hypoglycemic reaction to occur is:
A. 2 to 4 hours after administration
B. 4 to 12 hours after administration
C. 16 to 18 hours after administration
D. 18 to 24 hours after administration

A

B. 4 to 12 hours after administration

96
Q

A nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement, if made by the Client, indicates a need for further teaching?
A”I need to drink diet soft drinks
B.”I will eat a balanced meal plan.
C.”I need to purchase special diabetic foods
D “I’ll snack on fruits instead of cake

A

B.”I will eat a balanced meal plan.

di sure

A ata

97
Q

A client received 20 units of NPH insulin subcutaneously at 8:00 am. The nurse should assess the client for a hypoglycemic reaction at:
A 10:00 am
B 11:00 am
C 5:00 pm
D. 11:00 pm

A

C 5:00 pm

Correct answer is 3
Intermediate acting insulin onset at 1.5 hours, peak 4-12 hours which hypoglycemic occur during peak time

98
Q

The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which most important statement?
A. *Your hair will need to be shaved.”
B. Deep breathing and coughing will be needed after surgery.’
C Brushing your teeth will not be permitted for at least 2 weeks following surgery.
D. You will receive spinal anesthesia.

A

C Brushing your teeth will not be permitted for at least 2 weeks following surgery.

99
Q

A nurse caring for a client with Addison’s disease would expect to note which of the following on assessment of the client?
A. Obesity
B. Edema
C. Hypotension
D Hirsutism

A

C. Hypotension

100
Q

A nurse is assessing a client with a diagnosis of goiter. Which of the following would the nurse expect to note during the assessment of the client?
A Client complains of slow wound healing
B. Client complains of chronic fatigue
C An enlarged thyroid gland
D. The presence of heart damage

A

C An enlarged thyroid gland

101
Q

The nurse is caring for a client following thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to:
A. Treat thyroid storm
B Prevent cardiac irritability
C. Stimulate release of parathyroid hormone
D. Treat hypocalcemia tetany

A

D. Treat hypocalcemia tetany

102
Q

The client with type 1 diabetes mellitus is to begin an exercise program and the nurse is providing instructions to the client regarding the program. Which of the following does the nurse include in the teaching plan?
A. Exercise is best performed during peak times of insulin
B. Administer insulin after exercising
C. Take a blood glucose test before exercising
D. Try to exercise prior to mealtime

A

C. Take a blood glucose test before exercising

103
Q

The nurse is preparing to administer an IV insulin injection. The vial of regular insulin has been refrigerated On inspection of the vial, the nurse finds that the medication is frozen. The nurse should:
A Wait for the insulin to thaw at room temperature
B. check the temperature settings of the refrigerator
C Discard the insulin and obtain another vial
D Rotate the vial between the hands until the medication becomes liquid.

A

C Discard the insulin and obtain another vial

104
Q

A nurse is assessing the learning readiness ‘of a client newly diagnosed with diabetes mellitus. Which client behavior indicates to the nurse that the client is not ready to learn?
A. The client complains of fatigue whenever the nurse plans a teaching session
B. The client asks if the spouse can attend the teaching session
C. The client asks for written materials about diabetes mellitus before class
D. The client asks appropriate questions about what will be taught

A

A. The client complains of fatigue whenever the nurse plans a teaching session

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