Exam 2 Oxygenation & Perfusion Test Bank

Question 1

The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired gas exchange?

a. Blood glucose of 350 mg/dL
b. Anticoagulant therapy for 10 days
c. Hemoglobin of 8.5 g/dL
d. Heart rate of 100 beats/min and blood pressure of 100/60

Answer 1

c. Hemoglobin of 8.5 g/dL

Rationale: The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased.
High blood glucose and/or anticoagulants do not alter the oxygen-carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of the oxygen-carrying capacity of the blood.

Question 2

The nurse is reviewing the patient’s arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3
is 25 mEq/L. What might the nurse expect to observe on assessment of this patient?

a. Disorientation and tremors
b. Tachycardia and decreased blood pressure
c. Increased anxiety and irritability
d. Hyperventilation and lethargy

Answer 2

a. Disorientation and tremors

Rationale: The patient is experiencing respiratory acidosis (↓pH and ↑PaCO2) which may be manifested by disorientation, tremors, possible seizures, and decreased level of consciousness.
Tachycardia and decreased blood pressure are not characteristic of a problem of
respiratory acidosis.
Increased anxiety and hyperventilation will cause respiratory alkalosis, which is manifested by an increase in pH and a decrease in PaCO2.

Question 3

The nurse would identify which patient condition as a problem of impaired gas exchange secondary to a perfusion problem?

a. Peripheral arterial disease of the lower extremities
b. Chronic obstructive pulmonary disease (COPD)
c. Chronic asthma
d. Severe anemia secondary to chemotherapy

Answer 3

a. Peripheral arterial disease of the lower extremities

Rationale: Perfusion relates to the ability of the blood to deliver oxygen to the cellular level and return the carbon dioxide to the lung for removal.
COPD and asthma are examples of ventilation problems.
Severe anemia is an example of a transport problem of gas exchange.

Question 4

The nurse is assessing a patient’s differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient’s gas exchange?

a. An elevation of the total white cell count indicates generalized inflammation.
b. Eosinophil count will assist to identify the presence of a respiratory infection.
c. White cell count will differentiate types of respiratory bacteria.
d. Level of neutrophils provides guidelines to monitor a chronic infection.

Answer 4

a. An elevation of the total white cell count indicates generalized inflammation.

Rationale: Elevation of total white cell count is indicative of inflammation that is often due to an infection.
Upper respiratory infections are
common problems in altering a patient’s gas exchange.
Eosinophil cells are increased in an allergic response.
Neutrophils are more indicative of an acute inflammatory response.
White cells do not assist to differentiate types of respiratory bacteria.
Monocytes are an indicator of progress of a chronic infection.

Question 5

The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an
increased risk for the development of respiratory acidosis?

a. Chronic lung disease with increased carbon dioxide retention
b. Acute anxiety, hyperventilation, and decreased carbon dioxide retention
c. Decreased cardiac output with increased serum lactic acid production
d. Gastric drainage with increased removal of gastric acid

Answer 5

a. Chronic lung disease with increased carbon dioxide retention

Rationale: Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the underlying disease.
A decrease in carbon dioxide retention may lead to respiratory alkalosis.
An increase in production of lactic acid leads to metabolic acidosis.
Removal of an acid (gastric secretions) will lead to a metabolic alkalosis.

Question 6

A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk?

a. The infant is becoming more active.
b. There is an increase in intake of breast milk or formula.
c. The infant is unable to maintain an adequate iron intake.
d. A depletion of fetal hemoglobin occurs.

Answer 6

d. A depletion of fetal hemoglobin occurs.

Rationale: Fetal hemoglobin is present for about 5 months.
The fetal hemoglobin begins deteriorating, and around 2–3 months the infant is
at increased risk of developing an anemia due to decreasing levels of hemoglobin.
Breast milk or formula is the primary food
intake up to around 6 months.
Often iron supplemented formula is offered, and/or an iron supplement is given if the infant is breastfed.

Question 7

Which clinical management prevention concept would the nurse identify as representative of secondary prevention?

a. Decreasing venous stasis and risk for pulmonary emboli
b. Implementation of strict hand washing routines
c. Maintaining current vaccination schedules
d. Prevention of pneumonia in patients with chronic lung disease

Answer 7

d. Prevention of pneumonia in patients with chronic lung disease

Rationale: Prevention of and treatment of existing health problems to avoid further complications is an example of secondary prevention.
Primary prevention includes infection control (hand washing), smoking cessation, immunizations, and prevention of
postoperative complications.

Question 8

The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.)

a. Neurologic system
b. Endocrine system
c. Pulmonary system
d. Immune system
e. Cardiovascular system
f. Hepatic system

Answer 8

a. Neurologic system
c. Pulmonary system
e. Cardiovascular system

Rationale: The neurologic system controls respiratory drive; the respiratory system controls the delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs.
These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange.
The immune system primarily protects the body against infection.

Question 9

The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.)

a. Respiratory rate is 24 breaths/min.
b. Oxygen saturation level is 98%.
c. The right side of the thorax expands slightly more than the left.
d. Trachea is just to the left of the sternal notch.
e. Nail beds are pink with good capillary refill.
f. There is presence of quiet, effortless breath sounds at lung base bilaterally

Answer 9

b. Oxygen saturation level is 98%.
e. Nail beds are pink with good capillary refill.
f. There is presence of quiet, effortless breath sounds at lung base bilaterally

Rationale: Oxygen saturation level should be between 95 and 100%; nail beds should be pink with capillary refill of about 3 seconds; and breath sounds should be present at base of both lungs.
Normal respiratory rate is between 12 and 20 breaths/min.
The trachea should be in midline with the sternal notch.
The thorax should expand equally on both sides.

Question 10

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a
60–pack-year smoking history. Which action is most important for the nurse to take when interviewing this client?

a. Tell the client that he or she needs to quit smoking to stop further cancer development.
b. Encourage the client to be completely honest about both tobacco and marijuana use.
c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
d. Avoid giving the client false hope regarding cancer treatment and prognosis.

Answer 10

c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.

Rationale: Smoking assessments and cessation information can be an uncomfortable and sensitive topic among both clients and health care
providers.
The nurse would maintain a nonjudgmental attitude in order to foster trust with the client. Telling the client he or she needs to quit smoking is paternalistic and threatening. Assessing exposure to smoke includes more than tobacco and marijuana.
The nurse would avoid giving the client false hope but when taking a history, it is most important to get accurate information.

Question 11

A nurse assesses a client’s respiratory status. Which information is most important for the nurse to obtain?

a. Average daily fluid intake.
b. Neck circumference.
c. Height and weight.
d. Occupation and hobbies.

Answer 11

d. Occupation and hobbies.

Rationale: Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client’s occupation and hobbies.
Although it will be important for the nurse to assess the client’s fluid intake, height, and weight, these will not be as important as
determining his occupation and hobbies.
This is part of the I-PREPARE assessment model for particulate matter exposure.
Determining the client’s neck circumference will not be an important part of a respiratory assessment.

Question 12

A nurse observes that a client’s anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question would the nurse ask the client in response to this finding?

a. “Are you taking any medications or herbal supplements?”
b. “Do you have any chronic breathing problems?”
c. “How often do you perform aerobic exercise?”
d. “What is your occupation and what are your hobbies?”

Answer 12

b. “Do you have any chronic breathing problems?”

Rationale: The normal chest has an anteroposterior (AP or front-to-back) diameter ratio with the lateral (side-to-side) diameter. This ratio normally is about 1:1.5. When the AP diameter approaches the lateral diameter, and the ratio is 1:1, the client is said to have a
barrel chest.
Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic emphysema.
It can also be seen in people who have lived at a high altitude for many years.
Medications, herbal supplements, and
aerobic exercise are not associated with a barrel chest.
Although occupation and hobbies may expose a client to irritants that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more direct and would be asked first.

Question 13

A nurse is assessing a client who is recovering from a lung biopsy. The client’s breath sounds are absent. While another nurse calls
the Rapid Response Team, what action by the nurse takes is most important?

a. Take a full set of vital signs.
b. Obtain pulse oximetry reading.
c. Ask the patient about hemoptysis.
d. Inspect the biopsy site.

Answer 13

b. Obtain pulse oximetry reading.

Rationale: Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a needle biopsy or open lung biopsy.
The nurse would first obtain a pulse oximetry reading and perform other respiratory assessments.
Temperature is not a priority.
The nurse can ask about other symptoms while conducting the assessment.
The nurse would assess the biopsy site and/or
dressings, but this is not the first action.

Question 14

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure?

a. Measure oxygen saturation before and after a 12-minute walk.
b. Verify that the client understands all possible complications.
c. Explain the procedure in detail to the client and the family.
d. Validate that informed consent has been given by the client.

Answer 14

d. Validate that informed consent has been given by the client.

Rationale: A thoracentesis is an invasive procedure with many potentially serious complications.
The nurse would ensure signed informed
consent has been obtained.
Verifying that the client understands complications and explaining the procedure to be performed will be done by the primary health care provider, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis.

Question 15

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?

a. The client rates pain as a 5/10 at the site of the procedure.
b. A small amount of drainage from the site is noted.
c. Pulse oximetry is 93% on 2 L of oxygen.
d. The trachea is shifted toward the opposite side of the neck.

Answer 15

d. The trachea is shifted toward the opposite side of the neck.

Rationale: A shift of central thoracic structures toward one side is a sign of a tension pneumothorax, which is a medical emergency.
The other findings are normal or near normal. The nurse would report this finding immediately or call the Rapid Response Team.

Question 16

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse
take next?

a. Call the primary health care provider and request food and water for the client.
b. Provide the client with ice chips instead of a drink of water.
c. Assess the client’s gag reflex before giving any food or water.
d. Let the client have a small sip to see whether he or she can swallow.

Answer 16

c. Assess the client’s gag reflex before giving any food or water.

Rationale: The topical anesthetic used during the procedure will have affected the client’s gag reflex.
Before allowing the client anything to
eat or drink, the nurse must check for the return of this reflex.

Question 17

A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which
intervention would the nurse include in this client’s plan of care?

a. Assistance with activities of daily living
b. Physical therapy activities every day
c. Oxygen therapy at 2 L per nasal cannula
d. Complete bedrest with frequent repositioning

Answer 17

a. Assistance with activities of daily living

Rationale: A client with dyspnea and the inability to complete activities such as climbing a flight of stairs without pausing has class IV dyspnea.
The nurse would provide assistance with activities of daily living.
These clients would be encouraged to participate in activities as tolerated.
They would not be on complete bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.

Question 18

A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement would the nurse include in this client’s teaching?

a. “Make a list of reasons why smoking is a bad habit.”
b. “Rise slowly when getting out of bed in the morning.”
c. “Smoking while taking this medication will increase your risk of a stroke.”
d. “Stopping this medication suddenly increases your risk for a heart attack.”

Answer 18

c. “Smoking while taking this medication will increase your risk of a stroke.”

Rationale: Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart attack. Nurses would teach clients not to smoke while taking these drugs.
The nurse would encourage the client to make a list of reasons for stopping the habit but would not phrase it so judgmentally. Orthostatic hypotension is not a risk with nicotine replacement therapy.
Stopping suddenly does not increase the risk of heart attack.

Question 19

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. What action would the nurse take next?

a. Administer an albuterol treatment.
b. Notify the Rapid Response Team.
c. Assess the client’s peripheral pulses.
d. Obtain blood and sputum cultures.

Answer 19

b. Notify the Rapid Response Team.

Rationale: Cyanosis unresponsive to oxygen therapy is a sign of methemoglobinemia, which is an adverse effect of benzocaine spray.
This condition can lead to death.
The nurse would notify the Rapid Response Team to provide advanced care.
An albuterol treatment would not address the client’s oxygenation problem.
Assessment of pulses and cultures will not provide data necessary to treat the client.

Question 20

A nurse auscultates a harsh hollow sound over a client’s trachea and larynx. What action would the nurse take first?

a. Document the findings.
b. Administer oxygen therapy.
c. Position the client in high-Fowler position.
d. Administer prescribed albuterol.

Answer 20

a. Document the findings.

Rationale: Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx.
The nurse would document this finding.
There is no need to implement oxygen therapy, administer albuterol, or change the client’s position because the finding is normal.

Question 21

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?

a. Administer prescribed anxiolytic medication.
b. Ensure that informed consent is on the chart.
c. Reinforce any teaching done previously.
d. Start the preoperative antibiotic infusion.

Answer 21

b. Ensure that informed consent is on the chart.

Rationale: Since this is an operative procedure, the client must sign an informed consent, which must be on the chart.
Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.

Question 22

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the client’s face is puffy and the eyelids are
swollen. What action by the nurse takes best?

a. Assess the client’s oxygen saturation.
b. Notify the Rapid Response Team.
c. Oxygenate the client with a bag-valve-mask.
d. Palpate the skin of the upper chest.

Answer 22

a. Assess the client’s oxygen saturation.

Rationale: This client may have subcutaneous emphysema, which is the air that leaks into the tissues surrounding the tracheostomy.
The nurse would first assess the client’s oxygen saturation and other indicators of oxygenation.
If the client is stable, the nurse can palpate the skin of the upper chest to feel for air.
If the client is unstable, the nurse calls the Rapid Response Team.
A bag-valve-mask device may or may not be appropriate for the unstable client.

Question 23

An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a
coughing spell during the meal. What action by the nurse is best?

a. Assess the client’s lung sounds.
b. Assign a different AP to the client.
c. Report the AP to the manager.
d. Request thicker liquids for meals.

Answer 23

a. Assess the client’s lung sounds.

Rationale: The best action is to check the client’s oxygenation because he or she may have aspirated.
Once the client has been assessed, the
nurse would notify the primary health care provider of possible aspiration and would consult with the registered dietitian about
appropriately thickened liquids.
The UAP should have reported the incident immediately, but addressing that issue is not the immediate priority.

Question 24

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that outcomes for client safety with oxygen therapy are being met?

a. 100% of meals being eaten by the client
b. Intact skin behind the ears
c. The client understanding the need for oxygen
d. Unchanged weight for the past 3 days

Answer 24

b. Intact skin behind the ears

Rationale: Oxygen tubing can cause pressure injuries, so clients using oxygen have a high risk of skin breakdown.
Intact skin behind the ears indicates that goals for maintaining client safety with oxygen therapy are being met.
Nutrition and weight are not related to using
oxygen.
Understanding the need for oxygen is important but would not take priority over a physical problem.

Question 25

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the client’s decrease in self-esteem are being met? a. The client demonstrates good understanding of stoma care. b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection.

Answer 25

b. The client has joined a book club that meets at the library. Rationale: The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for disrupted self-esteem are being met. The other findings are all positive signs but do not relate to this client problem.

Question 26

A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to assistive personnel (AP)? a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Replaces the oxygen tubing with a different type. d. Turn the client every 2 hours or as needed.

Answer 26

a. Apply water-soluble ointment to nares and lips. Rationale: Oxygen can be drying, so the UAP can apply water-soluble lubricant to the client’s lips and nares. The AP would not adjust the oxygen flow rate or replace the tubing. Turning the client is not related to comfort measures for oxygen.

Question 27

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? a. Assess the client’s oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d. Turn the oxygen off while the client eats the meal and then restart it.

Answer 27

b. Determine if the client can switch to a nasal cannula during the meal. Rationale: Oxygen is a drug that needs to be delivered constantly. The nurse would determine if the primary healthcare provider has approved switching to a nasal cannula during meals. If not, the nurse would consult with the primary health care provider about this issue. The primary healthcare provider would need to prescribe discontinuing oxygen if the client’s oxygen saturation is normal. The oxygen would not be turned off. Lifting the mask to eat will alter the FiO2 delivered.

Question 28

The nurse is teaching a client who has pernicious anemia about necessary dietary changes. Which statement by the client indicates understanding about those changes? a. “I’ll increase animal proteins like fish and meat.” b. “I’ll work on increasing my fats and carbohydrates.” c. “I’ll avoid eating green leafy vegetables. d. “I’ll limit my intake of citrus fruits.”

Answer 28

a. “I’ll increase animal proteins like fish and meat.” Rationale: Clients who have pernicious anemia have a Vitamin B12 deficiency and need to consume foods high in Vitamin B12, such as animal and plant proteins, citrus fruits, green leafy vegetables, and dairy products. While carbohydrates and fats can provide sources of energy, they do not supply the necessary nutrient to improve anemia.

Question 29

A nurse is caring for four clients with leukemia. After the hand-off report, which client would the nurse assess first? a. Client who had two bloody diarrhea stools this morning. b. Client who has been premedicated for nausea prior to chemotherapy. c. Client with a respiratory rate change from 18 to 22 breaths/min. d. Client with an unchanged lesion to the lower right lateral malleolus.

Answer 29

a. Client who had two bloody diarrhea stools this morning. Rationale: The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI) tract and should be assessed first to monitor for or avoid the client from going into hypovolemic shock. The client with the slight change in respiratory rate may have an infection or worsening anemia and should be seen next. If the client’s respiratory rate was greater than 28 to 30 breaths/min, the client may need the initial assessment. Marked tachypnea is an early sign of a deteriorating client condition. The other two clients are not a priority at this time.

Question 30

"Beefy red tongue pic" What action by the nurse is most appropriate? a. Encourage the client to have genetic testing. b. Instruct the client on high-fiber foods. c. Place the client in protective precautions. d. Teach the client about cobalamin therapy.

Answer 30

d. Teach the client about cobalamin therapy. Rationale: This condition is known as glossitis, and is characteristic of B12 anemia. If the anemia is a pernicious anemia, it is treated with cobalamin. Genetic testing is not a priority for this condition. The client does not need high-fiber foods or protective precautions.

Question 31

A nurse assesses several clients who have a history of respiratory disorders. Which client would the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 35-year-old client who reports orthopnea in bed d. A 27-year-old client with a heart rate of 120 beats/min

Answer 31

d. A 27-year-old client with a heart rate of 120 beats/min Rationale: Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not considered an acute finding. Orthopnea at night in bed is breathlessness when lying down but is not an acute finding at this moment.

Question 32

A nurse cares for a client with arthritis who reports frequent asthma attacks. What action would the nurse take first? a. Review the client’s pulmonary function test results. b. Ask about medications the client is currently taking. c. Assess how frequently the client uses a bronchodilator. d. Consult the primary health care provider and request arterial blood gases.

Answer 32

b. Ask about medications the client is currently taking. Rationale: Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a likely culprit given the client’s history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good time to review response to bronchodilators, but assessing triggers is more important. Questioning the client about the use of bronchodilators will address interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks.

Question 33

A child has a chronic, nonproductive cough and diffuse wheezing during the expiratory phase of respiration. This suggests a. Asthma b. Pneumonia c. Bronchiolitis d. Foreign body in trachea

Answer 33

a. Asthma Rationale: Children with asthma usually have these chronic symptoms. B Pneumonia appears with an acute onset and fever and general malaise. C Bronchiolitis is an acute condition caused by RSV. D Foreign body in the trachea will occur with acute respiratory distress or failure and maybe stridor.

Question 34

What is a common trigger for asthma attacks in children? a. Febrile episodes b. Dehydration c. Exercise d. Seizures

Answer 34

c. Exercise Rationale: Febrile episodes are consistent with other problems, for example, seizures. B Dehydration occurs as a result of diarrhea; it does not trigger asthma attacks. Viral infections are triggers for asthma. C Exercise is one of the most common triggers for asthma attacks, particularly in school-age children. D Seizures can result from a too-rapid intravenous infusion of theophylline—a therapy for asthma.

Question 35

What explanation should the nurse give to the parent of a child with asthma about using a peak flow meter? a. It is used to monitor the child's breathing capacity. b. It measures the child's lung volume. c. It will help the medication reach the child's airways. d. It measures the amount of air the child breathes in.

Answer 35

a. It is used to monitor the child's breathing capacity. Rationale: The peak flow meter is a device used to monitor breathing capacity in the child with asthma. B A child with asthma would have a pulmonary function test to measure lung volume. C A spacer used with a metered-dose inhaler prolongs medication transit so medication reaches the airways. D The peak flow meter measures the flow of air in a forced exhalation in liters per minute.

Question 36

What is the best nursing response to the parent of a child with asthma who asks if his child can still participate in sports? a. "Children with asthma are usually restricted from physical activities." b. "Children can usually play any type of sport if their asthma is well controlled." c. "Avoid swimming because breathing underwater is dangerous for people with asthma." d. "Even with good asthma control, I would advise limiting the child to one athletic activity per school year."

Answer 36

b. "Children can usually play any type of sport if their asthma is well controlled." Rationale: Children with asthma should not be restricted from physical activity. B Sports that do not require sustained exertion, such as gymnastics, baseball, and weight lifting, are well tolerated. Children can usually play any type of sport if their asthma is well controlled. C Swimming is recommended as the ideal sport for children with asthma because the air is humidified and exhaling underwater prolongs exhalation and increases end-expiratory pressure. D If asthma is well controlled, the child can participate in any type of sport.

Question 37

Which classification of drugs is used to relieve an acute asthma episode? a. Short-acting beta2-adrenergic agonist b. Inhaled corticosteroids c. Leukotriene blockers d. Long-acting bronchodilators

Answer 37

a. Short-acting beta2-adrenergic agonist Rationale: Short-acting beta2-adrenergic agonist is the first medication administered. Later, systemic corticosteroids decrease airway inflammation in an acute asthma attack. They are given short courses of 5 to 7 days. B Inhaled corticosteroids are used for long-term, routine control of asthma. C Leukotriene blockers diminish the mediator action of leukotrienes and are used for long-term, routine control of asthma in children older than 12 years. D A long-acting bronchodilator would not relieve acute symptoms.

Question 38

The nurse getting an end-of-shift report on a child with status asthmaticus should question which intervention? a. Administer oxygen by nasal cannula to keep oxygen saturation at 100%. b. Assess intravenous (IV) maintenance fluids and site every hour. c. Notify physician for signs of increasing respiratory distress. d. Organize care to allow for uninterrupted rest periods.

Answer 38

a. Administer oxygen by nasal cannula to keep oxygen saturation at 100%. Rationale: Supplemental oxygen should not be administered to maintain oxygen saturation at 100%. Keeping the saturation around 95% is adequate. The administration of too much oxygen to a child may lead to respiratory depression by decreasing the stimulus to breathe, leading to carbon dioxide retention. B When the child cannot take oral fluids because of respiratory distress, IV fluids are administered. The child with a continuous IV infusion must be assessed hourly to prevent complications. C A physician should be notified of any changes indicating increasing respiratory distress. D A child in respiratory distress is easily fatigued. Nursing care should be organized so the child can get needed rest without being disturbed.

Question 39

What should the nurse teach a child about using an albuterol metered-dose inhaler for exercise-induced asthma? a. Take two puffs every 6 hours around the clock. b. Use the inhaler only when the child is short of breath. c. Use the inhaler 30 minutes before exercise. d. Take one to two puffs every morning upon awakening.

Answer 39

c. Use the inhaler 30 minutes before exercise. Rationale: A. This schedule will not relieve exercise-induced asthma. B Waiting until symptoms are severe is too late to begin using a metered-dose inhaler. C The appropriate time to use an inhaled beta2-agonist or Cromolyn is before an event that could trigger an attack. D This may be the child's usual schedule for medication. If exercise causes symptoms, additional medication is indicated.

Question 40

After teaching a client who is prescribed a long-acting beta 2 agonist medication, a nurse assesses the client’s understanding. Which statement indicates that the client comprehends the teaching? a. “I will carry this medication with me at all times in case I need it.” b. “I will take this medication when I start to experience an asthma attack.” c. “I will take this medication every morning to help prevent an acute attack.” d. “I will be weaned off this medication when I no longer need it.”

Answer 40

c. “I will take this medication every morning to help prevent an acute attack.” Rationale: Long-acting beta 2 agonist medications will help prevent an acute asthma attack because they are long-acting. The client will take this medication every day for best effect. The client does not have to always keep this medication with him or her because it is not used as a rescue medication. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his or her daily medications.

Question 41

After teaching a client who is prescribed salmeterol, the nurse assesses the client’s understanding. Which statement by the client indicates a need for additional teaching? a. “I will be certain to shake the inhaler well before I use it.” b. “It may take a while before I notice a change in my asthma.” c. “I will use the drug when I have an asthma attack.” d. “I will be careful not to let the drug escape out of my nose and mouth.”

Answer 41

c. “I will use the drug when I have an asthma attack.” Rationale: Salmeterol is a long-acting beta 2 agonist designed to prevent an asthma attack; it does not relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it would not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the client’s part allows the drug to escape through the nose and mouth.

Question 42

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that going out with friends is no longer enjoyable. How would the nurse respond? a. “There are a variety of support groups for people who have COPD.” b. “I will ask your primary health care provider to prescribe an antianxiety agent.” c. “I’d like to hear about thoughts and feelings causing you to limit social activities.” d. “Friends can be a good support system for clients with chronic disorders.”

Answer 42

c. “I’d like to hear about thoughts and feelings causing you to limit social activities.” Rationale: Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. While friends can be good sources of support, the client specifically is discussing going out of the home.

Question 43

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question would the nurse ask first? a. “Do you have a strong support system?” b. “What do you understand about your disease?” c. “Do you experience shortness of breath with basic activities?” d. “What medications are you prescribed to take each day?”

Answer 43

c. “Do you experience shortness of breath with basic activities?” Rationale: Clients with severe COPD may not be able to perform daily activities, including bathing and eating, because of excessive shortness of breath. The nurse would ask the client if shortness of breath is interfering with basic activities. Although the nurse would need to know about the client’s support systems, current knowledge, and medications, these questions do not address the client’s appearance.

Question 44

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client would the nurse assess first? a. A 46 year old with a 30–pack-year history of smoking b. A 52 year old in a tripod position using accessory muscles to breathe c. A 68 year old who has dependent edema and clubbed fingers d. A 74 year old with a chronic cough and thick, tenacious secretions

Answer 44

b. A 52 year old in a tripod position using accessory muscles to breathe Rationale: The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how effectively the client is breathing and provide interventions to minimize respiratory distress. The other clients are not in acute distress.

Question 45

A nurse cares for a client who has a pleural chest tube. What action would the nurse take to ensure safe use of this equipment? a. Strip the tubing to minimize clot formation and ensure patency. b. Secure tubing junctions with clamps to prevent accidental disconnections. c. Connect the chest tube to wall suction as prescribed by the primary health care provider. d. Keep padded clamps at the bedside for use if the drainage system is interrupted.

Answer 45

d. Keep padded clamps at the bedside for use if the drainage system is interrupted. Rationale: Padded clamps would be kept at the bedside for use if the drainage system becomes dislodged or is interrupted. The nurse would never strip the tubing. Tubing junctions would be taped, not clamped. Wall suction would be set at the level indicated by the device’s manufacturer, not the primary health care provider.

Question 46

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic action? a. Bronchodilator—stabilizes the membranes of mast cells and prevents the release of inflammatory mediators. b. Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system. c. Corticosteroid—relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta 2 receptors. d. Cromone—disrupts the production of pathways of inflammatory mediators.

Answer 46

b. Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system. Rationale: Cholinergic antagonist drugs cause bronchodilation by inhibiting the parasympathetic nervous system. This allows the sympathetic nervous system to dominate and release norepinephrine that activates beta 2 receptors. Bronchodilators relax bronchiolar smooth muscles by binding to and activating pulmonary beta 2 receptors. Corticosteroids disrupt the production of pathways of inflammatory mediators. Cromones stabilize the membranes of mast cells and prevent the release of inflammatory mediators.

Question 47

A patient diagnosed with hypertension asks the nurse how this disease could have happened to them. What is the nurse’s best response? a. “Hypertension happens to everyone sooner or later. Don't be concerned about it.” b. “Hypertension can happen from eating a poor diet, so change what you are eating.” c. “Hypertension can happen from arterial changes that block the blood flow.” d. “Hypertension happens when people do not exercise, so you should walk every day.”

Answer 47

c. “Hypertension can happen from arterial changes that block the blood flow.” Rationale: Hardening of the arteries from atherosclerosis can cause hypertension in the patient. Hypertension does not happen to everyone. Changing the patient’s diet and exercising may be a positive life change, but these answers do not explain to the patient how the disease could have happened.

Question 48

The patient asks the nurse to explain the function of the sinoatrial node in the heart. What is the nurse’s best response? a. “It stimulates the heart to beat in a normal rhythm.” b. “It protects the heart from atherosclerotic changes.” c. “It provides the heart with oxygenated blood.” d. “It protects the heart from infection.”

Answer 48

a. “It stimulates the heart to beat in a normal rhythm.” Rationale: The sinoatrial node is the natural pacemaker of the heart, and it assists the heart to beat in a normal rhythm. The sinoatrial node does not protect from atherosclerotic changes or infection, and it does not directly provide the heart with oxygenated blood.

Question 49

The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. What is the priority of care for this patient? a. Mental alertness b. Perfusion c. Pain d. Reaction to medications

Answer 49

b. Perfusion Rationale: Perfusion is the correct answer, because with internal bleeding, the nurse should monitor vital signs to be sure perfusion is happening. Mental alertness, pain, and medication reactions are important but not the primary concern.

Question 50

A patient’s serum electrolytes are being monitored. The nurse notices that the potassium level is low. What should the nurse monitor for in this patient? a. Tissue ischemia b. Brain malformations c. Intestinal blockage d. Cardiac dysrhythmia

Answer 50

d. Cardiac dysrhythmia Rationale: Cardiac dysrhythmia is a possibility when serum potassium is high or low. Tissue ischemia, brain malformations, or intestinal blockage do not have a direct correlation to potassium irregularities.

Question 51

A nurse is explaining the concept of perfusion to a student nurse. The nurse knows the student understands the concept of perfusion when the student makes which statement? a. “Perfusion is a normal function of the body, and I don't have to be concerned about it.” b. “Perfusion is monitored by the physician.” c. “Perfusion is monitored by vital signs and capillary refill.” d. “Perfusion varies as a person ages, so I would expect changes in the body.”

Answer 51

c. “Perfusion is monitored by vital signs and capillary refill.” Rationale: The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is not only monitored by the physician but the nurse too. Perfusion does not always change as the person ages.

Question 52

The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment? a. Elevated blood pressure b. Bounding pedal pulses c. Night blindness d. Reflux disease

Answer 52

a. Elevated blood pressure Rationale: Smokers have a constriction of the blood vessels due to the tar and nicotine in cigarettes. This constriction may lead to hypertension. Bounding pulses, night blindness, and reflux disease do not have a direct link to smoking.

Question 53

A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional assessment finding would the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min

Answer 53

a. Heart rate of 120 beats/min Rationale: When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturation and perfusion. The client may not be able to compensate for long and decreased oxygenation and cool, clammy skin will occur later.

Question 54

A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the nurse expect to find? a. Blood pressure increased from 98/42 to 132/60 mm Hg. b. Respiratory rate decreased from 25 to 14 breaths/min. c. Oxygen saturation increased from 88% to 96%. d. Pulse decreased from 100 to 80 beats/min.

Answer 54

d. Pulse decreased from 100 to 80 beats/min. Rationale: Beta blockers block the stimulation of beta 1 -adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta 2-adrenergic receptor sites. Cardiac output may drop because of decreased HR, but slowing the rate may allow for better filling and better cardiac output.

Question 55

A nurse assesses clients on a medical-surgical unit. Which client would the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma. b. A 32-year-old man with colorectal cancer. c. A 65-year-old woman with diabetes mellitus. d. A 53-year-old postmenopausal woman who takes bisphosphonates.

Answer 55

c. A 65-year-old woman with diabetes mellitus. Rationale: Of the options, the client with diabetes has a two- to four-fold increase in risk for death due to cardiovascular disease. Advancing age also increases risk, but not as much. Asthma, colorectal cancer, and bisphosphonate therapy do not increase the risk for cardiovascular disease.

Question 56

An emergency department nurse obtains the health history of a client. Which statement by the client would alert the nurse to the occurrence of heart failure? a. “I get short of breath when I climb stairs.” b. “I see halos floating around my head.” c. “I have trouble remembering things.” d. “I have lost weight over the past month.”

Answer 56

a. “I get short of breath when I climb stairs.” Rationale: Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.

Question 57

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client would alert the nurse to the presence of edema? a. “I wake up to go to the bathroom at night.” b. “My shoes fit tighter by the end of the day.” c. “I seem to be feeling more anxious lately.” d. “I drink at least eight glasses of water a day.”

Answer 57

b. “My shoes fit tighter by the end of the day.” Rationale: Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse would note whether the client feels that his or her shoes or rings are tight, and would observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.

Question 58

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg

Answer 58

c. Slurred speech and confusion Rationale: A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are not unexpected at the site. Urinary output less than intake may or may not be significant.

Question 59

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment would the nurse complete as the priority prior to this procedure? a. Client’s level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents

Answer 59

d. Allergies to iodine-based agents Rationale: Before the procedure, the nurse would ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine-based. This allergy can cause a life-threatening reaction, so it is a high priority. It is important for the nurse to assess anxiety, mobility, and baseline cardiac status, but allergies take priority for client safety.

Question 60

A nurse cares for a client who has advanced cardiac disease and states, “I am having trouble breathing while I’m sleeping at night.” What is the nurse’s best response? a. “I will consult your primary health care provider to prescribe a sleep study.” b. “You become hypoxic while sleeping; oxygen therapy via nasal cannula will help.” c. “A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night.” d. “Use pillows to elevate your head and chest while you are sleeping.”

Answer 60

d. “Use pillows to elevate your head and chest while you are sleeping.” Rationale: The client is experiencing orthopnea (shortness of breath while lying flat). The nurse would teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea.

Question 61

A nurse prepares a client for cardiac catheterization. The client states, “I am afraid I might die.” What is the nurse’s best response? a. “This is a routine test and the risk of death is very low.” b. “Would you like to speak with a chaplain prior to test?” c. “Tell me more about your concerns about the test.” d. “What support systems do you have to assist you?”

Answer 61

c. “Tell me more about your concerns about the test.” Rationale: The nurse would discuss the client’s feelings and concerns related to the cardiac catheterization. The nurse would not provide false hope or push the client’s concerns off on the chaplain. The nurse would address support systems after addressing the client’s current issue.

Question 62

An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first? a. Client who describes pain as a dull ache. b. Client who reports moderate pain that is worse on inspiration. c. Client who reports cramping substernal pain. d. Client who describes intense squeezing pressure across the chest.

Answer 62

d. Client who describes intense squeezing pressure across the chest. Rationale: All clients who have chest pain would be assessed more thoroughly. To determine which client would be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing and viselike (squeezing) substernal pain or pressure that spreads through the client ’s chest, arms, jaw, back, or neck are indicatives of a myocardial infarction. The nurse would plan to see this client first to prevent cardiac cell death. A dull ache, pain that gets worse with inspiration, and cramping pain are not usually associated with myocardial infarction.

Question 63

A nurse reviews a client’s laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL (7.3 mmol/L) b. High-density lipoprotein cholesterol: 50 mg/dL (1.3 mmol/L) c. Triglycerides: 200 mg/dL (2.3 mmol/L) d. Serum albumin: 4 g/dL (5.8 mcmol/L) e. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L)

Answer 63

a. Total cholesterol: 280 mg/dL (7.3 mmol/L) c. Triglycerides: 200 mg/dL (2.3 mmol/L) e. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L) Rationale: A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis.

Question 64

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates that the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread

Answer 64

b. Baked chicken breast, broccoli, tomatoes Rationale: The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.

Question 65

A client asks what “essential hypertension” is. What response by the registered nurse is best? a. “It means it is caused by another disease.” b. “It means it is ‘essential’ that it be treated.” c. “It is hypertension with no specific cause.” d. “It refers to severe and life-threatening hypertension.”

Answer 65

c. “It is hypertension with no specific cause.” Rationale: Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension.

Question 66

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the client’s support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the client’s obligations.

Answer 66

b. Assist in finding one change the client can control. Rationale: All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse would assist the client in choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can move forward with another change. Determining support systems, daily stressors, and delegation opportunities does not directly impact the client’s feelings of control.

Question 67

The nurse is caring for four hypertensive clients. Which drug–laboratory value combination would the nurse report immediately to the health care provider? a. Furosemide/potassium: 2.1 mEq/L b. Hydrochlorothiazide/potassium: 4.2 mEq/L c. Spironolactone/potassium: 5.1 mEq/L d. Torsemide/sodium: 142 mEq/L

Answer 67

a. Furosemide/potassium: 2.1 mEq/L Rationale: Furosemide is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and would be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal.

Question 68

A nurse is assessing a client with peripheral artery disease (PAD). The client states that walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. “Could you walk further than that a few months ago?” b. “Do you walk mostly uphill, downhill, or on flat surfaces?” c. “Have you ever considered swimming instead of walking?” d. “How much pain medication do you take each day?”

Answer 68

a. “Could you walk further than that a few months ago?” Rationale: As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain-free indicates that the client’s disease is worsening. The other questions are useful, but not as important.

Question 69

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. “I nearly always wear comfy sweatpants and house shoes.” b. “I’m glad I get energy assistance so my house isn’t so cold.” c. “My daughter makes sure I have plenty of lotion for my feet.” d. “My hands shake when I try to do things requiring coordination.”

Answer 69

d. “My hands shake when I try to do things requiring coordination.” Rationale: Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse would refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.

Question 70

A nurse is teaching a female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. “No, women should only have one beer a day as a general rule.” b. “No, you should not drink any alcohol with hypertension.” c. “Yes, since you are larger, you can have more alcohol.” d. “Yes, two beers per day is an acceptable amount of alcohol.”

Answer 70

a. “No, women should only have one beer a day as a general rule.” Rationale: Alcohol intake should be limited to two drinks a day for men and one drink a day for women. A “drink” is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited alcohol intake is acceptable with hypertension. The woman’s size does not matter.

Question 71

A nurse is caring for four clients. Which one would the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 98/58 mm Hg. b. Client who had a first dose of captopril and needs to use the bathroom. c. Hypertensive client with a blood pressure of 188/92 mm Hg. d. Client who needs pain medication prior to a dressing change of a surgical wound.

Answer 71

b. Client who had a first dose of captopril and needs to use the bathroom. Rationale: Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse would see this client first to prevent falling if the client decides to get up without assistance. The two blood pressure readings are abnormal but not critical. The nurse would check on the client with higher blood pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards state to hold it if the systolic blood pressure is below 90 to 100 mm Hg. The client who needs pain medication prior to the dressing change is not a priority over client safety and assisting the other client to the bathroom.

Question 72

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates that an important outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors

Answer 72

b. Oxygen saturation of 98% Rationale: A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not as important.

Question 73

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the assistive personnel (AP)? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the client’s leg. d. Provide an ice pack.

Answer 73

b. Apply a warm moist pack. Rationale: Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client’s legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.

Question 74

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal? a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an “Ask the nurse” booth at the pet store.

Answer 74

b. Participate in blood pressure screenings at the mall. Rationale: An important goal of HP2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. Participating in blood pressure screening in a public spot will best help meet that goal. The other options are all appropriate but do not specifically help meet a goal.

Question 75

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin. The client is adamant about refusing the drug because “it’s dangerous.” What action by the nurse is best? a. Assess the reason behind the client’s fear. b. Remind the client about laboratory monitoring. c. Tell the client that drugs are safer today than before. d. Warn the client about consequences of noncompliance.

Answer 75

a. Assess the reason behind the client’s fear. Rationale: The first step is to assess the reason behind the client’s fear, which may be related to the experience of someone the client knows who took warfarin or misinformation. If the nurse cannot address the specific rationale, teaching will likely be unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe. General statements like “drugs are safer today” do not address the root cause of the problem. Warning the client about possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial relationship.

Question 76

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? a. Consult with the wound care nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.

Answer 76

a. Consult with the wound care nurse. Rationale: A nonhealing wound needs the expertise of the wound care nurse. Premedicating prior to painful procedures and maintaining sterile technique are helpful, but if the wound is not healing, more needs to be done. The client may need an amputation, but other options need to be tried first.

Question 77

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. “I can use a heating pad on my legs if it’s set on low.” b. “I should not cross my legs when sitting or lying down.” c. “I will go out and buy some warm, heavy socks to wear.” d. “It’s going to be really hard but I will stop smoking.”

Answer 77

a. “I can use a heating pad on my legs if it’s set on low.” Rationale: Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.

Question 78

The nurse is assessing a client on admission to the hospital. The client’s leg appears as shown below: Rubor What action by the nurse is best? a. Assess the client’s ankle-brachial index. b. Elevate the client’s leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium.

Answer 78

a. Assess the client’s ankle-brachial index. Rationale: This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse would measure the client’s ankle-brachial index. Elevating the leg above the heart will further impede arterial blood flow. Ice will cause vasoconstriction, also impeding circulation and perhaps causing tissue injury. Heparin sodium is not the drug of choice for this condition.

Question 79

Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.) a. “A good abrasive pumice stone will keep my feet soft.” b. “I’ll always wear shoes if I can buy cheap flip-flops.” c. “I will keep my feet dry, especially between the toes.” d. “Lotion is important to keep my feet smooth and soft.” e. “Washing my feet in room-temperature water is best.” f. “I will inspect my feet daily.”

Answer 79

c. “I will keep my feet dry, especially between the toes.” d. “Lotion is important to keep my feet smooth and soft.” e. “Washing my feet in room-temperature water is best.” Rationale: Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry; wearing good, comfortable shoes; using lotion; washing the feet in room-temperature water; cutting the nails straight across; and inspecting the feet daily are all important measures. Abrasive material such as pumice stones would not be used. Cheap flip-flops may not fit well and won’t offer much protection against injury.

Question 80

A woman has several relatives who had gestational hypertension and wants to decrease her risk for it. What information does the nurse provide this woman? (Select all that apply.) a. There is no way to reduce risk factors for gestational hypertension. b. Losing weight before you get pregnant will help prevent it. c. Eating a diet high in protein and iron may help prevent it. d. The father contributes no risk factors for hypertension in pregnancy e. Waiting until you are 35 to get pregnant cuts the risk in half.

Answer 80

b. Losing weight before you get pregnant will help prevent it. c. Eating a diet high in protein and iron may help prevent it. Rationale: There are many risk factors for gestational hypertension, including obesity and anemia. The woman can take action to address these factors prior to becoming pregnant. The father's risks include the first baby and having fathered other preeclamptic pregnancies. Maternal age >35 increases the risk.

Question 81

What assessment findings indicate to the nurses that a woman's preeclampsia should now be considered severe? (Select all that apply.) a. Urine output 40 mL/hour for the past 2 hours b. Serum creatinine 3.1 mg/dL c. Seeing "sparkly" things in the visual field d. Crackles in both lungs e. Soft, non-tender abdomen

Answer 81

b. Serum creatinine 3.1 mg/dL c. Seeing "sparkly" things in the visual field d. Crackles in both lungs Rationale: Signs of severe preeclampsia include elevated creatinine, seeing sparkles, and pulmonary edema (manifested by crackles). The urine output is above the minimum requirements, and a soft non-tender abdomen is a reassuring sign.

Question 82

A woman who is 8 months pregnant is brought to the emergency department after a serious motor vehicle crash. Although she has no apparent injuries, she is admitted to the hospital. Her partner is upset and wants to know why she just can't come home. What response by the nurse is best? a. "This is standard procedure for all pregnant crash victims." b. "She needs to be monitored for some potential complications." c. "We may have to deliver the baby at any time now." d. "We are giving her medicine to keep her from laboring."

Answer 82

b. "She needs to be monitored for some potential complications." Rationale: After serious trauma, a woman may be admitted and observed because an abruptio placentae may take up to 24 hours to become apparent. Not all motor vehicle crash patients will need to be admitted. The baby may or may not need to be delivered at any time, but this statement will frighten the partner. There is no indication the patient is in labor.

Question 83

A woman with preeclampsia has a seizure. What action by the nurse takes priority? a. Insert an oral airway. b. Suction the mouth to prevent aspiration. c. Administer oxygen by mask. d. Stay with the patient and call for help.

Answer 83

d. Stay with the patient and call for help. Rationale: If a patient seizes, the nurse should stay with her and call for help. Nursing actions during a seizure are directed toward ensuring a patent airway and patient safety. Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should attempt to keep the airway patent by turning the patient's head to the side to prevent aspiration. Once the seizure has ended, it may be necessary to suction the patient's mouth. Oxygen may or may not be needed after the seizure has ended.

Question 84

A woman taking magnesium sulfate has respiratory rate of 10 breaths/min. In addition to discontinuing the medication, the nurse should a. vigorously stimulate the woman. b. instruct her to take deep breaths. c. administer calcium gluconate. d. increase her IV fluids.

Answer 84

c. administer calcium gluconate. Rationale: Calcium gluconate reverses the effects of magnesium sulfate. Stimulation, instruction on taking deep breaths, and increasing her fluid rate will not increase the respirations.

Question 85

A patient with pregnancy-induced hypertension is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate a. Anxiety due to hospitalization b. Worsening disease and impending seizure c. Effects of magnesium sulfate d. Gastrointestinal upset

Answer 85

b. Worsening disease and impending seizure Rationale: Headache and visual disturbances are due to increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a seizure is imminent. These signs are not due to anxiety or magnesium sulfate or related to gastrointestinal upset.

Question 86

The prenatal clinic nurse monitored women for preeclampsia. If all four women were in the clinic at the same time, which one should the nurse see first? a. Blood pressure increase to 138/86 mm Hg b. Weight gain of 0.5 kg during the past 2 weeks c. A dipstick value of 3+ for protein in her urine d. Pitting pedal edema at the end of the day

Answer 86

c. A dipstick value of 3+ for protein in her urine Rationale: Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A dipstick value of 3+ is indicative of severe preeclampsia and should alert the nurse that additional testing or assessment should be made. Generally, hypertension is defined as a BP of 140/90 or higher. Preeclampsia may be manifested as a rapid weight gain. Gaining 0.5 kg during the past 2 weeks does not qualify as rapid. Edema occurs in many normal pregnancies as well as in women with preeclampsia. Therefore, the presence of edema is no longer considered diagnostic of preeclampsia.

Question 87

The nurse is explaining how to assess edema to the nursing students working on the antepartum unit. Which score indicates edema of lower extremities, face, hands, and sacral area? a. +1 edema b. +2 edema c. +3 edema d. +4 edema

Answer 87

c. +3 edema Rationale: Edema of the extremities, face, and sacral area is classified as +3 edema. Edema classified as +1 indicates minimal edema of the lower extremities. Marked edema of the lower extremities is termed +2 edema. Generalized massive edema (+4) includes accumulation of fluid in the peritoneal cavity.

Question 88

The labor of a pregnant woman with preeclampsia is going to be induced. The nurse reviews the woman's latest laboratory test findings, which reveal a low platelet count, an elevated aspartate transaminase (AST) level, and a falling hematocrit. What action by the nurse is most important? a. Palpate the woman's abdomen for tenderness. b. Document findings and begin the Pitocin infusion. c. Instruct the woman to ask for help getting out of bed. d. Assess the woman's drinking history.

Answer 88

c. Instruct the woman to ask for help getting out of bed. Rationale: This woman has HELLP syndrome, with is characterized by low platelet counts and hepatic dysfunction. She is at risk for bleeding, so the nurse instructs her to call for assistance in getting in and out of bed. The nurse does not palpate the abdomen even though the woman may complain of abdominal pain because of possible rupture of a subcapsular hematoma. The findings should be documented but the nurse should intervene based on the abnormal findings. The liver enzymes are not elevated because of alcohol intake.

Question 89

A nurse is assessing a woman receiving magnesium sulfate. The nurse assesses her deep tendon reflexes at 0 and 1+. What action by the nurse is best? a. Hold the magnesium sulfate. b. Ask the provider to order a 24-hour UA. c. Assess the woman's temperature. d. Take the woman's blood pressure.

Answer 89

a. Hold the magnesium sulfate. Rationale: Absent or hypoactive deep tendon reflexes are indicative of magnesium sulfate toxicity. The nurse should hold the magnesium and notify the provider. There is no need for a 24- hour UA at this point. Temperature changes are not related to magnesium. Blood pressure can be assessed, but that is not the priority.

Question 90

Which clinical sign is not included in the symptoms of preeclampsia? a. Hypertension b. Edema c. Proteinuria d. Glycosuria

Answer 90

d. Glycosuria Rationale: Spilling glucose into the urine is not one of the three classic symptoms of preeclampsia. Hypertension is usually the first sign noted. Edema occurs but is considered a non-specific sign. Edema can lead to rapid weight gain. Proteinuria should be assessed through a 24- hour UA.

Question 91

What is the only known cure for preeclampsia? a. Magnesium sulfate b. Antihypertensive medications c. Delivery of the fetus d. Administration of acetylsalicylic acid (ASA) every day of the pregnancy

Answer 91

c. Delivery of the fetus Rationale: If the fetus is viable and near term, delivery is the only known definitive treatment for preeclampsia. Magnesium sulfate is one of the medications used to treat but not to cure preeclampsia. Antihypertensive medications are used to lower the dangerously elevated blood pressures in preeclampsia and eclampsia. Low doses of ASA (81 mg) have been administered to women at high risk for developing preeclampsia.

Question 92

A woman with severe preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is a. tocolytic. b. anticonvulsant. c. antihypertensive. d. diuretic.

Answer 92

b. anticonvulsant. Rationale: Anticonvulsant drugs act by blocking neuromuscular transmission and depress the central nervous system to control seizure activity. A tocolytic drug does slow the frequency and intensity of uterine contractions, but it is not used for that purpose in this scenario. Decreased peripheral blood pressure is a therapeutic response (side effect) of the anticonvulsant magnesium sulfate. Diuresis is a therapeutic response to magnesium sulfate.

Question 93

The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to a. assess fetal heart rate (FHR) and maternal vital signs. b. perform a venipuncture for hemoglobin and hematocrit levels. c. place clean disposable pads to collect any drainage. d. monitor uterine contractions.

Answer 93

a. assess fetal heart rate (FHR) and maternal vital signs. Rationale: Assessment of the FHR and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the mother and fetus. The blood levels can be obtained later. It is important to assess future bleeding and provide for comfort, but the top priority is mother/fetal well-being. Monitoring uterine contractions is important but not the top priority.